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BMJ Open Quality May 2022Tracheostomy is recommended within 7 days of intubation for patients with severe traumatic brain injury (TBI) or requiring prolonged mechanical ventilation. A quality...
BACKGROUND
Tracheostomy is recommended within 7 days of intubation for patients with severe traumatic brain injury (TBI) or requiring prolonged mechanical ventilation. A quality improvement project aimed to decrease time to tracheostomy to ≤7 days after intubation for eligible patients requiring tracheostomy in the surgical intensive care unit (SICU).
LOCAL PROBLEM
From January 2017 to June 2018, approximately 85% of tracheostomies were performed >7 days after intubation. The tracheostomy was placed a median of 10 days after intubation (range: 1-57).
METHODS
Quality improvement principles were applied at an American College of Surgeons-verified level I trauma centre to introduce and analyse interventions to improve tracheostomy timing. Using the electronic health record, we analysed changes in tracheostomy timing, hospital length of stay (LOS), ventilator-associated pneumonia and peristomal bleeding rates for three subgroups: patients with TBI, trauma patients and all SICU patients.
INTERVENTIONS
In July 2018, an educational roll-out for SICU residents and staff was launched to inform them of potential benefits of early tracheostomy and potential complications, which they should discuss when counselling patient decision-makers. In July 2019, an early tracheostomy workflow targeting patients with head injury was published in an institutional Trauma Guide app.
RESULTS
Median time from intubation to tracheostomy decreased for all patients from 14 days (range: 4-57) to 8 days (range: 1-32, p≤0.001), and median hospital LOS decreased from 38 days to 24 days (p<0.001, r=0.35). Median time to tracheostomy decreased significantly for trauma patients after publication of the algorithm (10 days (range: 3-21 days) to 6 days (range: 1-15 days), p=0.03). Among patients with TBI, family meetings were held earlier for patients who underwent early versus late tracheostomy (p=0.008).
CONCLUSIONS
We recommend regular educational meetings, enhanced by digitally published guidelines and strategic communication as effective ways to improve tracheostomy timing. These interventions standardised practice and may benefit other institutions.
Topics: Critical Care; Humans; Intensive Care Units; Respiration, Artificial; Time Factors; Tracheostomy
PubMed: 35551095
DOI: 10.1136/bmjoq-2021-001589 -
American Journal of Speech-language... Aug 2019Purpose The purpose of this clinical focus article is to describe the frequency, indications, and outcomes of fenestrated tracheostomy tube use in a large academic...
Purpose The purpose of this clinical focus article is to describe the frequency, indications, and outcomes of fenestrated tracheostomy tube use in a large academic institution. Method A retrospective chart review was conducted to evaluate the use of fenestrated tracheostomy tubes between 2007 and 2017. Patients were included in the study if they were ≥ 18 years of age and received a fenestrated tracheostomy tube in the recent 10-year period. Results Of 2,000 patients who received a tracheostomy, 15 patients had a fenestrated tracheostomy tube; however, only 5 patients received a fenestrated tracheostomy tube at the study institution. The primary reason why the 15 patients received a tracheostomy was chronic respiratory failure (73%); other reasons included airway obstruction (20%) and airway protection (7%). Thirteen (87%) patients received a fenestrated tracheostomy tube for phonation purposes. The remaining 2 patients received it as a step to weaning. Of the 13 patients who received a fenestrated tracheostomy tube for phonation, only 1 patient was not able to phonate. Nine (60%) patients developed some type of complications: granulation only, 2 (13.3%); granulation and tracheomalacia, 2 (13.3%); granulation and stenosis, 4 (26.7%); and granulation, tracheomalacia, and stenosis, 1 (6.7%). Conclusions Fenestrated tracheostomy tubes may assist with phonation in patients who cannot tolerate a 1-way speaking valve; however, the risk of developing granulation tissue, tracheomalacia, and tracheal stenosis exists. Health care providers should be educated on the safe use of a fenestrated tracheostomy tube and other options available to improve phonation while ensuring patient safety.
