Discussion
This study analysed the influence of TT on HRQoL, prevalence of psychiatric symptoms and return-to-work in 388 ARDS survivors 1 year after ICU discharge. The main finding was that TT was not significantly associated with physical (PCS-12) or mental impairment in quality of life (MCS-12). Secondary findings were (1) TT was not significantly related to the prevalence of psychiatric disorders and (2) TT was not significantly associated with return-to-work of ARDS survivors after 12 months.
Thus, the hypotheses underlying this study could not be confirmed. However, we did observe that TT was associated with a significant increase of ICU length of stay. ICU length of stay is a known independent factor associated with increased stationary healthcare use and 1-year mortality after ICU discharge and should be considered when deciding for the best time point of TT in critical ill patients [
24,
25]. In our study, associations observed in univariate analyses were lost mainly due to the strong confounding effect of ICU length of stay.
A current systematic review of patient-important outcomes for critically ill patients in randomised controlled clinical studies has shown ICU mortality to be the most frequently measured clinical outcome. Only 10% of studies have included at least one patient-important outcome in addition to mortality after ICU discharge [
26]. It should be noted that, in contrast to mortality, HRQoL is a complex construct that contains individual aspects with multiple dimensions, often operationalised as social, somatic and psychological variables [
4]. The individual dimensions of HRQoL could be recorded by different measurement tools and must be correlated for a better comparison of patient-reported outcomes [
27]. In an Italian study, 137 tracheotomised patients with respiratory and neurological diseases were analysed in relation to ICU mortality and HRQoL. Patients tracheotomised because of respiratory disease had a high ICU mortality rate of 50%; only 25 patients (20.5%) were still alive after 1 year. HRQoL of all tracheotomised patients was moderately compromised after 1 year, but the group of patients with respiratory diseases showed better HRQoL during follow-up [
28]. In the present study, HRQoL was not impaired by TT.
Symptoms of psychiatric disorders were often reported after survival of ARDS [
6,
29]. As an example, up to 27% of critical illness survivors suffered from PTSD, and depression was reported in 40% of ARDS survivors [
30,
31]. In the present study, TT did not influence the occurrence of psychiatric disorders. According to the results of the self-reported questionnaires shown in Tables
3 and
4, 25.9% of ARDS survivors had symptoms of PTSD (cut-off scores for symptoms of PTSD: ≥ 45) and 55.6% symptoms of depression (PHQ-9 score ≥ 5) at the 1-year follow-up [
19,
20].
Furthermore, TT did not affect return-to-work in ARDS survivors in this study. More than 50% of 1-year survivors had returned to work after a median of 16 weeks after ICU discharge. Considering the different socioeconomic systems, an US survey including 379 previously employed ARDS survivors found that 213 (56%) patients had returned to work after a median of 13 weeks after hospital discharge [
32]. Nevertheless, the fact remains that nearly 50% of patients were unemployed, which may have resulted in family problems and loss of substantial earnings. A 5-year follow-up of ARDS survivors showed that nearly one-third of previously employed ARDS survivors had never returned to work [
33].
TT is one of the most common surgical procedures in patients with acute respiratory failure. TT practices vary substantially amongst disciplines, ICUs and institutions [
34]. The TT rate of 55% found in this Germany-wide study seems to be rather high and could be explained by the inclusion of a higher number of patients with severe ARDS. In the worldwide LUNG-SAFE study, only 13% of patients with ARDS had received TT during their length of ICU stay; yet, the rate in European countries was higher at 15.7% [
15]. The ICU length of stay was also significantly longer for patients with TT (11 vs. 8 days). One possible explanation might be that the transfer of tracheostomised patients to a normal ward is difficult because of the elaborate airway management and more intensive care. Freeman and colleagues analysed over 44,000 patients with acute respiratory failure (10.8% of patients with TT) and found longer ICU treatment (24 vs. 7 days) in tracheotomised patients [
35]. In our study, the BMI was significantly higher in the tracheotomised group. A recent study from the US which also investigated patient factors associated with 30-day survival after TT did not find any influence of BMI and socioeconomic factors [
13].
