Thank you for that. And as Julie said, these are quick talks, so I'll do everything that I can to keep us on time. But obviously, this is a topic that could fall into respiratory, this could fall into neurology, this could fall into a lot of different things. And I'm going to try to keep the scope limited, but there are certainly questions I think people will have. First, no relevant disclosures. As I mentioned, I'm also in the Army, but I would just, although that's not a disclosure, I want to say that I'm here under my civilian hat. This, nothing should be construed to be part of the military here or the U.S. government or any of those other entities. And I also wanted to thank the Society of Critical Care Medicine for using the orange, because I think orange and blue UVA colors really work out well for everyone. So if you can wear those, that would be great. So I did do lots of work before. I worked in the hospital specifically with wilderness medicine and outdoor education. It's very hard for me to stand behind a podium, and it's also very hard for me to not get the audience involved a little bit. So just as a quick survey to start us off, after a severe stroke, we all work here in critical care medicine. So regardless of whether you're neurology, you work in an ICU, you're a nurse, a doctor, RT, I want you to take a vote here. So after a severe stroke, can you tell with reasonable certainty before day five if a patient will require a tracheostomy? How many people would say always? Nobody. Usually? Okay. Sometimes? A little bit more. And rarely. All right, so the sometimes takes the lead on that one. By best estimate, when do most of your patients with severe stroke actually undergo a tracheostomy? How many people would say as early as possible, but before day five? Nobody. Okay, between day six and 14? Good number. And as long as we can delay it, but most likely after day 14? There's a few in there for sure. Okay. So I brought this up because we started off with the idea, again, that we are talking about ventilator liberation as a whole, but I was given the topic of stroke and specifically tracheostomy and stroke and timing. So here's a 2021 paper. The data that came from this paper or contributed to this paper was actually done much earlier than that. And in the 2014 survey, this was done by the Neurocritical Care Society and specifically sent to members of that society. And so those exact questions I just gave you were asked in this paper. And you can see the results there. 74.8% surveyed said they get their trach between day six and 14. So I would say our percentage was actually maybe even a little bit higher than that, but consistent. And then if they, as a part of this paper, they looked at the National Inpatient Sample Analysis and figured out when people that meet these criteria actually got a trach between the years of 2005 and 2014. And 12.3 days was the mean. So certainly within six to 14, but trending towards that 14. Of the first question, 44.8% replied usually and 45.5% replied sometimes. So almost even numbers, but certainly within that middle. And there were very few outliers, right? Almost no one said always, and almost no one said never. So very evenly split along those lines. So what do we actually do and what does the literature tell us to do? This is not a guideline specifically related to trachs, but I wanted to use it because I thought their text was interesting. And I'm gonna quote here just for sake of being able to put it out there for you. We initiated our review by converting the need for information about optimal timing of tracheostomy into several answerable questions. Answerable questions. On the side there are there four answerable questions. East, for those of you that are familiar with this group, this is not a small or untrained group of people, right? So if there's an answer to this question, it seems like, they thought it was, seems like we could come up with that. Those four questions specifically, I wanna highlight one of them. That says, does early tracheostomy reduce the number of days on mechanical ventilation and intensive care unit length of stay? So there are four very good questions there that they felt like were answerable. They reviewed seven at the time, 2009 remember, they reviewed seven randomized controlled trials. And ultimately they decided there was no mortality benefit from early trach, which they defined as three to seven days. That's important, I'm gonna come back to that. So moving on into something that is a little bit more specific to my topic, which is stroke. The 2013 trach man, which again, multicenter randomized controlled trial, this was done in UK. Looked at whether early trach less than four days versus late trach 10 days, which show mortality benefit. In that trach, in that study, it did not. And interestingly, 36.8% of those patients that were randomized to receive the late trach were actually successfully weaned before they received the intervention. Important in terms of our ability to predict these things, right? Two trials that were specific to stroke, and I'm gonna talk about the SET score in a second because these two trials did use that score. But SET point stands stroke related early tracheostomy versus prolonged intubation, so you all can see these. Two different trials, one was a single center, then the followup done under multicenter. And I wanna read the bottom part. SET point two used secondary outcomes and did not find any difference in specific mortality, ventilation duration, sedation use. But interestingly, they also did not find a difference between six month functional outcome in early versus late. And I'm gonna come back to that idea as well. So more recently, last year alone, four specific papers looked at this topic. Not trachs as a whole, not when do we do trachs for trauma patients, but this exact topic. In one year, four specific papers. The references are all gonna be at the end of this, so you can go back and read all these. I tried to summarize as best I could, but when you look at the number of patients and studies that were included in these analyses, these are a lot of patients. And what's really challenging about this topic as a whole is that they all define it differently. What is an early trach? Less than seven, less than five, less than eight. We pick different numbers in almost every single observation study, and that makes it really hard to compare. But overall, if you look at the summarized findings, one thing that is similar across these is the mortality benefit and the outcomes overall. And by outcomes, I mean functional outcomes. The timing of the trach does not seem to correlate with mortality or with your functional outcome. However, the literature definitely trends towards lower cost, lower ventilation days, lower length of stay, and lower complications specifically related to pneumonia. So regardless of how you define early, and of course early, as I said, is defined in lots of different ways in all of this literature, one thing we have now essentially put to rest is that very few, if anyone, has suggested that the timing gives you a better outcome. But the complications and the things you're gonna have to deal with along the way do have some influence. So 90.3% said they usually or sometimes could tell with reasonable certainty that a patient would need a trach by day five. In this room, I didn't obviously count the numbers, but in this room, I would think that we're about that same way. So how do we actually predict whether these patients are gonna need a trach? Because we are thinking we can by day five, at least a good number of us think that we have some ability to. How do we actually do this? There are lots of different tools out there. I picked out three, and because these three all came up with their findings in different ways, I thought it was useful to kind of put it out there. Depends on who you're looking for. The first topic there, you can see the sensitivities and specificities. This group was looking at decompressive craniectomy, so patients that had a stroke that needed a decompressive craniectomy. The SET score, which as I mentioned, was the basis for several of those trials. And then the trach score, which specifically was looking at spontaneous intracerebral hemorrhage patients. And part of the reason I think it performed so much better is because they also included some radiology findings in part of that score. So how big the hemorrhage was, where the hemorrhage was, that sort of stuff helped define that score. And I think that's one of the reasons it performs a little bit better. But I wanna come back to this idea, the second bullet point on the side there. In these randomized control trials, 22% of patients in this one, 36.8% of patients in that one who were randomized to receive the late tracheostomy were actually weaned from the ventilator before the trach was performed. Those are not insignificant numbers, one in five or potentially even higher of patients. If you weighed that period of time, this is a significant number of people that are ultimately going to be weaned. So how do we use that and what challenges does that face? This is a long quote, but I wanted to use it because Dr. Durbin did used to work at UVA, he's now retired, but his topic in 2010, he wrote this paper, Tracheostomy, Why, When and How. So here we are in 2024 now, I've been given this exact same topic. And if you read what he wrote here, I don't think we have any better evidence or any better information, despite the fact that we have multiple large randomized control trials. And in last year alone, multiple papers that all looked at this exact same topic and came up with the challenge of saying, you need to look at your patient, figure out what you think, figure out what their values would be, figure out how hard it's gonna be to put a trache in and then throw all that into the blender and figure out whether you decide to do it or not. Thank you for listening. There are a couple of references along here. And obviously we've got some time to take questions afterwards. Thank you.

tracheostomy

severe stroke

early intervention

healthcare decision-making

patient assessment