Percutaneous Dilational Tracheostomy for Coronavirus Disease 2019 Patients Requiring Mechanical Ventilation*
Percutaneous Dilational Tracheostomy for Coronavirus Disease 2019 Patients Requiring Mechanical Ventilation*
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DOI：
10.1097/ccm.0000000000004969
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发表时间：
2021-07-01
影响因子：
8.8
通讯作者：
Cerfolio, Robert
中科院分区：
文献类型：
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作者：
Angel, Luis F.;Amoroso, Nancy E.;Cerfolio, Robert
目的：评估经皮扩张气管切开术对需要机械通气的冠状病毒病2019患者的影响以及对医疗保健提供者的风险。设计：前瞻性队列研究，患者入组时间为2020年3月11日-4月29日。末次随访日期为2020年7月30日。我们使用倾向评分匹配方法来比较结果。在数据收集和分析之前制定研究结果。单位：纽约市两所大都会医院的重症监护室。患者：541例确诊为2019年严重冠状病毒病呼吸衰竭需要机械通气的患者。干预措施：床边经皮扩张气管切开术，改良可视化和通气。测量和主要结果：停止机械通气所需的时间、住院总时间和患者总生存期。在541例患者中，394例患者符合气管造口术的条件。116例为早期经皮扩张气管切开术，机械通气开始后中位时间为9天（四分位距，7-12 d），而89例为晚期经皮扩张气管切开术，机械通气开始后中位时间为19天（四分位距，16-24 d）。与未行气管切开的患者相比，早期经皮扩张气管切开的患者有更高的中止机械通气的可能性（绝对差异，30%; p < 0.001;成功停药的风险比，2.8; 95% CI，1.34-5.84; p = 0.006）和较低的死亡率（绝对差异，34%，p < 0.001;死亡风险比，0.11; 95%CI，0.06-0.22; p < 0.001）。与晚期经皮扩张气管切开术患者相比，早期经皮扩张气管切开术患者的机械通气中止率较高（绝对差异7%; p < 0.35;成功停药的风险比，1.53; 95% CI，1.01-2.3; P = 0.04），存活者的机械通气中位持续时间较短（绝对差异，-15天; P < 0.001）。进行所有经皮扩张气管造口术手术的医疗服务提供者均未出现严重急性呼吸综合征冠状病毒2型感染的临床症状或任何阳性实验室检测。结论：在2019年接受机械通气的冠状病毒病患者中，早期改良的经皮扩张气管切开术对患者和医疗保健提供者来说是安全的，并且与改善的临床结果相关。
OBJECTIVES: To assess the impact of percutaneous dilational tracheostomy in coronavirus disease 2019 patients requiring mechanical ventilation and the risk for healthcare providers. DESIGN: Prospective cohort study; patients were enrolled between March 11, and April 29, 2020. The date of final follow-up was July 30, 2020. We used a propensity score matching approach to compare outcomes. Study outcomes were formulated before data collection and analysis. SETTING: Critical care units at two large metropolitan hospitals in New York City. PATIENTS: Five-hundred forty-one patients with confirmed severe coronavirus disease 2019 respiratory failure requiring mechanical ventilation. INTERVENTIONS: Bedside percutaneous dilational tracheostomy with modified visualization and ventilation. MEASUREMENTS AND MAIN RESULTS: Required time for discontinuation off mechanical ventilation, total length of hospitalization, and overall patient survival. Of the 541 patients, 394 patients were eligible for a tracheostomy. One-hundred sixteen were early percutaneous dilational tracheostomies with median time of 9 days after initiation of mechanical ventilation (interquartile range, 7-12 d), whereas 89 were late percutaneous dilational tracheostomies with a median time of 19 days after initiation of mechanical ventilation (interquartile range, 16-24 d). Compared with patients with no tracheostomy, patients with an early percutaneous dilational tracheostomy had a higher probability of discontinuation from mechanical ventilation (absolute difference, 30%; p < 0.001; hazard ratio for successful discontinuation, 2.8; 95% CI, 1.34-5.84; p = 0.006) and a lower mortality (absolute difference, 34%, p < 0.001; hazard ratio for death, 0.11; 95% CI, 0.06-0.22; p < 0.001). Compared with patients with late percutaneous dilational tracheostomy, patients with early percutaneous dilational tracheostomy had higher discontinuation rates from mechanical ventilation (absolute difference 7%; p < 0.35; hazard ratio for successful discontinuation, 1.53; 95% CI, 1.01-2.3; p = 0.04) and had a shorter median duration of mechanical ventilation in survivors (absolute difference, -15 d; p < 0.001). None of the healthcare providers who performed all the percutaneous dilational tracheostomies procedures had clinical symptoms or any positive laboratory test for severe acute respiratory syndrome coronavirus 2 infection. CONCLUSIONS: In coronavirus disease 2019 patients on mechanical ventilation, an early modified percutaneous dilational tracheostomy was safe for patients and healthcare providers and associated with improved clinical outcomes.