Topics: Adult; Airway Obstruction; Chronic Disease; Equipment Design; Female; Humans; Male; Middle Aged; Respiratory Insufficiency; Retrospective Studies; Tracheostomy; Treatment Outcome
PubMed: 31318610
DOI: 10.1044/2019_AJSLP-18-0187 -
Respiratory Care Apr 2005Tracheostomy tubes are used to administer positive-pressure ventilation, to provide a patent airway, to provide protection from aspiration, and to provide access to the... (Review)
Review
Tracheostomy tubes are used to administer positive-pressure ventilation, to provide a patent airway, to provide protection from aspiration, 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 length between tubes of the same inner diameter, but from different manufacturers, are not commonly appreciated but may have important clinical implications. Tracheostomy tubes can be angled or curved, a feature that can be used to improve the fit of the tube in the trachea. Extra proximal length tubes facilitate placement in patients with large necks, and extra distal length tubes facilitate placement in patients with tracheal anomalies. Several tube designs have a spiral wire reinforced flexible design and have an adjustable flange design to allow bedside adjustments to meet extra-length tracheostomy tube needs. Tracheostomy tubes can be cuffed or uncuffed. Cuffs on tracheostomy tubes include high-volume low-pressure cuffs, tight-to-shaft cuffs, and foam cuffs. The fenestrated tracheostomy tube has an opening in the posterior portion of the tube, above the cuff, which allows the patient to breathe through the upper airway when the inner cannula is removed. Tracheostomy tubes with an inner cannula are called dual-cannula tracheostomy tubes. Several tracheostomy tubes are designed specifically for use with the percutaneous tracheostomy procedure. Others are designed with a port above the cuff that allows for subglottic aspiration of secretions. The tracheostomy button is used for stoma maintenance. It is important for clinicians caring for patients with a tracheostomy tube to understand the nuances of various tracheostomy tube designs and to select a tube that appropriately fits the patient.
Topics: Catheterization; Equipment Design; Equipment Failure; Humans; Suction; Surgical Stomas; Tracheostomy
PubMed: 15807912
DOI: No ID Found -
European Review For Medical and... Nov 2022The role of ultrasound during various airway procedures has been in the spotlight in recent years. This study reconsiders the potential role and effectiveness of...
OBJECTIVE
The role of ultrasound during various airway procedures has been in the spotlight in recent years. This study reconsiders the potential role and effectiveness of ultrasound use during percutaneous dilatational tracheostomy in intensive care patient population. This study aims to assess the impact of real-time ultrasound (US) use on complication rates and procedural success in percutaneous dilational tracheostomy (PDT) opened with forceps dilatation technique using anatomical landmarks.
PATIENTS AND METHODS
In this study, 59 patients who had undergone PDT in the intensive care unit (ICU) were reached. Written-electronic files and intensive care follow-up forms of the patients were reviewed retrospectively. The patients were divided into two groups: 44 patients in Group G (anatomical landmark PDT) and 15 patients in Group U (real-time US PDT). Demographic data, duration of intubation and ICU stay, discharge status, procedural characteristics and postoperative complications of the patients were determined.
RESULTS
A total of 59 patients were analyzed. The mean age of the patients was 74.9±11.7 years, the mean tracheostomy duration was 33.3±20 days, and the mean duration of ICU stay was 60±45 days. Complications occurred in 62.7% of all patients. Minor bleeding was present in five (8.5%), moderate bleeding in 13 (22%), and major bleeding in 11 (18.6%) patients. In addition, pneumothorax was observed in one patient, misplacement of the tracheostomy cannula and emphysema in one patient, and esophageal injury in three patients. A total of 50 (84.7%) patients died, and nine (15.3%) patients continued to be treated in the ICU. Bleeding, hypoxemia, hypercapnia, tracheostomy opening time duration, and the number of attempts for the successful procedure were significantly higher in Group G than Group U (p<0.05). A negative correlation was found between the groups regarding the duration of tracheostomy (p = 0.001) and tracheostomy opening technique (p = 0.001).
