Tracheotomy in the intensive care unit: guidelines from a French expert panel

Abstract

Tracheotomy is widely used in intensive care units, albeit with great disparities between medical teams in terms of frequency and modality. Indications and techniques are, however, associated with variable levels of evidence based on inhomogeneous or even contradictory literature. Our aim was to conduct a systematic analysis of the published data in order to provide guidelines. We present herein recommendations for the use of tracheotomy in adult critically ill patients developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. These guidelines were conducted by a group of experts from the French Intensive Care Society (Société de Réanimation de Langue Française) and the French Society of Anesthesia and Intensive Care Medicine (Société Francaise d’Anesthésie Réanimation) with the participation of the French Emergency Medicine Association (Société Française de Médecine d’Urgence), the French Society of Otorhinolaryngology. Sixteen experts and two coordinators agreed to consider questions concerning tracheotomy and its practical implementation. Five topics were defined: indications and contraindications for tracheotomy in intensive care, tracheotomy techniques in intensive care, modalities of tracheotomy in intensive care, management of patients undergoing tracheotomy in intensive care, and decannulation in intensive care. The summary made by the experts and the application of GRADE methodology led to the drawing up of 8 formal guidelines, 10 recommendations, and 3 treatment protocols. Among the 8 formal guidelines, 2 have a high level of proof (Grade 1+/−) and 6 a low level of proof (Grade 2+/−). For the 10 recommendations, GRADE methodology was not applicable and instead 10 expert opinions were produced.

Tracheostomy in Adult Intensive Care Unit: An ISCCM Expert Panel Practice Recommendations

“…These recommendations have taken into account certain points mentioned in other international guidelines available on the tracheostomy. [154][155][156][157] references…”

Complications of surgical and percutaneous tracheostomies, and factors leading to decannulation success in a unique Middle Eastern population

“…Trouillet et al [7] noted similar results in their randomized trial that compared early PCT versus prolonged intubation in patients after cardiac surgery (n = 216). Subsequently, the French expert panel on tracheostomy in the intensive care unit [8] recommended that tracheostomy in intensive care should not be performed before the 4 th day of mechanical ventilation. Also per guidelines, our patients had low oxygen and PEEP requirements at the time of the tracheostomy and also had acceptable hemoglobin, platelet and white blood cell counts.…”

Documento de consenso de la Sociedad Española de Medicina Intensiva, Crítica, y Unidades Coronarias (SEMICYUC), la Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello (SEORL-CCC) y la Sociedad Española de Anestesiología y Reanimación (SEDAR) sobre la traqueotomía en pacientes con COVID-19

“…En estos casos, aunque no existe suficiente evidencia para recomendar el uso de ultrasonografía, para disminuir las complicaciones asociadas con el procedimiento, podría ser de utilidad para mejorar la precisión en el sitio de punción en pacientes que presenten dificultad para la identificación de las estructuras anatómicas 22 .…”