背景:重症卒中机械通气患者的气管造口术可以通过手术或透析方式进行。比较两种方法在中风患者中的前瞻性数据很少。神经重症监护试验2(SETPOINT2)中与中风相关的早期气管造口术和延长气管插管的随机研究将382例机械通气的中风患者分配到早期气管造口术与拔管或标准气管造口术。307例SETPOINT2患者中有41例进行了外科气管切开术(ST),大多数患者接受了扩张气管造口术(DT)。我们旨在比较这些患者的ST和DT。
方法:将所有SETPOINT2ST患者与接受DT(1:2)的卒中对照组患者进行比较,通过倾向得分匹配选择,包括因素中风类型,SETPOINT2随机化组,卒中早期气管切开评分,患者年龄,和病前功能状态。成功拔管是主要结果,次要结局参数包括6个月时的功能结局和气管造口术引起的不良事件.通过回归分析评估了拔管的潜在预测因素。
结果:两组接受ST的卒中患者(n=41)和接受DT的卒中患者(n=82)的基线特征相当。ST组的气管造口术明显晚于DT组(中位数9[四分位距{IQR}5-12]与插管后9[IQR4-11]天,p=0.025)。ST患者机械通气时间更长(中位数19[IQR17-24]vs.14[IQR11-19]天,p=0.008),并在重症监护室呆了更长时间(中位数23[IQR16-27]与17[IQR13-24]天,p=0.047),与DT患者相比。与DT组相比,ST组的医院内感染率明显高于DT组(14.6%vs.1.2%,p=0.002)。6个月时,拔管率(56%与61%),功能结果,和死亡率没有什么不同。然而,与DT组相比,ST组进行拔管的时间较晚(中位数81[IQR66-149]与58[IQR32-77]天,p=0.004)。较高的基线卒中早期气管造口术评分负预测拔管。
结论:在需要气管切开术的重度中风的通气患者中,手术和扩张方法在6个月时与相当的拔管率和功能结局相关.然而,ST与更长的拔管时间和更高的早期感染率相关,支持通气中风患者气管造口术的扩张方法。
BACKGROUND: Tracheostomy in mechanically ventilated patients with severe stroke can be performed surgically or dilationally. Prospective data comparing both methods in patients with stroke are scarce. The randomized Stroke-Related Early Tracheostomy vs Prolonged Orotracheal Intubation in Neurocritical Care Trial2 (SETPOINT2) assigned 382 mechanically ventilated patients with stroke to early tracheostomy versus extubation or standard tracheostomy. Surgical tracheostomy (ST) was performed in 41 of 307 SETPOINT2 patients, and the majority received dilational tracheostomy (DT). We aimed to compare ST and DT in these patients with patients.
METHODS: All SETPOINT2 patients with ST were compared with a control group of patients with stroke undergoing DT (1:2), selected by propensity score matching that included the factors stroke type, SETPOINT2 randomization group, Stroke Early Tracheostomy score, patient age, and premorbid functional status. Successful
decannulation was the primary outcome, and secondary outcome parameters included functional outcome at 6 months and adverse events attributable to tracheostomy. Potential predictors of
decannulation were evaluated by regression analysis.
RESULTS: Baseline characteristics were comparable in the two groups of patients with stroke undergoing ST (n = 41) and matched patients with stroke undergoing DT (n = 82). Tracheostomy was performed significantly later in the ST group than in the DT group (median 9 [interquartile range {IQR} 5-12] vs. 9 [IQR 4-11] days after intubation, p = 0.025). Patients with ST were mechanically ventilated longer (median 19 [IQR 17-24] vs.14 [IQR 11-19] days, p = 0.008) and stayed in the intensive care unit longer (median 23 [IQR 16-27] vs. 17 [IQR 13-24] days, p = 0.047), compared with patients with DT. The intrahospital infection rate was significantly higher in the ST group compared to the DT group (14.6% vs. 1.2%, p = 0.002). At 6 months,
decannulation rates (56% vs. 61%), functional outcomes, and mortality were not different. However,
decannulation was performed later in the ST group compared to the DT group (median 81 [IQR 66-149] vs. 58 [IQR 32-77] days, p = 0.004). Higher baseline Stroke Early Tracheostomy score negatively predicted
decannulation.
CONCLUSIONS: In ventilated patients with severe stroke in need of tracheostomy, surgical and dilational methods are associated with comparable decannulation rate and functional outcome at 6 months. However, ST was associated with longer time to decannulation and higher rates of early infections, supporting the dilational approach to tracheostomy in ventilated patients with stroke.