CONCLUSIONS
The use of real-time ultrasound in percutaneous tracheostomies opened under elective conditions in the ICU reduces the complications of hypoxemia, hypercapnia and bleeding by dwindling the duration of the procedure and the number of attempts than the conventional technique.
Topics: Aged; Aged, 80 and over; Humans; Middle Aged; Anatomic Landmarks; Dilatation; Hypercapnia; Hypoxia; Retrospective Studies; Tracheostomy; Ultrasonography, Interventional
PubMed: 36394736
DOI: 10.26355/eurrev_202211_30139 -
PloS One 2021Ultrasound-guided tracheostomy (UGT) and bronchoscope-guided tracheostomy (BGT) have been well compared. However, the differences in benefits between UGT and landmark... (Comparative Study)
Comparative Study Meta-Analysis
INTRODUCTION
Ultrasound-guided tracheostomy (UGT) and bronchoscope-guided tracheostomy (BGT) have been well compared. However, the differences in benefits between UGT and landmark tracheostomy (LT) have not been addressed and, in particular, lack a detailed meta-analysis. We aimed to compare the first-pass success, complication rate, major bleeding rate, and tracheostomy procedure time between UGT and LT.
METHODS
In a systematic review, relevant databases were searched for studies comparing UGT with LT in intubated patients. The primary outcome was the odds ratio (OR) of first-pass success. The secondary outcomes were the OR of complications, OR of major bleeding, and standardized mean difference (SMD) of the total tracheostomy procedure time.
RESULTS
The meta-analysis included three randomized controlled studies (RCTs) and one nonrandomized controlled study (NRS), comprising 474 patients in total. Compared with LT, UGT increased first-pass success (OR: 4.287; 95% confidence interval [CI]: 2.308 to 7.964) and decreased complications (OR: 0.422; 95% CI: 0.249 to 0.718). However, compared with LT, UGT did not significantly reduce major bleeding (OR: 0.374; 95% CI: 0.112 to 1.251) or the total tracheostomy placement time (SMD: -0.335; 95% CI: -0.842 to 0.172).
CONCLUSIONS
Compared with LT, real-time UGT increases first-pass success and decreases complications. However, UGT was not associated with a significant reduction in the major bleeding rate. The total tracheostomy placement time comparison between UGI and LT was inconclusive.
Topics: Anatomic Landmarks; Bronchoscopy; Humans; International Cooperation; Postoperative Complications; Tracheostomy; Ultrasonography, Interventional
PubMed: 34710141
DOI: 10.1371/journal.pone.0258972 -
British Journal of Anaesthesia Mar 2015Early tracheostomy may decrease the duration of mechanical ventilation, sedation exposure, and intensive care stay, possibly resulting in improved clinical outcomes, but... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Early tracheostomy may decrease the duration of mechanical ventilation, sedation exposure, and intensive care stay, possibly resulting in improved clinical outcomes, but the evidence is conflicting.
METHODS
Systematic review and meta-analysis of randomized trials in patients allocated to tracheostomy within 10 days of start of mechanical ventilation was compared with placement of tracheostomy after 10 days if still required. Medline, EMBASE, the Cochrane Controlled Clinical Trials Register, and Google Scholar were searched for eligible trials. The co-primary outcomes were mortality within 60 days, and duration of mechanical ventilation, sedation, and intensive care unit stay. Secondary outcomes were the number of tracheostomy procedures performed, and incidence of ventilator-associated pneumonia (VAP). Outcomes are described as relative risk or weighted mean difference with 95% confidence intervals.
RESULTS
Of note, 4482 publications were identified and 14 trials enrolling 2406 patients were included. Tracheostomy within 10 days was not associated with any difference in mortality [risk ratio (RR): 0.93 (0.83-1.05)]. There were no differences in duration of mechanical ventilation [-0.19 days (-1.13-0.75)], intensive care stay [-0.83 days (-2.05-0.40)], or incidence of VAP. However, duration of sedation was reduced in the early tracheostomy groups [-2.78 days (-3.68 to -1.88)]. More tracheostomies were performed in patients randomly assigned to receive early tracheostomy [RR: 2.53 (1.18-5.40)].
