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Jefferson Surgical Solutions

Pankaj H. Patel, MD, FACS

Tracheostomy – placement of a tube through an incision in the trachea, or windpipe – is routinely performed on a variety of patients in Medical Intensive Care Units (MICUs) and Surgical Intensive Care Units (SICUs). “Trach” patients may include those who will be spending a long time on a ventilator, as well as individuals who are neurologically impaired or need relief from a breathing obstruction.

Pankaj H. Patel, MD, FACS, Jefferson trauma surgeon and Assistant Professor, Sidney Kimmel Medical College at Thomas Jefferson University, recently co-authored an article in the Herald Scholarly Open Access (HSOA) Journal of Emergency Medicine, Trauma and Surgical Care. The article shared the findings of a first-of-its-kind study exploring the long-term outcomes of tracheostomy in critically ill patients. Dr. Patel conducted the study in collaboration with Bharat K. Awsare, MD, and Michael Baram, MD, and Fellows Ricardo Restrepo, MD, and Daron Kahn, MD, in the Department of Medicine, Division of Pulmonary and Critical Care, at Jefferson.

As Dr. Patel explains, prior studies have described the benefits of tracheostomy in terms of short-term results, such as Intensive Care Unit (ICU) length of stay, hospital-acquired pneumonia and duration of mechanical ventilation. However, most of those studies simply examined 30-day mortality. This new study was designed to determine longer-term survival of those who received a tracheostomy after a critical illness.

“We wanted to understand how many patients survive at least a year after receiving a tracheostomy following respiratory failure,” he says.

The team performed a retrospective analysis of 430 Jefferson patients who had undergone tracheostomies. With strict adherence to HIPAA privacy rules, they gathered one-year death data by cross-matching Social Security numbers with the death master file of the National Technical Information Service. That enabled the study team to identify deaths no matter where they occurred geographically.

They found that only about threequarters (74 percent) of patients survived to be discharged from the hospital, with none of the deaths attributable to the procedure itself. At one year, the overall survival rate was 53 percent – with variations among patients from the MICU (46 percent), the Neurologic Intensive Care Unit (NICU; 59 percent) and the SICU (63 percent).

Dr. Patel says the study’s findings suggest that tracheostomy is a marker for patients who may not survive a year – and that the need for the procedure should perhaps prompt patients and their families to think carefully about long-term goals.

“An example could be an elderly patient with a high cervical spinal-cord injury who is at high risk of mortality from infection,” he notes. “Does that person want to be paralyzed and permanently dependent on a ventilator? Similarly, patients in the MICU who have multiple organ dysfunction syndrome may want to consider carefully whether or not to undergo a tracheostomy. ”

“These findings suggest they may be better off opting for palliative measures over more aggressive procedures,” he says.

Further investigation may focus on identifying a subset of patients at highest risk of early mortality. The results would arm physicians with more hard data to share with patients and their family members to enable well-informed decisions about treatment plans.

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