Strengths and limitations
The strengths of the present study are its prospective design with three time point of follow-ups, the large number of included patients with ARDS from hospitals across Germany and the detailed collection of data on HRQoL and individual patient characteristics. Despite our best efforts to follow up each patient, the number of drop-outs was rather high, which may have resulted in attrition bias limiting this study. The instruments used for screening mental disorders do not allow making diagnoses such as major depression disorders and PTSD; only symptoms or the risk of being affected by such a disorder could be recorded. To the best of our knowledge, this is the largest multicentre study investigating the association of TT with return-to-work and patient-reported HRQoL as well as symptoms of psychiatric disorders and return-to-work in ARDS survivors.
Acknowledgements
We are grateful to Monika Schoell for the linguistic revision of the manuscript. We are indebted to all the intensivists and study assistants across Germany who had recruited patients for the DACAPO study with great commitment:
Aachen, Aachen University Hospital RWTH Aachen, Department of Anesthesiology (PD Dr. Johannes Bickenbach, Dr. Thorben Beeker, PD Dr. Tobias Schürholz, Jessica Pezechk); Amberg, Klinikum Amberg, Department for Anaesthesiology (Dr. Jens Schloer); Augsburg, Klinikum Augsburg (Dr. Ulrich Jaschinski, Ilse Kummer); Bamberg, Sozialstiftung Bamberg Hospital, Department for Anaesthesiology (Dr. Oliver Kuckein); Berlin, Charité - University Medicine Berlin, Department of Anaesthesiology and Intensive Care Medicine (PD Dr. Steffen Weber-Carstens, Dr. Anton Goldmann, Dr. Stefan Angermair, Krista Stoycheva); Berlin, HELIOS Klinikum Berlin-Buch, Department of Intensive Care Medicine (Prof. Dr. Jörg Brederlau, Nadja Rieckehr, Gabriele Schreiber, Henriette Haennicke); Bielefeld, Ev. Krankenhaus Bielefeld. Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy (Dr. Friedhelm Bach, Dr. Immo Gummelt, Dr. Silke Haas, Catharina Middeke, Dr. Ina Vedder, Marion Klaproth); Bochum, Ruhr University Bochum, Department of Anaesthesiology (Prof. Dr. Michael Adamzik, Dr. Jan Karlik, Dr. Stefan Martini, Luisa Robitzky); Bonn, University Hospital Bonn, Department of Anesthesiology and Intensive Care Medicine (Prof. Dr. Christian Putensen, Dr. Thomas Muders, Ute Lohmer); Bremen, Klinikum Bremen-Mitte, Department of Anesthesiology (Prof. Dr. Rolf Dembinski); Deggendorf, Medical Center, Department of Anaesthesiology and Intensive Care Medicine (Dr. Petra Schäffner, Dr. Petra Wulff-Werner); Dortmund, Klinikum Dortmund, Department of Critical Care Medicine (Elke Landsiedel-Mechenbier, Daniela Nickoleit-Bitzenberger, Ann-Kathrin Silber); Dresden, University Hospital Dresden Carl Gustav Carus, Department of Anesthesiology and Intensive Care Medicine (Prof. Dr. Maximilian Ragaller, Prof. Dr. Marcello Gama de Abreu, Alin Ulbricht, Linda Reisbach); Frankfurt am Main, University Hospital Frankfurt, Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy (Prof. Dr. Kai Zacharowski, Prof. Dr. Patrick Meybohm, Simone Lindau, Haitham Mutlak); Freiburg, University Medical Center Freiburg, Department of Anaesthesiology and Critical Care Medicine Freiburg (Prof. Dr. Alexander Hötzel, Dr. Johannes Kalbhenn); Freising, Klinikum Freising, Department of Anaesthesiology (Dr. Christoph Metz, Dr. Stefan