CONCLUSION
We found no evidence that early (within 10 days) tracheostomy reduced mortality, duration of mechanical ventilation, intensive care stay, or VAP. Early tracheostomy leads to more procedures and a shorter duration of sedation.
Topics: Critical Care; Critical Illness; Health Resources; Humans; Length of Stay; Outcome Assessment, Health Care; Pneumonia, Ventilator-Associated; Randomized Controlled Trials as Topic; Respiration, Artificial; Time Factors; Tracheostomy
PubMed: 25534400
DOI: 10.1093/bja/aeu440 -
Respiratory Care Sep 2006A minority of patients with neuromuscular disease require placement of a tracheostomy, usually for the purpose of providing mechanical ventilation. Often the... (Review)
Review
A minority of patients with neuromuscular disease require placement of a tracheostomy, usually for the purpose of providing mechanical ventilation. Often the tracheostomy is performed during a hospital admission for an acute illness. The debate about the appropriate timing of tracheostomy in critically ill patients has not been resolved; however, the weight of evidence now favors performing a tracheostomy early (within 7 d of translaryngeal intubation) if the period of mechanical ventilation is likely to be prolonged beyond 3 weeks. For patients with chronic progressive weakness who develop respiratory difficulty, the consensus of opinion is that tracheostomy should be performed in patients with severe bulbar involvement, inability to effectively cough up secretions despite mechanical aids for secretion clearance, or for those who are unable to tolerate or fail noninvasive ventilation. The decision to perform tracheostomy in patients with chronic neuromuscular weakness involves consideration of several factors, including complications, resources, quality of life, ethical issues, cosmetic issues, and cost. Complications from tracheostomy and physician-perceived poor quality of life often lead to a negative bias, such that some patients may be denied this life-saving procedure. Special training is needed to provide long-term tracheostomy care, and an organized approach should be followed to decannulate patients who recover from their acute illness. Appropriate and skilled care could significantly improve the longevity and quality of life of those patients with neuromuscular disease who have a tracheostomy for long-term ventilation.
Topics: Acute Disease; Humans; Neuromuscular Diseases; Quality of Life; Respiration Disorders; Respiration, Artificial; Time Factors; Trachea; Tracheostomy
PubMed: 16934163
DOI: No ID Found -
PloS One 2022Surgical tracheostomy (ST) and Percutaneous dilatational tracheostomy (PDT) are classified as high-risk aerosol-generating procedures and might lead to healthcare... (Review)
Review
Measurement of airborne particle emission during surgical and percutaneous dilatational tracheostomy COVID-19 adapted procedures in a swine model: Experimental report and review of literature.
INTRODUCTION
Surgical tracheostomy (ST) and Percutaneous dilatational tracheostomy (PDT) are classified as high-risk aerosol-generating procedures and might lead to healthcare workers (HCW) infection. Albeit the COVID-19 strain slightly released since the vaccination era, preventing HCW from infection remains a major economical and medical concern. To date, there is no study monitoring particle emissions during ST and PDT in a clinical setting. The aim of this study was to monitor particle emissions during ST and PDT in a swine model.
METHODS
A randomized animal study on swine model with induced acute respiratory distress syndrome (ARDS) was conducted. A dedicated room with controlled airflow was used to standardize the measurements obtained using an airborne optical particle counter. 6 ST and 6 PDT were performed in 12 pigs. Airborne particles (diameter of 0.5 to 3 μm) were continuously measured; video and audio data were recorded. The emission of particles was considered as significant if the number of particles increased beyond the normal variations of baseline particle contamination determinations in the room. These significant emissions were interpreted in the light of video and audio recordings. Duration of procedures, number of expiratory pauses, technical errors and adverse events were also analyzed.
RESULTS
10 procedures (5 ST and 5 PDT) were fully analyzable. There was no systematic aerosolization during procedures. However, in 1/5 ST and 4/5 PDT, minor leaks and some adverse events (cuff perforation in 1 ST and 1 PDT) occurred. Human factors were responsible for 1 aerosolization during 1 PDT procedure. ST duration was significantly shorter than PDT (8.6 ± 1.3 vs 15.6 ± 1.9 minutes) and required less expiratory pauses (1 vs 6.8 ± 1.2).
