[Weaning from mechanical ventilation. A survey of the situation in pneumologic respiratory facilities in Germany]. / Entwöhnung von der Beatmungstherapie. Eine Erhebung zur Situation pneumologischer Beatmungszentren in Deutschland.

BACKGROUND AND OBJECTIVE: The prevalence of difficult or prolonged weaning from mechanical ventilation is increasing because of a growing number of elderly patients with multiple diseases and pulmonary problems requiring mechanical ventilation. Intensive care units (ICU) are inclined to refer to specialized unit those patients who are difficult to wean. A nationwide survey of German facilities was conducted and this article reports the current state of weaning centers staffed by chest physicians. PATIENTS AND METHODS: 38 centers participated in the survey, which was divided into 10 items, covering characteristics of the hospital, weaning strategies, patients and outcomes during 2006. The survey included 2718 patients in whom weaning was difficult or prolonged. Almost three quarters of patients were transferred to one of the weaning centers from the ICU of another hospital. RESULTS: The weaning success rate was 66.4%. In 31,9 % of patients home mechanical ventilation was started after they had been weaned. The overall hospital mortality rate was 20.8%. There were major differences between individual centres concerning the number of patients, organization of the weaning unit and weaning strategies. CONCLUSIONS: Weaning was successful in two thirds of patients who had been on prolonged mechanical ventilation and had then been transferred to weaning facilities staffed by chest physicians. These centres effectively improved the quality of care of patients on prolonged mechanical ventilation by avoiding long-term invasive ventilation and sparing cost-intensive ICU resources. The problems that still exist may be overcome by a network of weaning facilities.

[Percutaneous dilatational tracheostomy]. / Bronchoskopisch gesteuerte Punktionstracheotomie.

BACKGROUND: Tracheostomy provides a method for long-term ventilation in intensive care, which reduces the risk of necrotizing lesions of the pharyngeal and laryngeal mucosa. Since the introduction of the percutaneous dilatational tracheostomy, experienced physicians are able to perform bedside tracheostomies. This presentation reviews the complication rate and long-term outcome of percutaneous dilatational tracheostomy. PATIENTS AND METHOD: The method was applied in 57 patients following previous orotracheal intubation averaging 7.8 days (3 to 15 days). Underlying diseases were sepsis/SIRS in 29, stroke in 7, cerebral hypoxemia after cardiopulmonary resuscitation in 10, trauma in 7, prolonged weaning in 2, primary neurological diseases in 2. RESULTS: The following complications occurred during the procedure: 1 major and 7 minor bleedings. 2 subcutaneous emphysemas, 1 mediastinal emphysema following tracheal injury. No complication required surgical intervention. In the follow-up 17 patients (30%) died from their underlying disease, none from complications of the tracheostomy. After removed of the tracheal tube, in 39 patients the stoma closed spontaneously within 7 to 14 days. In 8 patients the tracheostoma persisted for more than 3 months, but no clinically relevant tracheal stenosis was found. CONCLUSION: Percutaneous dilatational tracheostomy is a safe procedure easy to perform in intensive care units. Bronchoscopic control is necessary to avoid complications.

[Bronchoscopically controlled percutaneous puncture tracheotomy]. / Bronchoskopisch gesteuerte perkutane Punktionstracheotomie.

With extending duration of translaryngeal intubation the rate of lesions in the oral cavity, pharynx and trachea caused by the orotracheal tube increase. To prevent these complications ventilated patients receive early tracheostomy. PDT is an alternative procedure to the conventional, surgically performed tracheostomy. We performed 60 dilatational tracheostomies using the Ciaglia percutaneous tracheostomy set (W. Cook-Critical Care, Bjaeverskov). Complication rate was 17% due to minor bleeding (n = 7), subcutaneous emphysema (n = 2) and fracture of one tracheal cartilage ring (n = 1). This rate is equivalent to that of surgical procedure. Advantage of PDT is that it can be performed by intensive care doctors without a specific surgical background. Further follow up after removal of the tracheal cannula was uneventful. Tracheal stenosis requiring intervention are rare. The remaining scar after PDT is significantly smaller than after conventional tracheostomy.