NTSP Specials (Season 2): Dr Gonzalo Hernández discusses lessons in trachy care from Spain

Gonzalo Hernández is an intensive care doctor working in Toledo, Spain. Gonzalo published some high profile work in the pandemic about how to improve care and he spoke about "Lessons from Spain" at the 6th International Tracheostomy Symposium, held in Manchester UK, in October 2021. This presentation is an extract from that meeting.

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Transcript

SPEAKER_00 0:10

We called it part of the October 2021 International Tracheostomy Symposium. I'd like to introduce Dr. Gonzalo Hernandez Martinez, who's a technical head doctor working at the University Hospital of Toledo in Spain. Gonzalo published some high-profile publications during the COVID pandemic. We've asked him to talk about the lessons that they've learned about managing the pandemic and managing tracheostomies from Spain. Over to you, Gonzalo.

SPEAKER_01 0:38

Good morning or afternoon, wherever you are. It's my pleasure to be here and thank you so much for the invitation to this important symposium. And I will present what we have learned from Spain, not only during the COVID pandemic, but also before. These are my disclosures with uh uh high flow device manufacturer because some of the research we uh we have focused on on the use of this uh therapy in tracheostomized patients. Well, I will talk about two important points. The first one is timing of tracheostomy, and the second one is post-tracheostomy care. I just I will talk about just a few what I consider important uh papers on that have improved the trachea the management of these patients. According to timing of tracheostomy, it's a traditional uh controversy with confronting results in randomized trials and meta-analysis. I think it's been impossible to definitively conclude on this topic because mainly two points. The first one is that we uh have not uh obtained a consensus to define what is what means early tracheostomy. The definitions range from three days to 15. And the other important point is that we cannot predict problem mechanical ventilation, that finally the patients, the target for these uh randomized trials and studies. So, just as an example, this is an important randomized trial before the COVID. And in this case, uh patients uh randomized to early tracheostomy, the finite and during the first week after intubation, close to one-third of the patients did not receive the tracheostomy because of a clinical improvement or clinical deterioration. And similar in the case of late tracheostomy group, the finite uh after 14 days uh since uh trachal intubation. In this case, close to half of the patients did not receive the tracheostomy. So it's really difficult to obtain any definitive conclusion with these important limitations. What have happened during the COVID pandemic? Well, um obviously the the overwhelming conditions have modified uh decisions at the bedside, and many clinicians in in all around the world have increased the number of tracheostomies performed in the in their patients. These that are from 15 high volume intensive care units in Spain. We classify definitions of early according to previous uh definitions before the seven days after incubation, days eight to 10, from 11 to 14 days after, 14 to 21 days, and an extra group that presented here, patients' tracheostomyze after 21 days. And as you can see, there is a sudden increase in the in the patient's tracheostomy at any timing. Probably uh unconsciously, clinicians all around the world uh perceive that the more tracheostomies could liberate uh ICU beds or even ventilators, and that's the reason why maybe uh we observe so many tracheostomy spaces. We have this results in this paper. This is uh the this figure, so it's the a visual difference between the five uh timings according to the probability of being liberated from mechanical ventilation. This is seven during the seven, eight to ten, eleven to fourteen, fourteenth twenty one, and is more than twenty one days. And uh, as you can see, one conclusion could be the earliest the tracheostomy, the greater the reduction in the time on mechanical ventilation. This is the entire population. So, um, in my opinion, it was impossible to perform a randomized trial during these uh overwhelming conditions, at least on this topic, during the first wave. And well, we decided to perform a propensity analysis. Uh well, obviously, um in every clinician, consciously or unconsciously, usually uh decide which patient could probably benefit more with an early tracheostomy, and we observed in the baseline uh conditions of the patients, these are the seven days, eight, 10, 11, 14, and so on. We observe more uh comorbidities, uh more prevalent comorbidities in the late groups, and the same full severity at the ICU admission. So just trying to reduce this selection bias, we perform the propensity. And well, we perform that uh uh according to the what we, in our opinion, are the three most important timings to define early tracheostomy. The first one, patients tracheostomized during the first week. In this case, we observe a significant reduction in days on ventilator, days in the ICU and days in the hospital. And we perform um a ventilator failure-free days outcome combining mortality and liberation from from the ICU resource, uh ventilator of both, because we uh our most important aim performing this study was to try to help to um optimize the management and the capacity of ICU during so and overwhelming conditions. In this case, we observe a reduction in of six days. Well, that means our ventilator was liberated for six in additional days in patients, just for the simple decision to perform the tracheostomy before seven days after ortroche intubation, five uh days of an intensive care unit bed operated in this. We performed uh this uh analysis not only for the most early earliest tracheostomy, but also when performed between the eight and ten days after intubation, and in this case, we also observed a significant reduction in the use of ventilator and uh ICU and hospital bed. Hospital bed not uh with without uh significant results at 28 uh days, but