Attempting to balance relative complications and recognizing the benefits of tracheotomy in long-term ventilation, recent literature and common practice have recommended that patients may remain transla- ryngeally intubated with relative safety for 14 days, after which a tracheotomy should be performed if extubation is not imminent. This timing is supported by observations that irreversible laryngeal injury from translaryngeal ETs becomes cumulative by day 10 of intubation. Furthermore, the risks of laryngeal injury from tracheotomy appear directly related to the duration of preceding ET intubation before surgery. Therefore, once a tracheotomy appears inevitable, it should be performed as soon as possible, thereby limiting the degree of laryngeal inflammation and patient discomfort from ET intubation.
The recommendation to limit ET intubation to 14 days has been transformed in many institutions into the clinical practice of avoiding consideration of tracheotomy until a requisite 14 days of intubation prompts the issue. This practice, as demonstrated by the present study, frequently delays the actual performance of tracheotomy beyond two to three weeks. These delays may result from surgical scheduling difficulties and by the clinicians recurrent unrealistic expectations that extubation will occur in “another few more days.” Recognition of the clinical features identified in this study may avoid subjecting patients with ARDS to an unnecessary gauntlet of 14 or more days of ET intubation if the need for long-term intubation and eventual tracheotomy is evident on day 7. Patients not fulfilling day 7 criteria for prolonged ventilation can be reevaluated daily in an effort to proceed to extubation and avoid tracheotomy. cialis soft tabs online
The majority of group 2 patients who required prolonged intubation died during their hospitalization for ARDS. The importance of recognizing the need for earlier tracheotomy persists, however, because the majority of these patients remained mentally alert and survived from 16 to 109 days after intubation. Tracheotomy, however, was not implemented for 7 to 51 days after onset of respiratory failure. Since tracheotomy was eventually performed in an effort to improve patient comfort, facilitate communication and assist nursing care, these benefits would have contributed to well-being for a greater portion of these patients’ hospitalizations had the tracheotomy not been delayed.
We limited the study to patients with ARDS because the clinical course, complications and outcome of patients with respiratory failure from diverse disorders such as ARDS, emphysema, neuromuscular disease and pneumonia differ sufficiently to affect clinical predictors of intubation duration. Consequently, however, conclusions from the present study may not apply to patients undergoing mechanical ventilation who experience respiratory failure from etiologies other than ARDS. Additional studies investigating early clinical predictors of prolonged intubation in other conditions associated with respiratory failure are warranted.
In conclusion, previous studies indicate that most patients with ARDS should undergo initial intubation with ET tubes with the goal of achieving extubation within 14 days. The necessity of long-term intubation and likelihood of eventual tracheotomy, however, can be determined from clinical features apparent after seven days of ARDS, thereby allowing selection of patients for early tracheotomy. Although the specific clinical features that suggest prolonged intubation are interdependent to a degree, they serve to identify patients with severe ARDS who do not rapidly improve between the 7th and 14th days of respiratory failure. This approach avoids prolonging ET intubation in patients once eventual tracheotomy appears inevitable.
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