Early Decannulation Research Articles

Early Decannulation, Repatriation, and Hospital Discharges by Introducing a Tracheostomy Care Task Force for Noncritical Care Tracheostomized Patients

Objective. To determine the impact of an intensivist lead tracheostomy care team on the number of successful decannulations in non-critically ill patients and the time required for such decannulations and discharge from the hospital. Methods. Following the introduction of a multidisciplinary tracheostomy care task force, data was collected prospectively from July to December 2009. Matching control data was collected retrospectively from January to June 2009. Chi-Square and Mann-Whitney U- test were used to compare the differences in study variables with an α of 0.05. Results. A total of 44 and 47 patients with percutaneous tracheostomy (PCT) were discharged from the ICU pre- and post-implementation of the task force, respectively. Nine patients in pre- and 24 in post- implementation phase were decannulated, discharged from the hospital, and repatriated to their country of origin (Chi Sq. = 9.21, P = .002). Patients in pre-implementation group had longer hospital stay post ICU discharge compared to patients in post-implementation (58 vs. 34.1 days) group ( P< .001). Conclusion. Structured multidisciplinary tracheostomy care team was associated with significant increase in number of decannulations, hospital discharges, and repatriation post ICU discharge.

Flexible fiber CO2 laser ablation of subglottic and tracheal stenosis

Flexible fiber CO2 laser ablation of subglottic and tracheal stenosis

External Mandibular Distraction in Unusual Pediatric Syndromes with Micrognathia and Airway Obstruction

Mandibular hypoplasia is a craniofacial malformation that can cause airway obstruction and may affect the eating process. This anomaly is common in many polimalformed Syndromes, including the Pierre Robin Sequence and the Moebius Syndrome. It is also common in cases related to the dysgenesis of the brainstem. In order to avoid tracheostomy, or to allow for early decannulation in severely affected children, external distraction devices were employed in 3 clinical cases to repair mandibular deficiencies. A successful external mandibular distraction induces the removal of the airway obstruction, allowing spontaneous ventilation without devices, an independent eating process with no need of nasogastric or gastrostomy tubes, apart from the linguistic and facial asymmetry improvement.

Congenital stridor with feeding difficulty as a presenting symptom of Dok7 congenital myasthenic syndrome

Objective The congenital myasthenic syndromes (CMS) are a group of genetic disorders of neuromuscular transmission causing fatigable weakness. Symptoms may be present from birth, but diagnosis is often delayed for several years, notably in post-synaptic CMS due to mutations in the DOK7 gene. Recently, we noted a subgroup of children with CMS in whom congenital stridor and bilateral vocal cord palsy predated other symptoms. All had mutations in the DOK7 gene. The purpose of this study was to review our population of DOK7 CMS patients with congenital stridor and assess whether there were other phenotypic features which might raise suspicion of a diagnosis of CMS in the neonatal period, in the absence of limb weakness and ptosis and prompt earlier referral for neurophysiological investigation, genetic diagnosis and appropriate treatment. Methods A retrospective case review of 11 DOK7 CMS patients at a tertiary referral centre. Results Six patients were identified with DOK7 mutations and congenital stridor, four requiring intubation soon after birth. Four patients had a diagnosis of bilateral vocal cord palsy and three required tracheostomy, successfully decannulated in one after 3 years. All six patients had difficulty with feeding, with weak suck and swallow necessitating nasogastric feeding in five, two of whom required gastrostomy. Despite all six children having had neonatal symptoms, the mean age at CMS diagnosis was 5 years and 9 months. Conclusion CMS, particularly caused by mutations in the DOK7 gene, is a rare but treatable cause of congenital stridor in the neonate. A combination of congenital stridor, especially with an apparently idiopathic bilateral vocal cord palsy and weak suck and swallow should alert the clinician to the possibility of CMS and prompt early referral for neurophysiology and genetic investigations. Confirmation of a CMS diagnosis enables treatment to be initiated, informed management of the VCP and anticipation of myasthenic symptoms, particularly life-threatening respiratory decompensation. Treatment may allow early decannulation or possible avoidance of tracheostomy. At least 12 genes are known to cause CMS; the presence of congenital stridor may help target genetic diagnosis.

