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CoDAS 2019To perform a literature review on the existing international criteria and protocols for tracheostomy decannulation. (Review)
Review
PURPOSE
To perform a literature review on the existing international criteria and protocols for tracheostomy decannulation.
RESEARCH
strategies: Literature review using the PubMed database with the English keywords "Tracheostomy", "Weaning", "Decannulation", "Removal Tube", "Speech, Language and Hearing Sciences", "Intensive Care Units", "Dysphagia", "Swallowing", "Deglutition" and "Deglutition Disorders ".
SELECTION CRITERIA
Studies published in the last five years (2012 to 2017); studies with human adult population (i.e. ages above 18 years); articles published in English; unrestricted full access articles; and research related to the objectives of the study.
DATA ANALYSIS
we analyzed sample characterization; professionals involved in the decannulation process; steps of the decannulation process; total time in days of tracheostomy use; total time in days to complete decannulation process; and failure factors to complete the decannulation process.
RESULTS
Most of the studies investigated tracheostomy decannulation in a sample of males with neurological impairments. The professionals involved in the decannulation process were doctors, speech therapists, physiotherapists and nurses. The most cited decannulation steps were: swallowing assessment; occlusion training; evaluation of air permeability; ability to manipulate secretion and exchange of cannula; cuff deflation and cough training; use of speech valve.
CONCLUSION
Speech therapists are of great help during the decannulation process, since the assessment of swallowing was one of the decisive steps of the investigated studies. The processes of decannulation includes a multidisciplinary approach and should be performed by the cooperation between physicians, physiotherapists and speech therapists.
Topics: Airway Extubation; Deglutition Disorders; Device Removal; Female; Humans; Male; Respiration, Artificial; Tracheostomy; Ventilator Weaning
PubMed: 31800881
DOI: 10.1590/2317-1782/20192018228 -
Respiratory Care Jan 2021Children requiring a tracheostomy to maintain airway patency or to facilitate long-term mechanical ventilatory support require comprehensive care and committed, trained,... (Review)
Review
Children requiring a tracheostomy to maintain airway patency or to facilitate long-term mechanical ventilatory support require comprehensive care and committed, trained, direct caregivers to manage their complex needs safely. These guidelines were developed from a comprehensive review of the literature to provide guidance for the selection of the type of tracheostomy tube (cuffed vs uncuffed), use of communication devices, implementation of daily care bundles, timing of first tracheostomy change, type of humidification used (active vs passive), timing of oral feedings, care coordination, and routine cleaning. Cuffed tracheostomy tubes should only be used for positive-pressure ventilation or to prevent aspiration. Manufacturer guidelines should be followed for cuff management and tracheostomy tube hygiene. Daily care bundles, skin care, and the use of moisture-wicking materials reduce device-associated complications. Tracheostomy tubes may be safely changed at postoperative day 3, and they should be changed with some regularity (at a minimum of every 1-2 weeks) as well as on an as-needed basis, such as when an obstruction within the lumen occurs. Care coordination can reduce length of hospital and ICU stay. Published evidence is insufficient to support recommendations for a specific device to humidify the inspired gas, the use of a communication device, or timing for the initiation of feedings.
Topics: Child; Humans; Intermittent Positive-Pressure Ventilation; Positive-Pressure Respiration; Practice Guidelines as Topic; Tracheostomy
PubMed: 33380501
DOI: 10.4187/respcare.08137 -
Medizinische Klinik, Intensivmedizin... Nov 2021Weaning from invasive mechanical ventilation is challenging for the ICU team in terms of shortening time of ventilation via endotracheal tube in order to improve the...
Weaning from invasive mechanical ventilation is challenging for the ICU team in terms of shortening time of ventilation via endotracheal tube in order to improve the patient's prognosis by early extubation. Thereby prolonged mechanical ventilation (> 14 days), which is associated with risk of tracheotomy and prolonged weaning, shall be avoided. This article will give an overview about weaning categories, causes for weaning failure and strategies to overcome this problem. In the last part we will cover concepts in the process of prolonged weaning including discharge management with invasive mechanical ventilation.
Topics: Airway Extubation; Humans; Noninvasive Ventilation; Respiration, Artificial; Tracheostomy; Ventilator Weaning
PubMed: 34586430
DOI: 10.1007/s00063-021-00858-5 -
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 -
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 -
Otolaryngology--head and Neck Surgery :... Dec 2022(1) Assess overall COVID-19 mortality in ventilated patients with and without tracheostomy. (2) Determine the impact of tracheostomy on mechanical ventilation duration,...
OBJECTIVES
(1) Assess overall COVID-19 mortality in ventilated patients with and without tracheostomy. (2) Determine the impact of tracheostomy on mechanical ventilation duration, overall length of stay (LOS), and intensive care unit (ICU) LOS for patients with COVID-19.
STUDY DESIGN
Case series with planned chart review.
SETTING
Single-institution tertiary care center.
METHODS
Patients with COVID-19 who were ≥18 years old and requiring invasive positive pressure ventilation (IPPV) met inclusion criteria. Patients were stratified into 2 cohorts: IPPV with tracheostomy and IPPV with intubation only. Cohorts were analyzed for the following primary outcome measures: mortality, LOS, ICU LOS, and IPPV duration.
RESULTS
An overall 258 patients with IPPV met inclusion criteria: 46 (18%) with tracheostomy and 212 (82%) without (66% male; median age, 63 years [interquartile range, 18.75]). Average LOS, time in ICU, and time receiving IPPV were longer in the tracheostomy cohort ( < .01). Ability to wean from IPPV was similar between cohorts ( > .05). The number of deaths in the nontracheostomy cohort (54%) was significantly higher than the tracheostomy cohort (29%, < .01).
