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Respiratory Care Jun 2017Over the last decade, tracheostomy has been increasingly performed in children, aligned with the improvements in neonatal and pediatric ICU care. Nowadays, the majority... (Review)
Review
Over the last decade, tracheostomy has been increasingly performed in children, aligned with the improvements in neonatal and pediatric ICU care. Nowadays, the majority of children with tracheostomy represent a very complex cohort of patients with sustained reliance on tracheostomy and related medical technology for long-term survival. Tracheostomy is one of the most commonly performed procedures in the adult ICU. Contrary to adult practice, tracheostomy is a much less common procedure in the pediatric ICU, being performed in < 3% of patients. There is no definite consensus about the length of time a child should remain endotracheally intubated before the placement of a tracheostomy. Tracheostomy in children also continues to remain a predominantly surgical procedure, with percutaneous tracheostomy being performed infrequently and only considered feasible in older children. The indications, preoperative considerations, and procedure types for tracheostomy in children are reviewed. There is also a lack of consensus on an optimal pediatric decannulation protocol. The literature discusses a myriad of protocols that use varying combinations of in-patient/out-patient resources, specialized tests, and procedures An ideal decannulation protocol is presented, as well as review of recently published decannulation algorithms. Finally, children with tracheostomy have a higher risk of adverse events and mortality, which are largely secondary to their comorbidities rather than the tracheostomy. The majority of the tracheostomy-related events are in fact potentially preventable. There is a recognized need for improvement and coordination of care of pediatric patients with tracheostomy. A multidisciplinary coordinated approach to tracheostomy care has already shown promising results. This paper seeks to review the pertinent literature regarding quality improvement initiatives for tracheostomy care, including review of the recently established Global Tracheostomy Collaborative.
Topics: Adolescent; Airway Extubation; Catheterization; Child; Child, Preschool; Humans; Infant; Intensive Care Units, Pediatric; Quality Improvement; Tracheostomy
PubMed: 28546379
DOI: 10.4187/respcare.05366 -
Annals of Cardiac Anaesthesia Jan 2017Percutaneous dilatational tracheostomy (PDT) is a commonly performed procedure in critically sick patients. It can be safely performed bedside by intensivists.This has... (Review)
Review
Percutaneous dilatational tracheostomy (PDT) is a commonly performed procedure in critically sick patients. It can be safely performed bedside by intensivists.This has resulted in decline in the use of surgical tracheostomy in intensive care unit (ICU) except in few selected cases. Most common indication of tracheostomy in ICU is need for prolonged ventilation. About 10% of patients requiring at least 3 days of mechanical ventilator support get tracheostomised during ICU stay. The ideal timing of PDT remains undecided at present. Contraindications and complications become fewer with increase in experience. Various methods of performing PDT have been discovered in last two decades. Preoperative work up, patient selection and post tracheostomy care form key components of a successful PDT. Bronchoscopy and ultrasound have been found to be useful procedural adjuncts, especially in presence of unfavorable anatomy. This article gives a brief overview about the use of PDT in ICU.
Topics: Critical Care; Humans; Intensive Care Units; Minimally Invasive Surgical Procedures; Tracheostomy
PubMed: 28074819
DOI: 10.4103/0971-9784.197793 -
Respiratory Care Jun 2014Tracheostomy tubes are used to administer positive-pressure ventilation, to provide a patent airway, and to provide access to the lower respiratory tract for airway... (Review)
Review
Tracheostomy tubes are used to administer positive-pressure ventilation, to provide a patent airway, and to provide access to the lower respiratory tract for airway clearance. They are available in a variety of sizes and styles from several manufacturers. The dimensions of tracheostomy tubes are given by their inner diameter, outer diameter, length, and curvature. Differences in dimensions between tubes with the same inner diameter from different manufacturers are not commonly appreciated but may have important clinical implications. Tracheostomy tubes can be cuffed or uncuffed and may be fenestrated. Some tracheostomy tubes are designed with an inner cannula. It is important for clinicians caring for patients with a tracheostomy tube to appreciate the nuances of various tracheostomy tube designs and to select a tube that appropriately fits the patient. The optimal frequency of changing a chronic tracheostomy tube is controversial. Specialized teams may be useful in managing patients with a tracheostomy. Speech can be facilitated with a speaking valve in patients with a tracheostomy tube who are breathing spontaneously. In mechanically ventilated patients with a tracheostomy, a talking tracheostomy tube, a deflated cuff technique with a speaking valve, or a deflated cuff technique without a speaking valve can be used to facilitate speech.