Comparative Estimation of Tracheostomy Time and Procedures in Patients with Multiple Organ Dysfunction after Cardiosurgical Interventions

Objective: to comparatively evaluate the efficiency of tracheostomy by various methods in different artificial ventilation periods in patients with multiple organ dysfunction after cardiosurgical intervention. Subjects and methods. In the first stage, the patients in whom tracheostomy was performed in a classical surgical manner (a control group; n=15) not earlier than 7 days after arterial ventilation (AV) were compared. A study group comprised 19 patients in whom tracheostomy was carried out on days 3—4 after AV. In the second stage of the study, tracheostomy was made not later than 4 days following AV: by the puncture-dilatation method in study group 2 (n=28) and by the classical surgical procedure in control group 2 (n=49). Results. The time and procedures of an intervention were found to have an impact on the bacteriological profile of a patient, the duration of switch to spontaneous respiration, and the tracheobronchial tree. The advantages and disadvantages of the puncture-dilatation technique of tracheostomy were noted from the standpoint of hemodynamics, gas transport, possible complications, and long-term Results. Conclusion. Early tracheostomy caused a reduction in the number of infectious complications of the tracheobronchial tree, early decannulation with switch to spontaneous breathing. The puncture-dilatation procedure of tracheostomy is characterized by the minimum hypoxic period at cannula installation and ensures prompt healing in the absence of purulent complications. The classical surgical tracheostomy remains to be the method of choice during massive anticoagulant therapy. The accumulation of long-term results should be continued. Key words: tracheostomy, multiple organ dysfunction, cardiac surgery.

Early decannulation of the pediatric patient from tracheostomy to noninvasive positive pressure ventilation: Teamwork and patience*

Baylor College of Medicine; Texas Children's Hospital; Houston, Texas *See also p. 31. The author has not disclosed any potential conflicts of interest.

Noninvasive positive-pressure ventilation avoids recannulation and facilitates early weaning from tracheotomy in children*

To show that noninvasive positive-pressure ventilation by means of a nasal mask may avoid recannulation after decannulation and facilitate early decannulation. Retrospective cohort study. Ear-nose-and-throat and pulmonary department of a pediatric university hospital. The data from 15 patients (age = 2-12 yrs) who needed a tracheotomy for upper airway obstruction (n = 13), congenital diaphragmatic hypoplasia (n = 1), or lung disease (n = 1) were analyzed. Four patients received also nocturnal invasive ventilatory support for associated lung disease (n = 3) or congenital diaphragmatic hypoplasia (n = 1). Decannulation was proposed in all patients because endoscopic evaluation showed sufficient upper airway patency and normal nocturnal gas exchange with a small size closed tracheal tube, but obstructive airway symptoms occurred either immediately or with delay after decannulation without noninvasive positive-pressure ventilation. In nine patients, noninvasive positive-pressure ventilation was started after recurrence of obstructive symptoms after a delay of 1 to 48 mos after a successful immediate decannulation. Noninvasive positive-pressure ventilation was anticipated in six patients who failed repeated decannulation trials because of poor clinical tolerance of tracheal tube removal or tube closure during sleep. After noninvasive positive-pressure ventilation acclimatization, decannulation was performed with success in all patients. Noninvasive positive-pressure ventilation was associated with an improvement in nocturnal gas exchange and marked clinical improvement in their obstructive sleep apnea symptoms. None of the 15 patients needed tracheal recannulation. Noninvasive positive-pressure ventilation could be withdrawn in six patients after 2 yrs to 8.5 yrs. The other nine patients still receive noninvasive positive-pressure ventilation after 1 yr to 6 yrs. In selected patients with upper airway obstruction or lung disease, noninvasive positive-pressure ventilation may represent a valuable tool to treat the recurrence of obstructive symptoms after decannulation and may facilitate early weaning from tracheotomy in children who failed repeated decannulation trials.

Clinical Experience With the Application of Distraction Osteogenesis for Airway Obstruction