CONCLUSIONS
COVID-19 adaptations allow preventing for major aerosol leaks for both ST and PDT, contributing to preserving healthcare workers during COVID-19 outbreak, but failed to achieve a perfectly airtight procedure. However, with COVID-19 adaptations, PDT required more expiratory pauses and more time than ST. Human factors and adverse events may lead to aerosolization and might be more frequent in PDT.
Topics: Humans; Swine; Animals; Tracheostomy; COVID-19; Dilatation; Vascular Surgical Procedures
PubMed: 36417482
DOI: 10.1371/journal.pone.0278089 -
Ear, Nose, & Throat Journal Jul 2022To evaluate the utility and safety of tracheostomy for patients with respiratory failure from COIVD-19 and describe patient clinical characteristics and process of...
OBJECTIVE
To evaluate the utility and safety of tracheostomy for patients with respiratory failure from COIVD-19 and describe patient clinical characteristics and process of management.
METHODS
Case series of the first 24 COVID-19 patients who underwent tracheostomy at our institution, a single-center tertiary care community hospital intensive care/ventilator weaning unit. The patients all had respiratory failure from COVID-19 and required endotracheal intubation and mechanical ventilation. Outcomes reviewed include mortality, percent discharged, percent liberated from mechanical ventilation, percent decannulated, time from tracheostomy to ventilator liberation and discharge, and number of staff infected with COVID-19 during tracheostomy and management.
RESULTS
Of the 24 patients who underwent tracheostomy, 21 (88%) of 24 survived. Twenty (83%) were liberated from mechanical ventilation, and 19 (79%) were discharged. Fourteen (74%) of the discharged had been decannulated. The average (± SD) time from tracheostomy to ventilator liberation was 9 ± 4.3 days and from tracheostomy to discharge 21 ± 9 days. All discharged patients had been liberated from mechanical ventilation. No health care workers became infected with COVID-19 during the procedure or subsequent patient management.
CONCLUSION
Patients with respiratory failure from COVID-19 who underwent tracheostomy had a high likelihood of being liberated from mechanical ventilation and discharged. Tracheostomy and subsequent ventilator weaning management can be performed safely. Tracheostomy allowed for decompression of higher acuity medical units in a safe and effective manner.
Topics: COVID-19; Humans; Respiration, Artificial; Respiratory Insufficiency; Tracheostomy; Ventilator Weaning
PubMed: 33570431
DOI: 10.1177/0145561321993567 -
Pediatric Annals Jul 2022Feeding disorders and gastrostomy use are highly prevalent in children with invasive mechanical ventilation (IMV) due to both common risk factors (eg, prematurity,... (Review)
Review
Feeding disorders and gastrostomy use are highly prevalent in children with invasive mechanical ventilation (IMV) due to both common risk factors (eg, prematurity, neurological disorders) and resultant experiential deprivation (eg, long hospitalizations, delayed feeding experiences). Feeding in children with IMV is complicated by the presence of a tracheostomy, lung vulnerability, and medical complexity. The potential comorbidity of swallowing difficulties (dysphagia) and atypical early feeding experiences can result in complex feeding disorders. In this review of pediatric feeding disorders in children with invasive mechanical ventilation (IMV), we identify gaps in clinical translational research for this patient population and opportunities for improving evidence-based management. To improve long-term feeding outcomes and maximize oral feeding in this vulnerable population, children would benefit from earlier feeding opportunities during critical developmental windows, standardized protocols for advancing oral feeding, and involvement of intensive, comprehensive therapies throughout hospitalizations and early childhood. .
Topics: Child; Child, Preschool; Deglutition Disorders; Feeding and Eating Disorders; Home Care Services; Humans; Respiration, Artificial; Tracheostomy; Ventilators, Mechanical
PubMed: 35858218
DOI: 10.3928/19382359-20220504-05