Topics: Airway Extubation; Airway Management; Algorithms; Equipment Design; Equipment Failure; Humans; Tracheostomy
PubMed: 24891201
DOI: 10.4187/respcare.02920 -
BMJ Open Respiratory Research Jul 2020While there is an extensive body of literature surrounding the decision to insert, and methods for inserting, a tracheostomy, the optimal management of tracheostomies... (Review)
Review
OBJECTIVES
While there is an extensive body of literature surrounding the decision to insert, and methods for inserting, a tracheostomy, the optimal management of tracheostomies within the intensive care unit (ICU) from after insertion until ICU discharge is not well understood. The objective was to identify and map the key concepts relating to, and identify research priorities for, postinsertion management of adult patients with tracheostomies in the ICU.
DESIGN
Scoping review of the literature.
DATA SOURCES
PubMed, Embase and Cumulative Index to Nursing and Allied Health Literature were searched from inception to 3 October 2019. Additional sources were searched for published and unpublished literature.
ELIGIBILITY CRITERIA
We included studies of any methodology that addressed the a priori key questions relating to tracheostomy management in the ICU. No restrictions were placed on language or year of publication.
DATA EXTRACTION AND SYNTHESIS
Titles and abstracts were screened by two reviewers. Studies that met inclusion criteria were reviewed in full by two reviewers, with discrepancies resolved by a third. Data were extracted for included studies, and results mapped along the prespecified research questions.
RESULTS
6132 articles were screened, and 102 articles were included for detailed analysis. Protocolised weaning was found to be successful in liberating patients from the ventilator in several cohort studies. Observational studies showed that strategies that use T-pieces and high-flow oxygen delivery improve weaning success. Several lines of evidence, including one clinical trial, support early cuff deflation as a safe and effective strategy as it results in a reduced time to wean, shorter ICU stays and fewer complications. Early tracheostomy downsizing and/or switching to cuffless tubes was found to be of benefit in one study. A substantial body of evidence supports the use of speaking valves to facilitate communication. While this does not influence time to wean or incidence of complications, it is associated with a major benefit in patient satisfaction and experience. Use of care bundles and multidisciplinary team approaches have been associated with reduced complications and improved outcomes in several observational studies.
CONCLUSIONS
The limited body of evidence supports use of weaning protocols, early cuff deflation, use of speaking valves and multidisciplinary approaches. Clinical trials examining post-tracheostomy management strategies in ICUs are a priority.
Topics: Adult; Humans; Intensive Care Units; Patient Care Bundles; Patient Care Team; Randomized Controlled Trials as Topic; Respiration, Artificial; Respiratory Insufficiency; Tracheostomy
PubMed: 32723731
DOI: 10.1136/bmjresp-2020-000651 -
The Cochrane Database of Systematic... Jan 2015Long-term mechanical ventilation is the most common situation for which tracheostomy is indicated for patients in intensive care units (ICUs). 'Early' and 'late'... (Review)
Review
BACKGROUND
Long-term mechanical ventilation is the most common situation for which tracheostomy is indicated for patients in intensive care units (ICUs). 'Early' and 'late' tracheostomies are two categories of the timing of tracheostomy. Evidence on the advantages attributed to early versus late tracheostomy is somewhat conflicting but includes shorter hospital stays and lower mortality rates.