when analyzed at 60 days, there was a significant improvement in the capability of the results. The third analysis was performed in the later early uh definition, and also the same. The benefit is not so high, and we just just on uh as an um exploratory analysis, we tried you we performed a propensity score uh trying to analyze differences between the most earlier uh the earliest uh group tracheostomized before the seven days compared to this uh later group from 11 to 14, and we observed also significant improvement. So the the main message could be that uh, like this one, the earliest the tracheostomy, the greater the improvement in ICU and hospital capacity in terms of ventilators, ICU, and hospital beds. And another point that uh it's not presented in this paper, but we have now preparing uh a new one is that well, we have focused on this part, but there is no consensus, and there are many people most of you listening right now, this lecture think that this is not evident, uh there is no evidence enough to change the the previous uh uh CNC to perform the timing of tracheostomy. But another point is that there are many differences, an important difference between what we used to do before the pandemic, this is patient tracheostomyes after 21, and what we now consider late tracheostomies, that's patients tracheostomy after 14 days. We are now performing another an extra propensity analysis to compare these two groups, and obviously, what we and there are significant differences I can type in advance. So another important point would be the earliest the tracheostomy, the greater the the benefit, and the later the tracheostomy, the greater the risks for uh complications in in related to COVID and prolonged uh mechanical ventilation. So we could uh recommend not to perform so late tracheostomies that is after 21 days from the time. It's been published during the pandemic. This is in the earlier uh 2021, a few months ago. This is a meta-analysis including randomized trials performed before the COVID, because there is no randomized trial during the COVID. And well, in this case, uh this was published in YAMA, and uh this is uh an important result because uh what we what attors uh present here is an in significant uh benefit with early tracheostomy in terms of a reduced incidence of tracheostomy or ventilator-associated pneumonia. In my opinion, the one of the points, this is an analysis uh obtain these significant results is that focus on very early tracheostomy that is performed during the first week after overtrachy intubation. In my opinion, if you want to prevent an infection episode that happens uh during the first week, obviously the tracheostomy needs to be performed before this infection can appear. I think this uh clearly increased evidence to try to change our mind and start performing uh tracheostomies before pandemic before the COVID pandemic. Now I want to talk about some um uh important papers that have uh improved uh post-tracheostomy care. In this case, this uh this study was performed in the United States. And well, what one important message from this study is that if you want to accelerate wheeling uh from mechanical ventilation in tracheostomized patients, you need to disconnect from ventilator. And obviously, this generates uh aidosolts, and there is a potential risk for healthcare workers to get infected from COVID or any other virus that could uh be the reason for future pandemics. Another important uh point of this study is that while in the US, most of these patients are managed in in step-down units or long-term care centers. And what reflects in this results is that many centers or many, I don't know, many people, maybe that could be the correct word, do not pay special attention on these basis because they uh it's easier to transfer to uh a dedicated tender. But just after the patients were transferred to this center, many of them were directly winning. So there is a lot of room to improve and accelerate winning in these cases. And the other one is that the third important message of this study is that patients with the greater functional respiratory reserve are those more prone to benefit with disconnection from mechanical ventilation. This is uh a second important paper, in my opinion, obviously. This is uh published in the same year that the previous study in 2013. We here randomized uh not disconnecting because we assume that uh disconnection from mechanical ventilation was uh the main uh main point of the management of these patients, but we also increased the effectively with the monitor, the flooding the calf using fenestrated cannulas and uh a smile mile uh downsided trains uh to a smaller cannula. Another important point here is that uh Rway uh potency problems and uh swallowing swallowing uh problems should be detected earlier, that is, at the time we start uh winning attempts and start disconnection from mechanical ventilation. And this is the third and last study published last year. This is the last part of the of the liberation from mechanical ventilation uh management. This is patients win it from mechanical ventilation and time to decannulation, in this case using high flow and trying to avoid the traditional uh confirmatory test to decide the cannulation that is a capping trial lasting in this case we compare to 24 hours, but I know some centers use more prolonged uh capping trials. Evidence supports early timing of tracheostomy. Improving winning tracheostomy patients generate idosol particles, but well, it's not any warning about uh uh safety concern for healthcare workers managing these patients. So I'm actually at the beginning of this connection from the case and overload the system that is happy long happy trials. Unconditionally uh inspire medical data and the clinical consumer could benefit the patient. So thank you so much.

SPEAKER_00 15:55

Thanks to Consello for that talk. Uh at least reviews and opinions we discussed on the podcast on our own, and don't necessarily represent those of our value complaints. You can follow us on our social media channels and find out more podcasts and episodes, find out podcast web pages, YouTube, or whatever you podcast calls.