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气管切开拔管前应用高流量氧疗联合堵管或联合吸引的比较
High-Flow Oxygen with Capping or Suctioning for Tracheostomy Decannulation


Gonzalo Hernández Martínez ... 呼吸系统疾病 • 2020.09.10
相关阅读
• 对危重机械通气患者采取非镇静或浅镇静的比较 • 重症监护病房内机械通气患者的镇静措施是否应取消

摘要


背景

应用气管切开套管的患者在治疗中达到有可能拔管的阶段时,通常做法是将气管切开套管堵管24小时,确定患者可否自主呼吸。目前尚未明确通过该方法为患者做拔管准备是否比根据呼吸道吸引频率做拔管准备达到更好的结局。

 

方法

我们在5个重症监护病房(ICU)纳入了应用气管切开套管,且有意识的危重成人患者;机械通气撤机后的患者符合纳入标准。在这项非盲法试验中,我们将患者随机分为两组,一组接受24小时堵管试验+间歇性高流量氧疗(对照组),另一组接受连续高流量氧疗,并将吸引频率作为拔管准备指标(干预组)。主要结局是至拔管的时间,我们利用时序检验比较了主要结局。次要结局包括拔管失败、撤机失败、呼吸道感染、脓毒症、多器官衰竭、住ICU时长和住院时长,以及ICU内和院内死亡。

 

结果

本试验纳入了330例患者,患者的平均(±SD)年龄为58.3±15.1岁,68.2%为男性。共计161例患者被分配至对照组,169例被分配至干预组。干预组至拔管的时间比对照组短(中位数,6日[四分位距,5~7] vs. 13日[四分位距,11~14];绝对差异,7日[95% CI,5~9])。干预组的肺炎和气管支气管炎发生率低于对照组,住院时长也比对照组短。两组的其他次要结局相似。

 

结论

与依据24小时堵管试验制定的拔管决策和间歇性高流量氧疗相比,依据吸引频率制定的拔管决策和连续高流量氧疗缩短了至拔管的时间,并且无证据表明两组的拔管失败率存在差异(REDECAP在ClinicalTrials.gov注册号为NCT02512744)。





作者信息

Gonzalo Hernández Martínez, M.D., Ph.D., Maria-Luisa Rodriguez, M.D., Maria-Concepción Vaquero, M.D., Ramón Ortiz, M.D., Ph.D., Joan-Ramon Masclans, M.D., Ph.D., Oriol Roca, M.D., Ph.D., Laura Colinas, M.D., Ph.D., Raul de Pablo, M.D., Ph.D., Maria-del-Carmen Espinosa, M.D., Ph.D., Marina Garcia-de-Acilu, M.D., Cristina Climent, M.D., and Rafael Cuena-Boy, M.D.
From Virgen de la Salud University Hospital (G.H.M., M.-L.R., L.C.) and the Research Unit, Medical Council (R.C.-B.), Toledo, Ramón y Cajal University Hospital (M.-C.V., R.P.) and Ciber Enfermedades Respiratorias, Health Institute Carlos III (O.R.), Madrid, Ciudad Real University Hospital and Ciudad Real University, Ciudad Real (R.O., M.-C.E.), Medical Research Mar Institute (J.-R.M.), the Critical Care Department, Autònoma de Barcelona University (J.-R.M., M.G.-A.), Del Mar University Hospital (J.-R.M., C.C.), Vall d’Hebron Research Institute (O.R.), and Vall d’Hebron University Hospital (O.R., M.G.A.), Barcelona, and Alcala University, Alcalá de Henares (R.P.) — all in Spain. Address reprint requests to Dr. Hernández Martínez at the Department of Critical Care Medicine, Virgen de la Salud University Hospital, Tenerife No. 40, Fl. 2, Rm. D, 28039 Madrid, Spain, or at ghernandezm@telefonica.net.

 

参考文献

1. Abe T, Madotto F, Pham T, et al. Epidemiology and patterns of tracheostomy practice in patients with acute respiratory distress syndrome in ICUs across 50 countries. Crit Care 2018;22:195-195.

2. Esteban A, Frutos-Vivar F, Muriel A, et al. Evolution of mortality over time in patients receiving mechanical ventilation. Am J Respir Crit Care Med 2013;188:220-230.

3. Mitchell RB, Hussey HM, Setzen G, et al. Clinical consensus statement: tracheostomy care. Otolaryngol Head Neck Surg 2013;148:6-20.

4. Trouillet JL, Collange O, Belafia F, et al. Tracheotomy in the intensive care unit: guidelines from a French expert panel. Ann Intensive Care 2018;8:37-37.

5. McGrath BA, Brenner MJ, Warrillow SJ, et al. Tracheostomy in the COVID-19 era: global and multidisciplinary guidance. Lancet Respir Med 20208:717-725.

