贵院ICU建立人工气道的患者，一般多长时间气切？

蓝鱼o_0

VAP的诊断前提的建立有创通气的患者。即建立人工气道。涉及两种情况，气管插管和气管切开。而无创呼吸机使用不在监测范围。
目前对于气切时间的界定感控，重症医学界，甚至循证医学的文章都有不小的争论，例如重症医学组委邱海波主任编撰的《ICU主治医生手册》中，推荐对于长期使用气管插管的患者（>10 DAY）推荐学者推荐早期气切，3-7天。理由是认为可以缩短患者的机械通气时间和ICU入住时间。
当然这里面也有一些案例，比如需要气切的患者，但是家属不同意。

当然，也有的作者做了循证医学的研究认为气切并不能达到降低VAP发生，甚至患者死亡率的效果。那么能否在此说下，贵院ICU，一般患者气切时间是多少天？选择或者直接更贴回复。感谢您的参与！

蓝鱼o_0

正方的理由：气切可以降低VAP，降低ICU入住时间：

1、Eur Respir J. 2007 Aug;30(2):314-20. Epub 2006 Jul 26.

Relationship between tracheotomy and ventilator-associated pneumonia: a case control study.

Abstract

The aim of the present study was to determine the relationship between tracheotomy and ventilator-associated pneumonia (VAP). The study used a retrospective case-control study design based on prospective data. All nontrauma immunocompetent patients, intubated and ventilated for >7 days, were eligible for inclusion in the study. A diagnosis of VAP was based on clinical, radiographical and microbiological criteria. Four matching criteria were used, including duration of mechanical ventilation (MV). The indication and timing of tracheotomy were at the discretion of attending physicians. Univariate and multivariate analyses were performed to determine risk factors for VAP in cases (patients with tracheotomy) and controls (patients without tracheotomy). In total, 1,402 patients were eligible for inclusion. Surgical tracheotomy was performed in 226 (16%) patients and matching was successful for 177 (78%). The rate of VAP (22 versus 14 VAP episodes.1,000 MV-days(-1)) was significantly higher in controls than in cases. The rate of VAP after tracheotomy in cases, or after the corresponding day of MV in controls, was also significantly higher in control than in case patients (9.2 versus 4.8 VAP episodes.1,000 MV-days(-1)). In multivariate analysis, neurological failure (odds ratio (95% confidence interval) 2.7 (1.3-5)), antibiotic treatment (2.1 (1.1-3.2)) and tracheotomy (0.18 (0.1-0.3)) were associated with VAP. In summary, the present study demonstrates thattracheotomy is independently associated with decreased risk for ventilator-associated pneumonia.

2、Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation

Cite this article as: BMJ, doi:10.1136/bmj.38467.485671.E0 (published 23 May 2005)

Objective To compare outcomes in critically ill patients undergoing artificial ventilation who received a tracheostomy early or late in their treatment. Data sources The Cochrane Central Register of Clinical Trials, Medline, Embase, CINAHL, the National Research Register, the NHS Trusts Clinical Trials Register, the Medical Research Council UK database, the NHS Research and Development Health Technology Assessment Programme, the British Heart Foundation database, citation review of relevant primary and review articles, and expert informants.Study selection Randomised and quasi-randomised controlled studies that compared early tracheostomy with either late tracheostomy or prolonged endotracheal intubation. From 15 950 articles screened, 12 were identified as “randomised or quasi-randomised” controlled trials, and five were included for data extraction. Data extraction Five studies with 406 participants were analysed. Descriptive and outcome data were extracted. The main outcome measure was mortality in hospital. The incidence of hospital acquired pneumonia, length of stay in a critical care unit, and duration of artificial ventilation were also recorded. Random effects meta-analyses were performed. Results Early tracheostomy did not significantly alter mortality (relative risk 0.79, 95% confidence interval 0.45 to 1.39). The risk of pneumonia was also unaltered by the timing of tracheostomy (0.90, 0.66 to 1.21). Early tracheostomy significantly reduced duration of artificial ventilation weighted mean difference − 8.5 days, 95% confidence interval − 15.3 to − 1.7) and length of stay in intensive care ( − 15.3 days, − 24.6 to − 6.1). Conclusions In critically ill adult patients who require prolonged mechanical ventilation, performing a tracheostomy at an earlier stage than is currently practised may shorten the duration of artificial ventilation and length of stay in intensive care.

蓝鱼o_0

反方的理由：目前证据不足。

Chest. 2011 Dec;140(6):1456-65. doi: 10.1378/chest.11-2024. Epub 2011 Sep 22.

The timing of tracheotomy in critically ill patients undergoing mechanical ventilation: a systematic review and meta-analysis of randomized controlled trials.

[size=0.92em]Wang F1, Wu Y, Bo L, Lou J, Zhu J, Chen F, Li J, Deng X.

Author information

AbstractBACKGROUND:

The objective of this study was to systematically review and quantitatively synthesize all randomized controlled trials (RCTs), comparing important outcomes in ventilated critically ill patients who received an early or late tracheotomy.

METHODS:

A systematic literature search of PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, the Cochrane Central Register of Controlled Trials, the National Research Register, the National Health Service Trusts Clinical Trials Register, and the Medical Research Council UK database was conducted using specific search terms. Eligible studies were RCTs that compared early tracheotomy (ET) with either late tracheotomy or prolonged endotracheal intubation in critically ill adult patients.

RESULTS:

Seven trials with 1,044 patients were analyzed. ET did not significantly reduce short-term mortality (relative risk [RR], 0.86; 95% CI, 0.65-1.13), long-term mortality (RR, 0.84; 95% CI, 0.68-1.04), or incidence of ventilator-associated pneumonia (RR, 0.94; 95% CI, 0.77-1.15) in critically ill patients. The timing of the tracheotomy was not associated with a markedly reduced duration of mechanical ventilation (MV) (weighted mean difference [WMD], -3.90 days; 95% CI, -9.71-1.91) or sedation (WMD, -7.09 days; 95% CI, -14.64-0.45), shorter stay in ICU (WMD, -6.93 days; 95% CI, -16.50-2.63) or hospital (WMD, 1.45 days; 95% CI, -5.31-8.22), or more complications (RR, 0.94; 95% CI, 0.66-1.34).

CONCLUSIONS:

The present meta-analysis suggested that the timing of the tracheotomy did not significantly alter important clinical outcomes in critically ill patients. The duration of MV and sedation, as well as the long-term outcomes of ET in mechanically ventilated patients, should be evaluated in rigorously designed and adequately powered RCTs in the future。

蓝鱼o_0

那么新的论题摆在我们面前，若循证医学的文章（系统综述或者系统评价，META分析）的结果出现了矛盾。那么该如何解读呢？
我想这不仅仅是专家们思考的，（编写指南需要循证，需要证据的取舍）。我们草根也需要谨慎选择，去伪存真。究竟该何去何从？
欢迎探讨。

星火

南与个性化的判断，不易确定具体的时限。

满天星868

院规定：      预计短期（2周）内不能撤除人工气道的患者，宜尽早选择气管切开。

焚膏继晷

目前VAP目标性监测来说，  7天~10天最多。