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

Abstract

Background and Aim: Critically ill patients on mechanical ventilation undergo tracheostomy to facilitate weaning. The practice in India may be different from the rest of the world and therefore, in order to understand this, ISCCM conducted a multicentric observational study "DIlatational percutaneous vs Surgical tracheoStomy in intEnsive Care uniT: A practice pattern observational multicenter study (DISSECT Study)" followed by an ISCCM Expert Panel committee meeting to formulate Practice recommendations pertinent to Indian ICUs. Materials and methods: All existing International guidelines on the topic, various randomized controlled trials, meta-analysis, systematic reviews, retrospective studies were taken into account to formulate the guidelines. Wherever Indian data was not available, international data was analysed. A modified Grade system was followed for grading the recommendation. Results: After analyzing the entire available data, the recommendations were made by the grading system agreed by the Expert Panel. The recommendations took into account the indications and contraindications of tracheostomy; effect of timing of tracheostomy on incidence of ventilator associated pneumonia, ICU length of stay, ventilator free days & Mortality; comparison of surgical and percutaneous dilatational tracheostomy (PDT) in terms of incidence of complications and cost to the patient; Comparison of various techniques of PDT; Use of fiberoptic bronchoscope and ultrasound in PDT; experience of the operator and qualification; certain special conditions like coagulopathy and morbid obesity. Conclusion: This document presents the first Indian recommendations on tracheostomy in adult critically ill patients based on the practices of the country. These guidelines are expected to improve the safety and extend the indications of tracheostomy in critically ill patients.

The impact of tracheostomy delay in intensive care unit patients: a two-year retrospective cohort study

“…A study from 2006 showed that early tracheostomy in intensive care trauma patients improves resource utilisation, and delayed tracheostomy (> 14 days) was an independent predictor of prolonged ICU stay [ 9 ]. Similar findings are seen in systematic reviews and isolated studies, with most reporting statistically significant reductions in ICU length of stay and intubation-related complications when a tracheostomy is placed soon after intubation [ 9 – 11 ]. A study examining the effect of delayed tracheostomy (from the moment of decision to the procedure) on clinical outcomes found that shorter delays were also associated with successful weaning [ 12 ].…”

Fiber-optic Bronchoscope-guided vs Mini-surgical Technique of Percutaneous Dilatational Tracheostomy in Intensive Care Units

“…Scarcity of recommendations on necessity of FOB during PCDTs has led the authors to review more literature and only two such recommendations could be traced. 22 , 23 French expert panel have recommended routine use of FOB during PCDTs but their opinion was based on two nonrandomized and one randomized trials on just 60 patients, mostly from Western countries. 22 On the contrary, in a recently published multicentric study on 923 patients from India, the researchers have performed FOB in only 28.1% of all PCDTs, although they have mentioned that the use of FOB may reduce hemorrhagic complications during PCDT.…”

“… 24 The Indian Society of Critical Care Medicine (ISCCM) expert panel has also published a practice recommendation in 2020 which mentions that FOB can be used during PCDT if available but it does not decrease the incidence of complications during PCDTs. 23 So, to be in sync with recent pieces of evidence, we wish to state that the use of FOB may be desirable but it is not mandatory during PCDT. MS-PCDT can be a safe and effective alternative to FOB-guided PCDTs.…”

The role of routine FIBERoptic bronchoscopy monitoring during percutaneous dilatational TRACHeostomy (FIBERTRACH): a study protocol for a randomized, controlled clinical trial

“…The French Society of Intensive Care [ 15 ] guidelines established a weak recommendation based on a study in 60 patients in which endoscopic guidance was associated with fewer minor complications. The Indian Society of Critical Care Medicine expert panel states that fiberoptic bronchoscope may be used, whenever available to aid PDT although it does not reduce the rate of complications [ 16 ].…”

“…The duration of the procedure in all four patients lasted between 10 and 15 min, and the authors stated that the use of endoscopic guidance prevented damage to the posterior tracheal wall and helped in identifying the puncture site thanks to transillumination. Currently, the “routine” use of endoscopic guidance as part of percutaneous tracheostomy is controversial [ 10 – 13 ] and guidelines cannot establish recommendation levels [ 14 – 16 ].…”