6. Stelfox HT, Crimi C, Berra L, et al. Determinants of tracheostomy decannulation: an international survey. Crit Care 2008;12:R26-R26.

7. Stelfox HT, Hess DR, Schmidt UH. A North American survey of respiratory therapist and physician tracheostomy decannulation practices. Respir Care 2009;54:1658-1664.

8. Singh RK, Saran S, Baronia AK. The practice of tracheostomy decannulation — a systematic review. J Intensive Care 2017;5:38-38.

9. Ceriana P, Carlucci A, Navalesi P, et al. Weaning from tracheotomy in long-term mechanically ventilated patients: feasibility of a decisional flowchart and clinical outcome. Intensive Care Med 2003;29:845-848.

10. Mah JW, Staff II, Fisher SR, Butler KL. Improving decannulation and swallowing function: a comprehensive, multidisciplinary approach to post-tracheostomy care. Respir Care 2017;62:137-143.

11. Santus P, Gramegna A, Radovanovic D, et al. A systematic review on tracheostomy decannulation: a proposal of a quantitative semiquantitative clinical score. BMC Pulm Med 2014;14:201-201.

12. Heidler MD, Salzwedel A, Jöbges M, et al. Decannulation of tracheotomized patients after long-term mechanical ventilation — results of a prospective multicentric study in German neurological early rehabilitation hospitals. BMC Anesthesiol 2018;18:65-65.

13. Hernández G, Ortiz R, Pedrosa A, et al. The indication of tracheotomy conditions the predictors of time to decannulation in critical patients. Med Intensiva 2012;36:531-539.

14. Tobin AE, Santamaria JD. An intensivist-led tracheostomy review team is associated with shorter decannulation time and length of stay: a prospective cohort study. Crit Care 2008;12:R48-R48.

15. Fisher DF, Kondili D, Williams J, Hess DR, Bittner EA, Schmidt UH. Tracheostomy tube change before day 7 is associated with earlier use of speaking valve and earlier oral intake. Respir Care 2013;58:257-263.

16. Suntrup S, Marian T, Schröder JB, et al. Electrical pharyngeal stimulation for dysphagia treatment in tracheotomized stroke patients: a randomized controlled trial. Intensive Care Med 2015;41:1629-1637.

17. Roche-Campo F, Thille AW, Drouot X, et al. Comparison of sleep quality with mechanical versus spontaneous ventilation during weaning of critically ill tracheostomized patients. Crit Care Med 2013;41:1637-1644.

18. Pandian V, Miller CR, Schiavi AJ, et al. Utilization of a standardized tracheostomy capping and decannulation protocol to improve patient safety. Laryngoscope 2014;124:1794-1800.

19. Fernandez R, Bacelar N, Hernandez G, et al. Ward mortality in patients discharged from the ICU with tracheostomy may depend on patient’s vulnerability. Intensive Care Med 2008;34:1878-1882.

20. Hernandez G, Pedrosa A, Ortiz R, et al. The effects of increasing effective airway diameter on weaning from mechanical ventilation in tracheostomized patients: a randomized controlled trial. Intensive Care Med 2013;39:1063-1070.

21. American Association for Respiratory Care. AARC clinical practice guidelines: endotracheal suctioning of mechanically ventilated patients with artificial airways 2010. Respir Care 2010;55:758-764.

22. Hernandez G, Vaquero C, Gonzalez P, et al. The role of high flow conditioned oxygen therapy on reducing time to decannulation in critically ill tracheostomized patients: a preliminary cohort study. Intensive Care Med 2013;39:Suppl 2:S406-S406. abstract.

23. Bonett DG, Price RM. Statistical inference for a linear function of medians: confidence intervals, hypothesis testing, and sample size requirements. Psychol Methods 2002;7:370-383.

24. Newcombe RG. Interval estimation for the difference between independent proportions: comparison of eleven methods. Stat Med 1998;17:873-890.

25. Boles JM, Bion J, Connors A, et al. Weaning from mechanical ventilation. Eur Respir J 2007;29:1033-1056.

26. Birk R, Händel A, Wenzel A, et al. Heated air humidification versus cold air nebulization in newly tracheostomized patients. Head Neck 2017;39:2481-2487.

27. Stripoli T, Spadaro S, Di Mussi R, et al. High-flow oxygen therapy in tracheostomized patients at high risk of weaning failure. Ann Intensive Care 2019;9:4-4.

28. Natalini D, Grieco DL, Santantonio MT, et al. Physiological effects of high-flow oxygen in tracheostomized patients. Ann Intensive Care 2019;9:114-114.

29. Choate K, Barbetti J, Currey J. Tracheostomy decannulation failure rate following critical illness: a prospective descriptive study. Aust Crit Care 2009;22:8-15.

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