Tracheostomy protocol: Experience with development and potential utility*

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Abstract

Objectives:

To examine the feasibility and potential utility of a tracheostomy protocol based on a standardized approach to ventilator weaning.

Design:

Prospective, observational data collection.

Setting:

Academic medical center.

Patients:

Surgical intensive care unit patients requiring mechanical ventilatory support.

Interventions:

None.

Measurements and Main Results:

Tracheostomy practice in 200 patients was analyzed in relation to spontaneous breathing trial (SBT) weaning. Decision for, and performance of, tracheostomy occurred (median [interquartile range]) 5.0 (3.75–8.0) and 7.0 (5.0–10.0) days following initiation of mechanical ventilation, respectively. Duration of mechanical ventilation was greater in tracheostomy compared with nontracheostomy patients (15.0 [11.0–19.0] vs. 6.0 [4.0–8.0], p < .001). For patients requiring ventilatory support for ≥20 days, 100% of patients were maintained via tracheostomy. A protocol based on weaning performance, which included technical considerations, was developed. Individuals who failed preliminary weaning assessment or SBT for 3 successive days following 5 days (nonreintubated patients) or 3 days (reintubated patients) of ventilatory support met tracheostomy criteria. The protocol was implemented on a pilot basis in 125 individuals. Of the 55 (44.0%) patients undergoing tracheostomy, 25 (45.5%) did so consistent with criteria. Eighteen patients (32.7%) underwent tracheostomy before the time interval of data collection targeting weaning protocol performance, and 12 patients (21.8%) passed SBT on one or more occasions, were not extubated, and proceeded to tracheostomy.

Conclusions:

A standardized approach in which the decision for tracheostomy is based on objective measures of weaning performance may be a means of using this procedure more consistently and effectively.

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