Haschka); Göppingen, Klinik am Eichert, ALB FILS Kliniken, Department of Anaesthesiology and Intensive Care (Dr. Stefan Rauch); Göttingen, University Medical Center, Department of Anaesthesiology, Emergency and Intensive Care Medicine (Prof. Dr. Michael Quintel, Dr. Lars-Olav Harnisch, Dr. Sophie Baumann, Andrea Kernchen); Greifswald, University Medicine Greifswald, Department of Internal Medicine B (Dr. Sigrun Friesecke, Sebastian Maletzki); Hamburg, University Hospital Hamburg-Eppendorf, Department of Intensive Care Medicine, Center of Anesthesiology and Intensive Care Medicine (Prof. Dr. Stefan Kluge, Dr. Olaf Boenisch, Dr. Daniel Frings, Birgit Füllekrug, Dr. Nils Jahn, Dr. Knut Kampe, Grit Ringeis, Brigitte Singer, Dr. Robin Wüstenberg); Hannover, Hannover Medical School, Department of Anaesthesiology and Intensive Care Medicine (Dr. Jörg Ahrens, Dr. Heiner Ruschulte, Dr. Andre Gerdes, Dr. Matthias Groß); Hannover, Hannover Medical School, Department of Respiratory Medicine (Dr. Olaf Wiesner, Aleksandra Bayat-Graw); Heidelberg, University of Heidelberg, Department of Anaesthesiology (Dr. Thorsten Brenner, Dr. Felix Schmitt, Anna Lipinski); Herford, Klinikum Herford, Clinic for Anaesthesiology, Surgical Intensive Care Medicine, Emergency Care Medicine, Pain Management (Prof. Dr. Dietrich Henzler, Dr. Klaas Eickmeyer, Dr. Juliane Krebs, Iris Rodenberg); Homburg, Homburg University Medical Centre, Department of Anaesthesiology, Intensive Care and Pain Medicine (Dr. Heinrich Groesdonk, Kathrin Meiers, Karen Salm, Prof. Dr. Thomas Volk); Ibbenbüren, Ibbenbüren General Hospital, Division of Thoracic Surgery and Lung Support (Prof. Dr. Stefan Fischer, Basam Redwan); Immenstadt, Kempten-Oberallgaeu Hospitals, Clinic for Pneumology, Thoracic Oncology, Sleep- and Respiratory Critical Care (Dr. Martin Schmölz, Dr. Kathrin Schumann-Stoiber, Simone Eberl); Ingolstadt, Klinikum Ingolstadt, Department of Anaesthesiology and Critical Care Medicine (Prof. Dr. Gunther Lenz, Thomas von Wernitz-Keibel, Monika Zackel); Jena, Jena University Hospital, Deptartment of Anesthesiology and Intensive Care Therapy (Dr. Frank Bloos, Dr. Petra Bloos, Anke Braune, Anja Haucke, Almut Noack, Steffi Kolanos, Heike Kuhnsch, Karina Knuhr-Kohlberg); Kassel, Klinikum Kassel, Department of Anaesthesiology (PD Dr. Markus Gehling); Kempten, Klinikum Kempten-Oberallgäu gGmbH, Department for Anesthesia and Operative Intensive Care (Prof. Dr. Mathias Haller, Dr. Anne Sturm, Dr. Jannik Rossenbach); Kiel, University Medical Center Schleswig–Holstein, Campus Kiel, Department of Anesthesiology and Intensive Care Medicine (Dr. Dirk Schädler, Stefanie D’Aria); Köln, Cologne-Merheim Hospital, Department of Pneumology and Critical Care Medicine (Prof. Dr. Christian Karagiannidis, Dr. Stephan Straßmann, Prof. Dr. Wolfram Windisch); Köln, University Hospital of Cologne, Department of Anaesthesiology and Intensive Care Medicine (Prof. Dr. Thorsten Annecke, PD Dr. Holger Herff); Langen, Asklepios Kliniken Langen-Seligenstadt, Department of Anesthesiology and Intensive Care Medicine (Dr. Michael Schütz); Leipzig, University of Leipzig, Department of Anesthesiology and Intensive Care Medicine (PD Dr. Sven Bercker, Hannah Reising, Mandy Dathe, Christian Schlegel); Ludwigsburg, Klinikum Ludwigsburg, Academic Teaching Hospital, University of Heidelberg, Department of Anaesthesiology (Katrin Lichy); Ludwigshafen, Klinikum