The objective of this study was to evaluate the long-term success of mandibular distraction osteogenesis in patients with mandibular airway obstruction syndrome (MAOS), defined as obstructive sleep apnea, swallowing abnormalities, and failure to thrive in the presence of micrognathia, glossoptosis, gastroesophageal or laryngeal reflux, and microaspiration. This is a cross-sectional study at the International Craniofacial Institute in the Medical City Hospital, Dallas, TX. From January 1997 to July 2008, a group of 81 patients were examined for MAOS using medical history and physical examination. They all met the criteria for a multidisciplinary team evaluation consisting of upper airway endoscopy, swallowing evaluations, standard overnight polysomnography, and radiologic evaluations of the airway and craniofacial structures. In the 81 patients examined, Pierre Robin Sequence was diagnosed in 65; micrognathia and glossoptosis without cleft palate, in 13; and micrognathia as a component of a craniofacial syndrome (Treacher Collins syndrome), in 3. A total of 45 patients were documented to have gastroesophageal or laryngeal reflux.Only 41 patients had yet to receive any treatment at the time of evaluation; 40 patients presented with a tracheotomy.Of the 41 untreated patients, 14 responded to conservative treatment; Pierre Robin syndrome was diagnosed in all of them, and they did not require mandibular distraction or other surgical procedure to improve the MAOS.Bilateral distraction osteogenesis of the mandible was performed in 67 patients; 27 were younger than 6 months at the beginning of the distraction, and 40 were older than 6 months (mean age at distraction, 1.2 yr). Of this group, 26 patients did not have any prior surgical treatment, and 41 patients already had a tracheotomy. The distraction devices used were internal in 33 (49.26%) and external in 34 (50.74%) of 67 patients. The distraction protocol consisted of a 24-hour latency period and then a 1-mm/d activation period. The mean activation period was 19.4 days (range, 10-27 d), the mean consolidation period was 73 days, and the mean length of distraction was 22 mm (range, 10-32 mm). Tracheostomy was prevented in 25 (96%) of 26 patients, and decannulation after distraction was possible in 38 (92%) of 41 patients. Success, defined as decannulation within 1 year of the start of distraction or prevention of tracheostomy in a patient otherwise deemed as a candidate, was found in 63 (94%) of 67 patients. Oral feedings have been resumed in 61 (91%) of 67 patients.Complications observed were mostly related to pin site infections requiring antibiotics. Device failure was experienced in 2 (3%) of 66 internal devices and in 7 (10.2%) of 68 external devices.Distraction osteogenesis of the mandible provides an excellent treatment for mandibular airway obstruction in patients younger than 6 years who do not respond to conservative measures and allows for early decannulation in patients who previously underwent tracheotomy.

Mandibular distraction in a tracheostomized patient with Pierre‐Robin sequence

The triad of glossoptosis, micrognathia, and cleft palate characterizes the Pierre Robin sequence (PRS). Complications can be severe and the clinical manifestations are very heterogeneous, but airway obstruction is almost present and may be life threatening. To avoid tracheostomy or allow for early decannulation in severely affected children, external or bioresorbable internal distraction devices can be applied to repair mandibular deficiencies. We report a case of a children submitted to bilateral mandibular distraction with external nonresorbable devices. After optimal lengthening of mandibles, laryngotracheoplasty was performed to close the tracheostomy with improvement of respiratory pattern and quality of life this child. Bioresorbable internal distraction devices offers some advantages, but complications include device failure to support resistance. Distraction osteogenesis has become a safe, less-invasive procedure with a negligible risk of infection making it effective to substitute tracheostomy as first choice in treatment of patients with Pierre Robin Sequence and life threatening airway obstruction.

Decannulation and Outcome following Pediatric Tracheostomy

We investigated the long-term outcome of pediatric tracheostomy to identify predictive factors of early decannulation. We performed a retrospective chart review of a consecutive series of 75 patients less than 20 years of age who underwent tracheostomy between 1998 and 2003 during their admission in a tertiary pediatric institution. Complete information was available on 65 patients. There were 41 male patients and 24 female patients (median age, 7 months). The indications for tracheostomy were an obstructed airway in 36 patients, prolonged mechanical ventilation in 15, and tracheobronchial toilet or aspiration risk in 14. Twelve patients died, and 30 of the 53 survivors were decannulated (median cannulation time, 123.5 days). Additional airway procedures were required for decannulation in those with obstructed airways. Patients who had tracheostomy performed for tracheobronchial toilet had a significantly shorter cannulation time than those with the other two indications (log-rank test, chi2(2) = 47.11; p < .00001). Patient diagnosis was also a significant predictor of cannulation time (log-rank test, chi2(2) = 66.05; p < .00001). Tracheobronchial toilet as a tracheostomy indication and both trauma and neurologic conditions as admission diagnoses were statistically significant independent variables that predicted earlier decannulation on multivariate analysis. Analysis of other group variables--age, sex, and tracheostomy insertion technique--did not reveal any significant difference in cannulation times. Tracheostomy indication and patient diagnosis are significant variables that predict early decannulation in pediatric patients in whom tracheostomy is required. Other variables were not shown to be significant independent predictors.

