الفهرس 
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Abstract
Stroke is considered one of the life changing diseases that has a great effect on those who survived as well as their families, society, and healthcare resources. Not all stroke patients who require prolonged airway protection through intubation, need mechanical ventilation. These patients cannot protect their upper airways due to many causes, such as bulbar dysfunction, impaired airway protective reflexes, decreased level of consciousness and muscle weakness. Accordingly, tracheostomy provides a great opportunity to liberate these patients from mechanical ventilation whilst maintaining an open protected airway.
Tracheostomy has many advantages over continued trans-laryngeal intubation. It facilitates removal of airway mucus and other secretions and reduces damage of upper airway. It allows easier ambulation of patients, less need for analgesia and sedation. Tracheostomy is also believed to reduce dead space and airway resistance which may contribute to a higher weaning success rate.
Timing of tracheostomy in patients on MV is still a subject of debate. However, there is some new evidence to support performing early tracheostomy whenever it is indicated. The bulk of research in this topic has incorporated different critical care populations. However, it should be noted that data with respect to outcomes of early tracheostomy in specific critical care subgroups are very limited. It was proposed that evaluating specific critical care subgroups would be more relevant.
We conducted a prospective randomized controlled trial. Our study included mechanically ventilated stroke patients who were admitted to the general ICUs of the Department of Critical Care Medicine at Alexandria University Hospitals. Enrolled patients were allocated to either group (1), who received percutaneous tracheotomy within seven-days after intubation (early tracheotomy) or to group (2), underwent percutaneous tracheotomy from day 14 after intubation (conventional tracheotomy) if the application of a standard weaning protocol does not lead to successful extubation. The study included 50 cases in each group. In this study, Ciaglia percutaneous tracheotomy technique was applied. Patients enrolled in the study were then followed up for six months to detect the occurrence of VAP, duration of MV, length of ICU stay, and their final outcome either discharge or death.
According to the results of our study, patients were homogeneously distributed between the two groups in regard to age and sex. The mean age of studied patients in the early tracheotomy group was 70.98± 12.75 years (ranging from 50 to 90 years) compared to 68.68 ± 10.57 years (ranging from 37 to 89 years) for the conventional tracheotomy group. As regard to sex of studied patients, slightly more than half (54%) of studied patients in group (1) were males compared to 42% of patients in group (2) with no significant difference observed between both groups. As regard presence of risk factors for either ischemic or hemorrhagic stroke, history of hypertension was the most reported risk factor in both groups (82% and 90% in group (1) and (2) respectively).
There was a significant difference between the two groups as regard the occurrence of VAP before and after tracheotomy and the duration of mechanical ventilation. VAP occurred in about one third (32%) of studied patients in group (1) before they underwent tracheotomy. On the other hand, approximately all patients in group (2) had VAP before tracheotomy. While, in group (1), slightly less than one quarter (22%) of studied patients suffered from VAP after they received tracheotomy compared to majority (88%) of studied patients in group (2). The mean duration of MV among group (1) patients was 9.48±10.5 days with a median of 5 days compared to 24.12±26.56 days and a median 14 days for patients in group (2). Furthermore, around three quarters (76%) of studied patients in group (1) were successfully weaned from MV compared to only about one third (30%) of studied patients in group (2).Whilst, the mean length of ICU stay among group (1) patients was 24.1±30.19 days with a median of 22 days compared to 63.14±44.08 days and a median of 39.5 days for patients in group (2).
As regard final outcome of studied patients, slightly more than half (n= 27, 54%) of studied patients in group (1) died compared to majority (n= 47, 94%) of studied patients in group (2). Whereas, in group (1), 23 patients were discharged from ICU representing around (46%) of studied patients in group (1) compared to only 3 patients representing (6%) of studied patients in group (2). Additionally, the causes of death were categorized into causes related to mechanical ventilation and other causes not related to mechanical ventilation. In group (1), 40.7% of studied patients died due to complications of MV compared to 63.8% of studied patients in group (2). Whilst, 16 patients representing 59.3% of studied patients in group (1) died due to causes not directly related to MV compared to 17 patients representing 36.2% of studied patients in group (2).
We can conclude that, among mechanically ventilated stroke patients included in our study, early tracheotomy within 7 days from initiation of MV was associated with decreased incidence of VAP, faster weaning from MV, reduced length of ICU stay, decreased mortality rate, and higher probability of discharge from ICU.
We recommend that early tracheotomy (within 7 days from intubation) should be considered in stroke patients who are expected to need prolonged mechanical ventilation (more than 7 days).