Complexity of Pediatric Tracheostomy Practice and Its Understanding.
Complexity of Pediatric Tracheostomy Practice and Its Understanding.
复制标题
儿童气管切开术实践的复杂性及其理解。
DOI：
10.1097/ccm.0000000000004241
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发表时间：
2020
影响因子：
8.8
通讯作者：
P. Jouvet
中科院分区：
文献类型：
--
作者：
A. Kawaguchi;G. Emeriaud;P. Jouvet
致编辑：我们饶有兴趣地阅读了 Ahmed 等人在最近一期《重症监护医学》上发表的文章 (1)，其中检查了儿科患者气管切开术的时机。该综述包括八项回顾性研究，以年龄和机械通气时间（MV）作为潜在的混杂因素进行亚组分析。该研究表明，早期气管切开术可能为儿科人群提供潜在的临床益处。这是一篇非常有趣的综述，具有很强的方法论，但临床医生还有一些额外的要点需要牢记。气管切开术的实践和对儿童时间安排的讨论不应该是直截了当的。气管造口术的时机可能受到医学和非医学因素的影响，例如疾病病因和合并症、术后、父母的想法和医疗资源的可用性。这些因素通常很难在回顾性研究中捕获，并且可能会强烈影响选择和信息偏差的效果测量。本综述中几乎没有研究涉及疾病病因或这些因素的细节。例如，如果不考虑因已知上呼吸道解剖阻塞而进行早期气管切开的患者与因严重脑损伤或急性呼吸窘迫综合征在数周内缓慢恢复而拔管失败而进行晚期气管切开的患者之间的差异，我们如何才能探索早期气管切开的效果呢？早期和晚期气管造口组的疾病严重程度也可能不同。例如，我们可以假设，较轻的患者在气管切开晚期组中的代表性可能本质上较低，这可以解释部分结果。我们还需要考虑非临床或非通气问题（即父母的支持、PICU 外的资源可用性、PICU 的工作量管理以及姑息治疗等治疗的限制）来全面讨论气管切开术的时机，特别是对于 PICU 患者的气管切开术（PMV）延长的情况。研究报告称，大多数 PICU 患者需要的 MV 时间少于 10-14 天 (2, 3)。然而，在我们最近对 PMV 儿科定义的系统回顾中 (4)，21 天的 MV 天数是现有儿科研究中使用最广泛的。此外，我们最近在加拿大进行的横断面调查显示，在 MV 21 天时，医生仍然不愿意为仅因肺部疾病而需要 PMV 的儿童推荐气管切开术 (5)。这一证据可能表明，医生对 PMV 气管切开术的实际实践与他们所掌握的临床知识之间存在潜在的差异。总而言之，小儿气管切开术的实践和未来可能的研究设计需要从多个角度进行审视； PMV 的定义、医疗保健资源负担，包括支付或保险系统、患者和社会概况以及知识翻译。从这个意义上说，对更新后的队列的全面了解应该是核心（https://longventkids.ca/，ClinicalTrials.gov 标识符：NCT04112459）。这可能会让我们了解哪些人群可能会从早期气管切开术中获得最大的益处，反之亦然，以及我们在未来的介入研究中应该看到什么样的结果测量。 Jouvet 博士透露，医疗设备是由 Hamilton Medical、Philips 和 Dymedso 借用的。 Emeriaud 博士的机构获得了 Fonds de recherche du Québec Santé 和 Maquet Critical Care 的资助（一项研究的财务支持）。川口博士得到魁北克研究基金会的支持。
To the Editor: We read with interest the article published in a recent issue of Critical Care Medicine by Ahmed et al (1), in which the timing of tracheostomy in pediatric patients was examined. This review included eight retrospective studies, subgroup analyzing with age and length of mechanical ventilation (MV) as a potential confound factor. The study suggested that early tracheostomy may provide potential clinical benefits in pediatric populations. This is a very interesting review with strong methodology, but there are few additional points for clinicians to bear in mind. The tracheostomy practice and the discussion of the timing for the children should not be straightforward. The timing of the tracheostomy could be influenced by medical and nonmedical factors, such as disease etiology and comorbidity, post-surgery, parental thoughts, and healthcare resource availability. Those factors are, generally, difficult to be captured in a retrospective study and possibly strongly affect the effect measurements by selection and information biases. Almost no studies included in this review get into the details of the disease etiology or those factors. For instance, how can we explore the effect of early tracheostomy without considering the difference between the patient early-tracheostomized with known upper airway anatomical obstruction and the patients late-tracheostomized for failed extubation due to such as severe brain injury or acute respiratory distress syndrome recovering slowly over weeks? The severity of illness may also differ between the early and late tracheostomy cohorts. For example, we could assume that less-severe patients may inherently be less-represented in the late-tracheostomized groups, which could explain the part of the results. We also need to consider the nonclinical or nonventilatory issues (i.e., parental support, resource availability outside of PICUs, workload management in PICUs, and limitation of treatment such as palliative care) to discuss the timing of tracheostomy, particularly with prolonged MV (PMV) in PICU patients comprehensively. Studies reported that the majority of PICU patients require less than 10–14 days of MV (2, 3). However, in our recent systematic review of pediatric definition of PMV (4), 21 days of MV days were the most widely used in the existing pediatric studies. Furthermore, our recent cross-sectional survey in Canada revealed that physicians remain reluctant to recommend tracheostomy for children requiring PMV due to lung disease alone at 21 days of MV (5). This evidence may indicate that there is a potential discrepancy between actual physician practice toward tracheostomy for PMV and the clinical knowledge they have. To sum, the pediatric tracheostomy practice and the possible future study design needs to be examined from multiple points of view; definition of PMV, healthcare resource burden including such as payment or insurance system, patient and social profiles, and knowledge translation. A comprehensive understanding of the updated cohort should be central in this sense (https://longventkids.ca/, ClinicalTrials.gov Identifier: NCT04112459). This may lead us to understand which cohort may receive the largest benefit of early tracheostomy and vice versa, and what kind of outcome measurements we should see in the future interventional studies. Dr. Jouvet disclosed that medical devices were leant by Hamilton Medical, Philips, and Dymedso. Dr. Emeriaud’s institution received funding from Fonds de recherche du Québec Santé and Maquet Critical Care (financial support for a research study). Dr. Kawaguchi is supported by Fonds de la recherche en santé du Québec.