Successful Use of Early Percutaneous Dilatational Tracheotomy and the No Sedation Concept in Respiratory Failure in Critically Ill Obese Subjects

Abstract

BACKGROUND:The prevalence of obesity in developed countries is rising. Currently, Europe has a prevalence of 9 -30% with significant impact on public health systems. Obese patients in ICUs require special management and treatment. Altered anatomy in obese patients complicates procedures such as mechanical ventilation. Obesity affects cardiopulmonary physiology and requires elevated ventilation pressures. In our retrospective study, we determined the effect of early percutaneous dilatational tracheotomy (PDT) and cessation of sedation on respiratory parameters in severely obese subjects. METHODS: From June 2010 to July 2014, we included all subjects with a body weight of >130 kg (body mass index >35 kg/m 2 ) and respiratory failure who were admitted to the medical ICU of the University Hospital of Mü nster. All subjects were treated with early PDT and immediate cessation of sedative drugs. We compared ventilator parameters and blood gas analysis before and after PDT. Parameters were recorded on days 0, 1, 3, and 5. Day 0 represents values during ventilation via an endotracheal tube, and days 1, 3, 5 represent values during ventilation via a tracheotomy tube. PDT was performed on day 0 after recording values during ventilation via an endotracheal tube. RESULTS: We included 23 subjects with a mean body mass index of 53.1 kg/m 2 and respiratory failure. After PDT and cessation of sedation, the required ventilation pressures and F IO 2 could be rapidly reduced (P < .001), whereas blood gas parameters significantly improved. We observed no severe PDT-associated complications in our cohort. CONCLUSIONS: In severe obesity, respiratory failure might be increased by problems in mechanical ventilation due to required high pressures and obesity-induced pulmonary restriction. Rapid tracheotomy with reduction of dead-space ventilation and airway resistance as well as cessation of sedation to enable spontaneous breathing might be a key factor in the therapy of respiratory failure.

A safer and more practical tracheotomy in invasive mechanical ventilated patients with COVID-19: A quality improvement study

“…The sequelae of prolonged endotracheal intubation are well known and recognized. Performing a tracheotomy may improve patients' comfort, lower frequency of oral lesions, clear airway secretions, reduce the dose and duration of analgesia and sedative drugs, avoid complications related to prolonged analgesia and sedation, reduce dead-space ventilation and airway resistive load, improve expiratory flow, expedite rehabilitation and allow for easier, safer and faster weaning from ventilator (17,(33)(34)(35)(36)(37). In clinical practice, the decision to perform tracheotomy should be based on the balance between exact expected benefits and optimal care of the selected patients and the possible risk of SARS-CoV-2 transmission to operators.…”

Comparison of Ciaglia and Griggs Percutaneous Dilatation Tracheostomy Methods: Which one is more effective and safe?

“…Although there are studies claiming the contrary [19,20] , it is known that obesity makes the PDT procedure more difficult [21,22] . Indeed, in some studies it has been accepted as the exclusion criteria [5,8] .…”

Management of obese patients with respiratory failure – A practical approach to a health care issue of increasing significance

“…Additionally, tracheotomy leads to a reduction of airway resistance and deadspace ventilation, as the tracheal tube used for tracheotomy has a larger inside diameter and creates a shorter artificial airway. Current data of a single center study shows that performing early tracheotomy and termination of sedation enables a reduction of ventilation pressure and is associated with an improvement of blood gas parameters [28]. This indicates that early tracheotomy may lead to better implementation of lung protective ventilation and thus, a shorter stay on the ICU that may have a beneficial effect on long-term outcome.…”