CONCLUSIONS
While tracheostomy placement in patients with COVID-19 did not shorten overall LOS, mechanical ventilation duration, or ICU LOS, patients with a tracheostomy experienced a significantly lower number of deaths vs those without. One goal for tracheostomy is improved pulmonary toilet with associated shortened IPPV requirements. Our study did not identify this advantage among the COVID-19 population. However, this study demonstrates that the need for tracheostomy in the COVID-19 setting does not portent a poor prognostic factor, as patients with a tracheostomy experienced a significantly higher survival rate than their nontracheostomy counterparts.
Topics: Humans; Male; Middle Aged; Adolescent; Female; Tracheostomy; COVID-19; Respiration, Artificial; Intensive Care Units; Length of Stay
PubMed: 35104190
DOI: 10.1177/01945998221075610 -
JAMA Otolaryngology-- Head & Neck... May 2021The timing of tracheostomy placement in adult patients undergoing critical care remains unestablished. Previous meta-analyses have reported mixed findings regarding... (Meta-Analysis)
Meta-Analysis
IMPORTANCE
The timing of tracheostomy placement in adult patients undergoing critical care remains unestablished. Previous meta-analyses have reported mixed findings regarding early vs late tracheostomy placement for ventilator-associated pneumonia (VAP), ventilator days, mortality, and length of intensive care unit (ICU) hospitalization.
OBJECTIVE
To compare the association of early (≤7 days) vs late tracheotomy with VAP and ventilator days in critically ill adults.
DATA SOURCES
A search of MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, references of relevant articles, previous meta-analyses, and gray literature from inception to March 31, 2020, was performed.
STUDY SELECTION
Randomized clinical trials comparing early and late tracheotomy with any of our primary outcomes, VAP or ventilator days, were included.
DATA EXTRACTION AND SYNTHESIS
Two independent reviewers conducted all stages of the review. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline was followed. Pooled odds ratios (ORs) or the mean difference (MD) with 95% CIs were calculated using a random-effects model.
MAIN OUTCOMES AND MEASURES
Primary outcomes included VAP and duration of mechanical ventilation. Intensive care unit days and mortality (within the first 30 days of hospitalization) constituted secondary outcomes.
RESULTS
Seventeen unique trials with a cumulative 3145 patients (mean [SD] age range, 32.9 [12.7] to 67.9 [17.6] years) were included in this review. Individuals undergoing early tracheotomy had a decrease in the occurrence of VAP (OR, 0.59 [95% CI, 0.35-0.99]; 1894 patients) and experienced more ventilator-free days (MD, 1.74 [95% CI, 0.48-3.00] days; 1243 patients). Early tracheotomy also resulted in fewer ICU days (MD, -6.25 [95% CI, -11.22 to -1.28] days; 2042 patients). Mortality was reported for 2445 patients and was comparable between groups (OR, 0.66 [95% CI, 0.38-1.15]).
CONCLUSIONS AND RELEVANCE
Compared with late tracheotomy, early intervention was associated with lower VAP rates and shorter durations of mechanical ventilation and ICU stay, but not with reduced short-term, all-cause mortality. These findings have substantial clinical implications and may result in practice changes regarding the timing of tracheotomy in severely ill adults requiring mechanical ventilation.
Topics: Critical Illness; Humans; Intensive Care Units; Length of Stay; Pneumonia, Ventilator-Associated; Tracheostomy
PubMed: 33704354
DOI: 10.1001/jamaoto.2021.0025 -
Chest Jan 2021
Topics: COVID-19; Humans; Pandemics; Physicians; Pulmonary Medicine; SARS-CoV-2; Tracheostomy; United States
PubMed: 33422228
DOI: 10.1016/j.chest.2020.09.244 -
Anaesthesia Jul 2020We reviewed the literature on management of general and regional anaesthesia in pregnant women with anticipated airway difficulty. We identified 138 publications... (Review)
Review
We reviewed the literature on management of general and regional anaesthesia in pregnant women with anticipated airway difficulty. We identified 138 publications comprising 158 cases; these either described equipment or techniques for the provision of general anaesthesia, or the management of women with regional analgesia or anaesthesia, with the aim of avoiding general anaesthesia. Most of the former group described women requiring caesarean section alone, or in combination with other surgery, which was sometimes airway-related. Management techniques were largely similar to those in non-obstetric patients requiring surgery who have airway difficulties, although suggested differences related to physiological changes of pregnancy and avoidance of nasal intubation. In the reports discussing regional anaesthesia, consideration was often given to the possible requirement for urgent out-of-hours anaesthetic intervention, and the predicted difficulty of management of general anaesthesia should it be required. In a number of reported cases, multidisciplinary planning led to the conclusion that elective caesarean section should be performed in order to avoid emergency airway management. Based on this literature review, we advise antenatal planning that includes: assessment of the patient's clinical characteristics; consideration of the equipment and personnel available to provide safe airway management out-of-hours; and elective caesarean section should these be lacking. If general anaesthesia is required, a risk assessment must be made as to the probability of safe airway management after the induction of anaesthesia, and awake tracheal intubation should be used if this cannot be assured. Decision aids are provided to illustrate these points. Online appendices include a comprehensive compendium of case reports on the management of a number of rare syndromes and airway conditions.
Topics: Airway Management; Analgesia, Epidural; Analgesia, Obstetrical; Anesthesia, General; Anesthesia, Obstetrical; Cesarean Section; Female; Humans; Intubation, Intratracheal; Pregnancy; Tracheostomy
PubMed: 32144770
DOI: 10.1111/anae.15007 -
Critical Care Medicine May 2022
Topics: COVID-19; Gastrostomy; Humans; Respiration, Artificial; Retrospective Studies; Tracheostomy
PubMed: 35200195
DOI: 10.1097/CCM.0000000000005504