Résumé
Alors que la trachéotomie est fréquemment pratiquée en réanimation adulte chez les patients nécessitant une ventilation mécanique prolongée, il n’existe pas de recommandations de bonnes pratiques. Cet article se propose de fournir une synthèse de la littérature. Il s’articule autour des questions les plus débattues: pourquoi réaliser une trachéotomie ? quels patients trachéotomiser ? existe-t-il un délai optimal de réalisation de la trachéotomie ? quelle technique de trachéotomie choisir ? quelle gestion jusqu’à la décanulation ? Le niveau de preuves globalement faible des études disponibles ne permet pas pour l’heure d’apporter des réponses définitives. Cependant, ces études mettent en lumière plusieurs points importants. Premièrement, la trachéotomie précoce n’est pas supérieure à l’intubation translaryngée prolongée en termes de mortalité, de complications infectieuses ou de durée de ventilation mécanique mais pourrait réduire les besoins en sédation, améliorer le confort et permettre une mobilisation et un retour à l’autonomie plus précoces. Deuxièmement, aucun sous-groupe spécifique de patients susceptibles de tirer le meilleur profit de la trachéotomie n’a encore été identifié. Troisièmement, la trachéotomie dilatatrice percutanée semble être préférable à la trachéotomie chirurgicale sur le plan des complications et des coûts. Enfin, la gestion optimale des patients trachéotomisés est loin d’être standardisée. Les investigations futures devront donc s’attacher à cibler les meilleurs candidats à la trachéotomie et à élaborer des protocoles de nature à optimiser la gestion des patients de la trachéotomie à la décanulation. D’ici là, les pratiques resteront influencées par les préférences et les opinions préconçues des cliniciens et des patients.
Abstract
While tracheostomy is commonly performed in critically ill adult patients requiring prolonged mechanical ventilation, no consensual recommendations exist regarding its use. The aim of this article is to provide a synthesis of the contemporary literature on tracheostomy. The currently most debated questions are addressed: What are the expected benefits of tracheostomy? In which patients should tracheostomy be performed? Should tracheostomy be performed early in the course of mechanical ventilation? Is percutaneous dilatational tracheostomy (PDT) preferable to surgical tracheostomy? How should patients be managed following tracheostomy placement? Due to the relatively low level of evidence of available studies, no definitive recommendations for tracheostomy can be made. However, these studies highlight several important issues. Firstly, early tracheostomy has failed to demonstrate any beneficial impact over prolonged translaryngeal intubation on mortality, infectious complications and duration of mechanical ventilation; however, it may reduce the need for sedative drugs, improve patients’ comfort and lead to earlier mobilisation and autonomy. Secondly, no specific subgroup of patients likely to draw the maximum benefit from tracheostomy has been identified so far. Thirdly, PDT seems to be preferable to surgical tracheostomy with respect to complications and costs. Finally, the optimal management of tracheostomized patients is far from being standardized. Further investigations are thus warranted to identify the best candidates for tracheostomy and delineate optimal care following tracheostomy placement. Until then, tracheostomy practices will remain largely influenced by physicians and patients’ preferences and preconceived opinions on tracheostomy.
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Cet article correspond à la conférence faite par l’auteur au congrès de la SRLF 2013 dans la session: La trachéotomie en question.
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Clec’h, C. La trachéotomie en réanimation adulte: utile ou futile ?. Réanimation 22 (Suppl 2), 473–478 (2013). https://doi.org/10.1007/s13546-012-0623-1
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DOI: https://doi.org/10.1007/s13546-012-0623-1