OBJECTIVES
To evaluate the effectiveness and safety of early (≤ 10 days after tracheal intubation) versus late tracheostomy (> 10 days after tracheal intubation) in critically ill adults predicted to be on prolonged mechanical ventilation with different clinical conditions.
SEARCH METHODS
This is an update of a review last published in 2012 (Issue 3, The Cochrane Library) with previous searches run in December 2010. In this version, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 8); MEDLINE (via PubMed) (1966 to August 2013); EMBASE (via Ovid) (1974 to August 2013); LILACS (1986 to August 2013); PEDro (Physiotherapy Evidence Database) at www.pedro.fhs.usyd.edu.au (1999 to August 2013) and CINAHL (1982 to August 2013). We reran the search in October 2014 and will deal with any studies of interest when we update the review.
SELECTION CRITERIA
We included all randomized and quasi-randomized controlled trials (RCTs or QRCTs) comparing early tracheostomy (two to 10 days after intubation) against late tracheostomy (> 10 days after intubation) for critically ill adult patients expected to be on prolonged mechanical ventilation.
DATA COLLECTION AND ANALYSIS
Two review authors extracted data and conducted a quality assessment. Meta-analyses with random-effects models were conducted for mortality, time spent on mechanical ventilation and time spent in the ICU.
MAIN RESULTS
We included eight RCTs (N = 1977 participants). At the longest follow-up time available in these studies, evidence of moderate quality from seven RCTs (n = 1903) showed lower mortality rates in the early as compared with the late tracheostomy group (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.70 to 0.98; P value 0.03; number needed to treat for an additional beneficial outcome (NNTB) ≅ 11). Divergent results were reported on the time spent on mechanical ventilation and no differences were noted for pneumonia, but the probability of discharge from the ICU was higher at day 28 in the early tracheostomy group (RR 1.29, 95% CI 1.08 to 1.55; P value 0.006; NNTB ≅ 8).
AUTHORS' CONCLUSIONS
The whole findings of this systematic review are no more than suggestive of the superiority of early over late tracheostomy because no information of high quality is available for specific subgroups with particular characteristics.
Topics: Critical Care; Critical Illness; Humans; Length of Stay; Pneumonia; Randomized Controlled Trials as Topic; Respiration, Artificial; Time Factors; Tracheostomy
PubMed: 25581416
DOI: 10.1002/14651858.CD007271.pub3 -
Soins; La Revue de Reference Infirmiere Sep 2015Nursing care is specific in otorhinolaryngology, particularly in oncology. The three dimensions of the care, technical, relational and educational, are essential and...
Nursing care is specific in otorhinolaryngology, particularly in oncology. The three dimensions of the care, technical, relational and educational, are essential and reflect the quality of the patient management which must be multi-disciplinary.
Topics: Humans; Patient Education as Topic; Tracheostomy; Tracheotomy
PubMed: 26369746
DOI: 10.1016/j.soin.2015.07.006 -
Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies.Anaesthesia Sep 2012Adult tracheostomy and laryngectomy airway emergencies are uncommon, but do lead to significant morbidity and mortality. The National Tracheostomy Safety Project... (Meta-Analysis)
Meta-Analysis
Adult tracheostomy and laryngectomy airway emergencies are uncommon, but do lead to significant morbidity and mortality. The National Tracheostomy Safety Project incorporates key stakeholder groups with multi-disciplinary expertise in airway management. , the Intensive Care Society, the Royal College of Anaesthetists, ENT UK, the British Association of Oral and Maxillofacial Surgeons, the College of Emergency Medicine, the Resuscitation Council (UK) the Royal College of Nursing, the Royal College of Speech and Language Therapists, the Association of Chartered Physiotherapists in Respiratory Care and the National Patient Safety Agency. Resources and emergency algorithms were developed by consensus, taking into account existing guidelines, evidence and experiences. The stakeholder groups reviewed draft emergency algorithms and feedback was also received from open peer review. The final algorithms describe a universal approach to managing such emergencies and are designed to be followed by first responders. The project aims to improve the management of tracheostomy and laryngectomy critical incidents.
