الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
 |  | from | 72 |  |  |
| | | from | 72 | | |
Abstract
Cerebrovascular stroke is considered to be one of the most disabling chronic conditions, as it is often associated with devastating long-term neurologic deficits.
Neurological outcome following a stroke depends largely on the initial area affected in the brain, size of area affected and the complications that may result from this affection over time.
Airway compromise either caused by bulbar dysfunction or disturbed level of consciousness, is considered to be one of the worst complications of stroke as endotracheal intubation and mechanical ventilation become a must in the management of these patients.
The goal of intubation and ventilatory support is to guard against aspiration with its complications, and to optimize oxygen delivery to the brain and vital organs.
Weaning off mechanical ventilation is challenging in stroke patients as there are no reliable predictors of early respiratory muscles fatigue and valuable time may be lost in liberating patients from the mechanical ventilator.
Extubation trials should be done after full clinical assessment of the patient to guard against complications of prolonged intubation and mechanical ventilation such as ventilator-associated pneumonia, ventilator-induced lung injury and diaphragmatic dysfunction and atrophy.
Ultrasonographic assessment of the diaphragm before extubation of the patient has become a routine in the era of ultrasonographic imaging as ultrasonography is not only non-invasive and safe but also easy to use and accurate.
Assessment parameters of the diaphragm function by ultrasonography include diaphragmatic excursion, diaphragmatic thickness and thickening fraction. When diaphragmatic dysfunction is diagnosed by ultrasonography, timing of tracheostomy application for mechanically ventilated patients should be considered.
The aim of this study is to compare between early and late tracheotomy on diaphragm function assessed by ultrasonography in mechanically ventilated stroke patients and its impact on weaning off mechanical ventilation, days of intensive care unit stay and 30-days mortality.
The Stroke-related Early Tracheostomy score is validated to assess the need for early tracheostomy in stroke patients with score > 8, based on combined factors including:
o Neurological function , from which dysphagia is the worest .
o Neurological lesion
o General organ function
All items are assessed within the first 24 hours after admission to the hospital.
For each physiological variable, the worst value in the first 24 hours after admission is used to achieve an estimation as early as possible.
This Study was carried out on 60 patients according to sample size estimation, in the Critical Care Medicine department of Alexandria Main University Hospital.
Patients were randomized blindly into two main groups:
The first group was subjected to bedside percutaneous tracheostomy performed early during Intensive Care Unit stay, within 4 days from hospital admission.
The second group was tracheostomized after 14 days of ICU stay.
The results of our study showed that the demographic and basic clinical data of the two groups were homogenous regarding age and sex. Also, the basic clinical data were matched in the two groups without significant statistical difference. These results were crucial to eliminate the consequences of initial assessment data on the net results of the study, and the timing of tracheotomy was the sole factor affecting the outcome.
It was found that the majority of patients of the two groups had left sided lesions, followed by brain stem, then right-sided lesions. Occipital lesions were found in 20% of the early tracheotomy group patients, and only one patient in the late tracheotomy group. There was no significant statistical difference noted between the two groups regarding stroke site. There was also no significant difference between the two groups regarding indications for intubation.
There was a highly significant increase in Diaphragm Thickness as well as the Diaphragmatic Thickening Fraction in the early tracheotomy group in comparison to the late tracheotomy group.
Also, there was found a significant increase in the duration of Intensive Care Unit stay in late tracheotomy group more than the early tracheotomy group patients. Moreover, patients in the late tracheotomy group experienced statistically highly significant increase in number of days spent on the mechanical ventilator compared to patients who had an early tracheotomy.
The ventilator days parameter was found to be significantly negative when correlated with Diaphragmatic Excursion and Diaphragmatic Thickening Fraction. On the other hand, the mechanical ventilator days was found to be positively significant when correlated with the Stroke-related Early Tracheostomy score. Regarding the Intensive Care Unit stay duration, it was found that there was a significantly negative correlation with both Diaphragmatic Excursion and Diaphragmatic Thickening Fraction, while proving positive but not statistically significant correlation with Stroke-related Early Tracheostomy score.
The Diaphragmatic Excursion as well as the Diaphragmatic Thickening Fraction were significantly higher in the surviving group more than the deceased group of patients.
Finally, there was no significant difference between the two groups regarding the 28-days morality rate.
To conclude our study, it has been found that early tracheostomy application for cerebrovascular stroke patients who are critically ill and requiring mechanical ventilator support, results in lower Intensive Care Unit mortality rates in comparison to late application. Furthermore, the study results show that patients who are subjected to early tracheostomy experience lower incidence of ventilator-associated pneumonia and require shorter durations of mechanical ventilation and shorter overall Intensive Care Unit stay. These results raise speculations regarding the traditional strategies of postponing tracheostomy application till after the first week of endotracheal intubation. Nevertheless, the consequences and long term complications of tracheostomy application validate the need for further scientific research weighing its benefits versus the negative implications.