The Epidemiology of Adult Tracheostomy in the United States 2002-2017: A Serial Cross-Sectional Study.

Describe the longitudinal national epidemiology of tracheostomies performed in acute care hospitals and describe the annual rate of tracheostomy performed for patients with respiratory failure with invasive mechanical ventilation. DESIGN: Serial cross-sectional study. SETTING: The 2002-2014 and 2016-2017 Healthcare Utilization Project's National Inpatient Sample datasets. PATIENTS: Discharges greater than or equal to 18 years old, excluding those with head and neck cancer or transferred from another hospital. We used diagnostic and procedure codes from the International Classification of Diseases, 9th and 10th revisions to define cases of respiratory failure, invasive mechanical ventilation, and tracheostomy. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were an estimated 80,612 tracheostomies performed in 2002, a peak of 89,545 tracheostomies in 2008, and a nadir of 58,840 tracheostomies in 2017. The annual occurrence rate was 37.5 (95% CI, 34.7-40.4) tracheostomies per 100,000 U.S. adults in 2002, with a peak of 39.7 (95% CI, 36.5-42.9) in 2003, and with a nadir of 28.4 (95% CI, 27.2-29.6) in 2017. Specifically, among the subgroup of hospital discharges with respiratory failure with invasive mechanical ventilation, an annual average of 9.6% received tracheostomy in the hospital. This changed over the study period from 10.4% in 2002, with a peak of 10.9% in 2004, and with a nadir of 7.4% in 2017. Among respiratory failure with invasive mechanical ventilation discharges with tracheostomy, the annual proportion of patients 50-59 and 60-69 years old increased, whereas patients from 70 to 79 and greater than or equal to 80 years old decreased. The mean hospital length of stay decreased, and in-hospital mortality decreased, whereas discharge to intermediate care facilities increased. CONCLUSIONS: Over the study period, there were decreases in the annual total case volume and adult occurrence rate of tracheostomy as well as decreases in the rate of tracheostomy among the subgroup with respiratory failure with invasive mechanical ventilation. There is some evidence of changing patterns of patient selection for in-hospital tracheostomy among those with respiratory failure with invasive mechanical ventilation with decreasing proportions of patients with advanced age.

The Epidemiology of Respiratory Failure in the United States 2002-2017: A Serial Cross-Sectional Study.

OBJECTIVES: Respiratory failure with mechanical ventilation is a limited labor-intensive resource that is associated with high mortality. Understanding the longitudinal national epidemiology is essential for the organization of healthcare resources. DESIGN: Serial cross-sectional study. SETTING: The 2002-2017 Healthcare Utilization Project's National Inpatient Sample datasets. INTERVENTIONS: None. MEASUREMENTS: We use six diagnosis codes and five procedural codes from International Classification of Diseases, 9th Revision, Clinical Modification, and 19 diagnosis codes and 15 procedures codes from International Classification of Diseases, 10th Revision, Clinical Modification to examine national epidemiology of different case definitions for respiratory failure. RESULTS: In the United States in 2017, there were an estimated 1,146,195 discharges with a diagnosis of respiratory failure and procedural code for mechanical ventilation, with an average length of stay of 10.5 days and hospital charge of $158,443. Over the study period, there was an 83% increase in incidence from 249 to 455 cases per 100,000 adults with a 48% decrease in hospital mortality from 34% to 23%. Exploring a case definition that captures only diagnosis codes for respiratory failure, there was a 197% increase in annual incidence, from 429 to 1,275 cases per 100,000 adults with a 57% decrease in hospital mortality from 28% to 12%. For invasive mechanical ventilation without a requisite diagnosis code, there was no change in incidence over the study period, with the 2017 incidence at 359 cases per 100,000 adults, but a 19% decrease in hospital mortality from 37% to 30%. For the noninvasive mechanical ventilation procedural codes, there was a 437% increase in incidence from 41 to 220 cases per 100,000 adults, with a 38% decrease in hospital mortality from 16% to 10%. CONCLUSIONS: Examining different case definitions for respiratory failure, there was a large increase in the population incidence and decrease in the hospital mortality for respiratory failure diagnosis codes with more modest changes procedural codes for invasive mechanical ventilation. There was a large increase in incidence of noninvasive mechanical ventilation.

Regional differences in the treatment of refractory vasodilatory shock using Angiotensin II in High Output Shock (ATHOS-3) data.

INTRODUCTION: Despite international guidelines, regional differences in treatment of vasodilatory shock remain. We characterized these differences using data from Angiotensin II in High Output Shock (ATHOS-3) trial. METHODS: The 321 patients treated in the ATHOS-3 trial were included. Baseline and hour-48 data were analyzed for differences in demographics, clinical characteristics, and treatment patterns, and grouped into four geographical areas: United States, Canada, Europe, and Australasia. Differences were analyzed by Kruskal-Wallis tests for continuous, and chi-square tests for categorical data. Temporal analysis compared changes in the treatment of shock during the treatment period. RESULTS: Differences in baseline characteristics across geographic areas were noted in BMI, albumin, CVP, MELD score, APACHE II score, and total SOFA score. Baseline norepinephrine and norepinephrine equivalent doses (NED) were higher (p < .0001 and p = .0494, respectively), and vasopressin use was lower (p < .0001) in Europe. Baseline steroids were utilized more in the US and Canada (p = .0011). CONCLUSIONS: Management of vasodilatory shock differs globally with respect to utilization of steroids and vasopressors. This practice heterogeneity may influence shock trials interpretation and patient outcomes, though more definitive evidence would require larger prospective intervention data.

Diagnosis of Capnocytophaga canimorsus Sepsis by Whole-Genome Next-Generation Sequencing.

We report the case of a 60-year-old man with septic shock due to Capnocytophaga canimorsus that was diagnosed in 24 hours by a novel whole-genome next-generation sequencing assay. This technology shows great promise in identifying fastidious pathogens, and, if validated, it has profound implications for infectious disease diagnosis.