Topics: Adult; Airway Management; Algorithms; Child; Device Removal; Emergency Medical Services; Equipment Design; Humans; Laryngectomy; Oxygen Inhalation Therapy; Patient Safety; Respiration; Societies, Medical; Suction; Tracheostomy; United Kingdom
PubMed: 22731935
DOI: 10.1111/j.1365-2044.2012.07217.x -
Respiratory Care Jan 2021Management of patients with a tracheostomy tube includes many components of care provided by clinicians from various health care disciplines. In recent years, clinicians...
Management of patients with a tracheostomy tube includes many components of care provided by clinicians from various health care disciplines. In recent years, clinicians worldwide have demonstrated a renewed interest in the management of patients with tracheostomy due to the recognition that more effective and efficient management of this patient population is necessary to decrease morbidity and mortality and to optimize the value of the procedure. Commensurate with the goal of enhancing the care of patients with tracheostomy, we conducted a systematic review to facilitate the development of recommendations relevant to the care of adult patients with tracheostomy in the acute care setting. From our systematic review, clinical practice guidelines were developed to address questions regarding the impact of tracheostomy bundles, tracheostomy teams, and protocol-directed care on time to decannulation, length of stay, tracheostomy-related cost, tracheostomy-related adverse events, and other tracheostomy-related outcomes in tracheostomized adult patients in the acute care setting. Using a modification of the RAND/UCLA Appropriateness Method, 3 recommendations were developed to assist clinicians with tracheostomy management of adult patients in the acute care setting: (1) evidence supports the use of tracheostomy bundles that have been evaluated and approved by a team of individuals experienced in tracheostomy management to decrease time to decannulation, tracheostomy-related adverse events, and other tracheostomy-related outcomes, namely, improved tolerance of oral diet; (2) evidence supports the addition of a multidisciplinary tracheostomy team to improve time to decannulation, length of stay, tracheostomy-related adverse events, and other tracheostomy-related outcomes, namely, increased speaking valve use; (3) evidence supports the use of a weaning/decannulation protocol to guide weaning and removal of the tracheostomy tube to improve time to decannulation.
Topics: Adult; Critical Care; Device Removal; Humans; Systematic Reviews as Topic; Tracheostomy
PubMed: 32962998
DOI: 10.4187/respcare.08206 -
Anaesthesiology Intensive Therapy 2019Point-of-care ultrasound in the intensive care unit has emerged as a routine bedside diagnostic tool. This article provides literature review on the ultrasound-guided... (Review)
Review
Point-of-care ultrasound in the intensive care unit has emerged as a routine bedside diagnostic tool. This article provides literature review on the ultrasound-guided percutaneous dilational tracheostomy (US-PDT), which is a relatively novel technique. US-PDT reduces periprocedural complication rate, facilitates identification of proper tube insertion site and provides other additional safety-measures non-ultrasound Seldinger-based PDT technique.
Topics: Humans; Intensive Care Units; Point-of-Care Systems; Tracheostomy; Ultrasonography, Interventional
PubMed: 31268274
DOI: 10.5114/ait.2019.86277 -
Respiratory Care Apr 2005The respiratory therapist plays an integral role in tracheostomy tube decannulation. Removal of the tracheostomy tube should be considered only if the original... (Review)
Review
The respiratory therapist plays an integral role in tracheostomy tube decannulation. Removal of the tracheostomy tube should be considered only if the original upper-airway obstruction is resolved, if airway secretions are controlled, and if mechanical ventilation is no longer needed. Predictors of success include ability to produce a vigorous cough and the absence of aspiration. Tracheostomy decannulation requires caution, particularly following a prolonged period of tracheostomy use. The tracheostomy tube decannulation process is well suited for therapist-implemented protocols.
Topics: Clinical Protocols; Device Removal; Humans; Patient Selection; Tracheostomy
PubMed: 15807918
DOI: No ID Found