Safety of the endotracheal tube for prolonged mechanical ventilation

• Published in: Journal of critical care Vol. 61; pp. 144 - 151
• Main Authors: Duke, Graeme J., Moran, John L., Santamaria, John D., Roodenburg, Owen
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.02.2021; Elsevier Limited
• Subjects: Adolescent; Adult; Artificial respiration; Blood & organ donations; Datasets; Epidemiology; Guillain-Barre syndrome; Hospitals; Humans; Intensive care; Intensive Care Units; Intubation, Intratracheal - adverse effects; Mortality; Ostomy; Patient admissions; Population; Respiration, Artificial; Retrospective Studies; Software packages; Statistical analysis; Tracheostomy; Tracheostomy - adverse effects; Tracheotomy; Trends; Variables; Ventilators; Tracheostomy; Epidemiology; Mortality; Artificial respiration
• ISSN: 0883-9441; 1557-8615
• DOI: 10.1016/j.jcrc.2020.10.018

The endotracheal tube (ETT) is the most common route for invasive mechanical ventilation (MV) yet controversy attends its long-term safety. Assess the safety of ETT compared with tracheostomy tube (TT) for MV support in the intensive care unit (ICU). Retrospective analysis of five year national dataset of 128,977 adults (age > 15-years) admitted for MV therapy with tracheostomy tube (TT; n = 4772) or without (ETT; n = 124,204), excluding those with neurological diagnoses or likely to require a surgical airway (n = 27,466), in 93 public health service ICUs across Australia, between July 2013–June 2018. Hospital survival (including liberation from MV) for ETT Group compared with TT Group using a probit regression model adjusted for confounding using fixed, endogenous and non-random treatment assignment covariates, and their interactions; analysed and plotted as marginal effects by duration of MV. Median duration of MV was 2 (IQR =1–4) days, predominantly via ETT (124,205; 96.3%), and 21,620 (16.7%) died. Temporal trend for ETT increased (OR = 1.06 per year, 95%CI =1.03–1.10) compared to TT, even for prolonged (>3 weeks) MV (38.1%). Higher risk-adjusted mortality was associated with longer duration of MV and after 9 days of MV with retention of ETT compared with TT - average (mortality) treatment effect 12.6% (95%CI =10.7–14.5). The latter was not significant after 30 days of MV. The safety of ETT compared with TT beyond short-term MV (≤9-days) is uncertain and requires prospective evaluation with additional data. •Duration of mechanical ventilation (MV) appears to be a confounder when estimating mortality risk.•Early cessation of MV or replacement of the ETT with a tracheostomy may reduce the mortality risk beyond short-term MV (<9-days).•Statistical methods that permit endogenous covariates and non-random treatment assignment address common problems in clinical research.