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JournalInfection,
ofTRAUMAand Critical Care
Volume
Ibn From57 for
Anesthesiologist
thesiology
Morocco;
Rochd
Manuscript
Address
DOI:email:
and Number
Hospital,
the 2in Unit
10.1097/01.TA.0000087646.68382.9A
Intensive
Department
mabouderka@yahoo.fr.
(ASA)
published
reprints:
Casablanca,
Annual
Care
Moulay
of Anesthesiology
abstract
Meeting,
Morocco.
Ahmed
(P33),
formOctober
Ibn
Bouderka,
inRochd
and
The2001. not
Intensive
American 6.01.
Hospital, prolonged
Department
Careendoscopic
All ofOur
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Casablanca,
UnitAnes-hypothesis
were
of(P33), Statistics
endotracheal
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PC
early
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CDC
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Epi
criteria.
andinfo
The
251
re-
to
15
TheInjury,
JournalInfection,
ofTRAUMAand Critical Care
Number of weaning attempts 1.6 0.7 1.5 0.9 0.6 Table 4 Outcome and Mortality
Total ventilation days 14.5 7.3 17.5 10.6 0.02
Day of extubation or 26.3 13.7 19.4 10.4 0.03 T Group I Group
p
(n 31) (n 31)
tracheostomy off
Recovery n (%) 19 (61.3) 23 (74.2) 0.41
Table 3 Frequency of Nosocomial Pneumonia and Bleeding n (%) 2 (6.4) 0 (0) 0.47
Death n (%) 12 (38.7) 7 (22.5) 0.27
Sinusitis
Day of death 30.6 20.1 27.7 14.6 0.72
T Group I Group
p
(n 31) (n 31)
on the optimal timing of the procedure in mechanically protection. ven-Early tracheostomy may assist in early termina-
tilated patients. 1 6 1 8 The consensus conferencetion of 1989
of mechanical
rec- ventilatory support and therefore, reduce
ommended conversion to tracheotomy if the anticipated need the ICU and hospital stay for these patients.
for mechanical ventilation is 21 days. 4 Few studies have
In our experience, two clinical features at the time of
tried to resolve this question: is there any benefitintubation to practice aid identification of unlikely to be extubated: pa-
tracheotomy? If yes, at what time? tients with a GCS score 8, brain stem deficit and cerebral
Few studies methodologically acceptable tried to answer
contusion in CT scan. That is why we chose these conditions
these questions. 8 , 9 , 19 2 2 Rodriguez et al. suggested
8 that therecriteria in our study. The limitation of this ap-
as inclusion
was a reduction in the duration of mechanical ventilation, proach is the high mortality rate during the first week of
ICU and hospital stay. He did not comment on sequellea of
hospitalization. In our opinion tracheostomy should depend
prolonged intubation versus early tracheostomy.not Dunham et
only on the probability of successful extubation but also
al.1 9 found no difference with respect to importantonclinical the probability that a patient had good chance of being
outcomes. However, they noted that the frequency discharged of major alive. That is why we avoided in our protocol
laryngotracheal damage was similar for early andtracheostomy late trache- in patients who will be potentially extubated
ostomy. El-Naggard et al. 2 0 found a higher percentage
early (GCS of score 8) and the patient who would die during
extubation and lower frequency of airway lesions inthethefirst lateweek and would not benefit from the procedure.
tracheotomy groups. Two retrospective studies were Presently, con- most physicians decide the timing of trache-
ducted by Lesnik et al. and Blot et al. Lesnikostomy
8 21 reviewed 101
in patients with neurologic disease based on results
adult patients who were admitted after blunt injuries, 32 had
derived from observations in patients mechanically ventilated
tracheostomy within the first 4 days and 69 underwent tra- for pulmonary
Most ofcauses. the patients
3 , 2 3 with sever
cheostomy after 4 days. The author found that the mean
head injury, as seen in our study, required intubation for at
duration of ventilatory support was 6.0 days in early trache-
least one week but not necessarily mechanically ventilation
ostomy group versus 20.6 days in the late tracheotomy group
for a long time, However, airway protection is permanently
(p 0.001). Blot et al. 2 1 in their retrospective study com-
needed. Tracheostomy provides an early alternative for air-
pared early (with in 48 h) versus late ( 7days) tracheostomy
way protection and seems to decrease the need for prolonged
in 53 neutropenic patients. The frequency of nosocomial
mechanical ventilation support. Secondly, severe head injury
pneumonia, death in ICU and hospital were not significantly
patient requires a long time for recovery and the airways
different but the length of the hospital stay and of the me-
protective reflexes are rarely optimal. This was confirmed by
chanical ventilation were significantly longer in early trache-
the high frequency of reintubation attributable to poor control
ostomy group ( p 0.05).
over secretions aspiration in intubation groups. 2 4 ,2 5
However all these studies have some methodological
Frequency of nosocomial pneumonia seems to be lower
bias:
with early tracheostomy. Many studies confirm theses
Inhomogeneous population 1 8 -2 0
Other
findings.
authors
9 , 2 found
1 ,2 6 that tracheostomy in-
Retrospective study 9 , 2 0
No randomization 9 , 1 8 creases the frequency Weofdidpneumonia.
not find2 any
7 2 9
If randomization was present, it was substandard, statistical difference in term of frequency of pneumonia be-
(alter-
native allocation, the day of the studies were tween the 2 groups.
blinded)8 , 1 8 ,1 9 The association between the risk of laryngotracheal in-
Comparison between early and late tracheotomy jury andnotduration
ver- of intubation is another important consid-
sus prolonged endotracheal intubation 8 , 9, 1 7 21 eration in the timing of tracheostomy. Nowak reported
et al.30
chosen must be ventilated for a long time in orderevaluated not to dothe frequency rate of laryngotracheal stenosis in
tracheostomy abusively (for patients who did not315 patients
require it). with neurologic disease (Head injury, tetraple-
We believe that the ideal population study is patients gia. .with
.), the risk of laryngotracheal stenosis was not depen-
isolate
methodology.
who
unsuccessful
the
ical
Volume
first observed
ventilatory
We
were
severe
57
week,
had
mechanically
extubation
Number
head
most
support injury
of2that
these
but
ventilated
and
who
patients
were
patients
required
metintubated
had
with
the
didnt
tracheostomies.
criteria
asever
high
mainly
require
performed
frequency
complications.
difference
head
ical
cited
was
dent
cheal
symptoms
for
mechan-
injury
in
done
on
After
airway
complication.
our
before
of
the
between
only
duration
were
However,
if
thethere
the
recorded
time
We
of
two
was
we
intubation.
period
think
groups
should
clinical
and that
when
laryngotracheal
inremember
Tracheostomy
Our
suspicion
term
laryngotracheal
study
of laryngotracheal
that
of
didlaryngotra-
endoscopy
should
only
not injury
find
clin-
253
bea
TheInjury,
JournalInfection,
ofTRAUMAand Critical Care