VARIATION IN REPORTED PRACTICE OF TRACHEOSTOMY IN ICUs

There is a considerable amount of heterogeneity regarding the reported routine practice of tracheostomy in French ICUs, suggested a report in the April Chest. Results of the study were based on data obtained from a questionnaire completed by 152 of 708 ICUs; the questionnaire focused on the frequency, timing, indications, and techniques of tracheostomy.

Results indicated that overall, 35,322 patients had received mechanical ventilation; a median of 7.2% of patients had undergone a tracheostomy. According to François Blot, MD, and Christian Melot, MD, PhD, MscBiostat, “the prevalence of tracheostomy seems to be higher in France compared with that in other European countries.”

Frequently reported indications for tracheostomy included prolonged mechanical ventilation and failure of attempted extubation or reintubation. “In this setting, tracheostomy is most often considered after a mean time of three weeks (later than recommended by several consensus conferences),” said the researchers.

Physicians who responded to the survey reported several advantages and disadvantages of tracheostomy. Reported advantages included facilitation of weaning, better patient comfort, earlier oral nutrition and speech, and easier care of airways. “The main disadvantages listed were tracheal complications, the aggressiveness of the procedure, and the risk of infection,” related Drs. Blot and Melot. However, these disadvantages cannot be specifically attributed to tracheostomy, they said.

According to the researchers, 15 physicians believed that performing a tracheostomy may facilitate ICU discharge, whereas 11 others believed that tracheostomy was a potential barrier to ICU discharge. Contraindications for tracheostomy varied as well, they reported.

Data from the questionnaire also suggested that surgical techniques remain preferable over percutaneous techniques. “Unfortunately,” said the researchers, “ICU physicians were not queried about the reasons for their reluctance to use percutaneous techniques.” However, Drs. Blot and Melot suspected that “organizational aspects and lack of adequate training in the use of these techniques” could, in part, explain this finding.

As suggested by three fourths of the physicians answering the questionnaire, said Drs. Blot and Melot, “a randomized study comparing prolonged translaryngeal intubation and early tracheostomy in patients who are expected to receive prolonged mechanical ventilation” is necessary.

In an accompanying editorial, Kenneth D. Chinsky, MD, FCCP, stated that the study by Drs. Blot and Melot “is unable to ask why these differences in tracheostomy rates and techniques exist.”

According to Dr. Chinsky, while the decision to perform a tracheostomy is a complex one, it can be broken down into two questions: What is the benefit for the individual patient? and What is the estimated duration of mechanical ventilation? Nevertheless, he pointed out, objective proof of the potential advantages of tracheostomy remains difficult to obtain.

Dr. Chinsky highlighted the importance of using available medical literature to make decisions about the timing of tracheostomy and of searching for evidence-based medicine to document objective proof of the purported advantages and disadvantages.

Blot F, Melot C. Indications, timing, and techniques of tracheostomy in 152 French ICUs. Chest. 2005;127:1347-1352.
Chinsky KD. Varying approaches to tracheostomy: “Vive le différence.” Chest. 2005;127:1083-1085.

EXERCISE-INDUCED DYSPNEA IN CHILDREN AND ADOLESCENTS NOT ALWAYS ASTHMA

While a diagnosis of asthma is often correct, physicians at the University of Iowa caution that other unrelated conditions can also cause shortness of breath during exercise. According to Miles Weinberger, MD, “If a patient is not responding to the simplest measure, such as use of a bronchodilator inhaler, and there are no other asthmatic symptoms, the exercise-induced … dyspnea requires further detailed evaluation.”

As presented in the March Annals of Allergy, Asthma, and Immunology, researchers reviewed the results of exercise tests performed in 142 patients with exercise-induced dyspnea, 98 of whom had been previously diagnosed with asthma.

During exercise testing, symptoms of exercise-induced dyspnea were reproduced in 117 patients. According to Dr. Weinberger and his colleagues, exercise-induced asthma was identified as the main cause of exercise-induced dyspnea in only 11 of these patients. Among the remaining 106 patients, other diagnoses that were associated with exercise-induced dyspnea included restrictive abnormalities (n = 15), vocal cord dysfunction (n = 13), laryngomalacia (n = 2), primary hyperventilation (n = 1), and supraventricular tachycardia (n = 1). Seventy-four of the 106 patients demonstrated normal physiologic exercise limitation, despite varying levels of cardiovascular conditioning.

“Being kids, they thought they should be able to do anything they want without limits,” Dr. Weinberger said of his young study subjects. “We were able to reassure the patients and parents that there was no abnormality and advise the type of cardiovascular conditioning or athletic training that would enable them to be physically active without the natural anxiety that occurs with dyspnea.”

Dr. Weinberger added, “The biggest benefits to these patients were getting them off medication that was not doing them any good and eliminating the anxiety that is often associated with shortness of breath.”

Abu-Hasan M, Tannous B, Weinberger M. Exercise-induced dyspnea in children and adolescents: if not asthma then what? Ann Allergy Asthma Immunol. 2005;94:366-371.

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