Ludwigshafen, Department of Anesthesiology and Intensive Care Medicine (Prof. Dr. Wolfgang Zink, Dr. Jana Kötteritzsch); Mainz, University Medical Center Mainz, Department of Anaesthesiology (Dr. Marc Bodenstein, Susanne Mauff, Peter Straub); Magdeburg, Magdeburg University Medical Centre, Department of Anaesthesiology and Intensive Care Medicine (Dr. Christof Strang, Florian Prätsch, Prof. Dr. Thomas Hachenberg); Mannheim, University Medical Center Mannheim, Department of Anaesthesiology and Surgical Intensive Care Medicine (Dr. Thomas Kirschning, Dr. Thomas Friedrich, Dr. Dennis Mangold); Marburg, University Hospital, Department of Anaesthesiology (Dr. Christian Arndt, Tilo Koch); Mönchengladbach, Kliniken Maria-Hilf GmbH, Department of Cardiology (Dr. Hendrik Haake, Katrin Offermanns); München, Bogenhausen Hospital, Department of Anaesthesiology (Prof. Dr. Patrick Friederich, Dr. Florian Bingold); München, Klinikum Großhadern, Department of Anaesthesiology (Dr. Michael Irlbeck, Prof. Dr. Bernhard Zwissler); München, Klinikum Neuperlach, Städtisches Klinikum München GmbH, Department of Anesthesiology, Critical Care and Pain Medicine (PD Dr. Ines Kaufmann); München, Klinikum rechts der Isar, Department for Anaesthesiology of the Technical University of Munich (Dr. Ralph Bogdanski, Dr. Barbara Kapfer, Dr. Markus Heim, PD Dr. Günther Edenharter); Münster, University Hospital Münster, Department for Anaesthesiology, Intensive Care Medicine and Pain Therapy, (Prof. Dr. Björn Ellger, Daniela Bause); Neumarkt, Kliniken des Landkreises Neumarkt i.d.OPf, Department for Anaesthesiology and Intensive Care Medicine (Dr. Götz Gerresheim); Nürnberg, General Hospital Nuremberg, Paracelsus Medical University, Department of Emergency Medicine and Intensive Care (Dr. Dorothea Muschner, Prof. Dr. Michael Christ, Arnim Geise); Osnabrück, Marienhospital Osnabrück, Department of Anaesthesiology (PD Dr. Martin Beiderlinden, Dr. Thorsten Heuter); Passau, Klinikum Passau, Department for Anaesthesiology (Dr. Alexander Wipfel); Regensburg, Caritas Krankenhaus St. Josef, Department for Anaesthesiology (Dr. Werner Kargl, Dr. Marion Harth, Dr. Christian Englmeier); Regensburg, Regensburg University Hospital, Department of Anaesthesiology, Operative Intensive Care (Prof. Dr. Thomas Bein, Dr. Sebastian Blecha, Dr. Kathrin Thomann-Hackner, Marius Zeder); Stuttgart, Katharinenhospital, Department of Anesthesiology (Dr. Markus Stephan); Traunstein, Klinikum Traunstein, Department of Anaesthesiology (Dr. Martin Glaser); Tübingen, Tübingen University Hospital, Eberhard-Karls University Tübingen, Department of Anaesthesiology and Intensive Care Medicine (PD Dr. Helene Häberle); Ulm, Ulm University, Department of Anesthesiology (Prof. Dr. Hendrik Bracht, Christian Heer, Theresa Mast); Würzburg, University of Würzburg, Department of Anaesthesia and Critical Care (PD Dr. Markus Kredel, PD Dr. Ralf Müllenbach)
Further, we are grateful to previous members of the Regensburg DACAPO study team (medical documentation: Phillip Sebök, study physician: Kathrin Thomann-Hackner), to the members of the Advisory Board of the DACAPO-Study (Prof. Dr. Julika Loss, Prof. Dr. Bernhard Graf, Prof. Dr. Michael Leitzmann, Prof. Dr. Michael Pfeifer, Regensburg, Germany) and to our student assistants (Simon Bein, Vreni Brunnthaler, Carina Forster, Stefanie Hertling, Sophie Höhne, Carolin Schimmele, Elisa Valletta).