Mandibular Distraction Osteogenesis in Pierre Robin Sequence: Application of a New Internal Single-Stage Resorbable Device

Pierre Robin sequence may result in physiologically significant obstructive apnea in the neonatal and infant period. This may be life threatening and is most often treated by tracheostomy. To avoid tracheostomy or allow for early decannulation in severely affected infants and children, the authors have developed a new class of neonatal and infant mandibular bone distraction devices. These devices require a single operative procedure for placement and no operative removal is necessary. Fifteen infants (aged 7 days to 11 months; mean age, 3 months) and five children (aged 2 to 8 years; mean age, 5.5 years), 10 boys and 10 girls, with severe obstructive apnea and Pierre Robin sequence were treated with the mandibular infant devices over a 24-month period. Tracheostomy was avoided in 14 patients, whereas five of six patients who had previous tracheostomy were decannulated after mandibular distraction. The final tracheostomy status in one patient will be determined after surgery for gastroesophageal reflux. There were no major complications and no structural device failures.

Distraction osteogenesis of the mandible

Airway obstruction and craniofacial deformities resulting from mandibular deficiency are challenging and complex clinical problems. Mandibular distraction osteogenesis is playing a rapidly expanding role in the treatment of these children and has supplanted traditional management techniques in many centers. Several recent studies have reviewed clinical experience, described technical refinements, and addressed issues in patient selection and preoperative workup. The extension of mandibular distraction osteogenesis to newborns with Pierre Robin sequence or craniofacial syndromes associated with micrognathia and airway obstruction has radically altered treatment protocols at several institutions. Early bilateral mandibular distraction has obviated tracheostomy in most newborns, with low operative morbidity. In addition, early decannulation and resolution of obstruction has occurred when mandibular distraction osteogenesis was applied to selected micrognathic children. Some of these patients were tracheotomized and others presented with severe obstructive symptoms. Studies have described success with external and internal distraction techniques. Recent publications have also demonstrated the surgeon's ability to mold the regenerate safely, the dynamic characteristics of the consolidation phase, and success with secondary and tertiary distraction. After 15 years of clinical use in children for craniofacial deformities, recent advances in distraction osteogenesis have obviated tracheostomy in most newborns with micrognathia and severe airway obstruction. Applications of this technique to children with airway issues related to micrognathia or retrognathia have been rapidly expanding. In addition, refinements in distraction technique have advanced treatment of nonairway-related mandibular deformities.

Videofluoroscopic evaluation of the swallowing function after supracricoid laryngectomy

This study was designed to evaluate the swallowing function in patients with supracricoid laryngectomy (SCL) compared to normal subjects and to search for the factors affecting postoperative aspiration. Ten patients who underwent SCL with cricohyoidopexy (CHP) for primary laryngeal squamous cell carcinoma were included in the study. The control group consisted of 13 normal adult volunteer men with similar ages. The swallowing act of the subjects was evaluated by using videofluoroscopy (VFS) and videolaryngostroboscopy (VLS). The movements of the larynx were measured with regard to the hyoid bone, mandible and vertebral spine. The patients with SCL-CHP, except for two who had slight aspiration, had effective and near normal swallowing regarding the measurements of the movements of the hyoid bone. They could tolerate a near-normal oral diet. We have observed that the preventive precautions for aspiration are preserving the superior laryngeal nerves, suturing and positioning the cricoarytenoid unit as anterosuperiorly as possible, early decannulation and early onset of swallowing rehabilitation; the risk factors for aspiration are advanced stage of cancer, postoperative radiation and shortening of bolus transit time. VFS is useful for the patients with postoperative aspiration, because it is the definitive technique for anatomical and physiological evaluation of swallowing. We consider that the parameters of VLS and VFS, such as tongue base-arytenoid contact, presence of bolus splitting, pseudoepiglottis function, maximal opening of the pharyngoeosophageal sphincter and total movement of hyoid bone are important criteria to evaluate swallowing.

Manejo actual en síndrome de Pierre Robin

Introduction: Airway obstruction in children with Pierre Robin syndrome (PRS)could be an important determinant of the prognosis and quality of life of the child. Objective: to analyze mandibular distraction as an early management in children with PRS and airway obstruction. Method: PRS patients treated between January 1998 and March 2003 at the Luis Calvo Mackenna Hospital were included. Clinical evaluation, lateral cephalograms, nasoendoscopy, oxygen saturation and polysomnograms were used as parameters in the decision to perform mandibular distraction. Long term follow up included evaluation of complications, nutritional evolution, facial growth and development. Results: 23/31 PRS patients underwent mandibular distraction, relieving airway obstruction in all the cases. 2 cases underwent tracheotomy at birth that were removed during the process. 2 patients had pulmonary hypertension and reversed clinical signs after distraction. Their weight charts improved significantly after the operation. Conclusion: Mandibular distraction is a successful method for young patients with PRS to relieve airway onstruction, improve feeding and avoid tracheotomy or early decannulation in previously tracheotomized patients.

Current airway management in craniofacial anomalies

Airway obstruction requiring intervention occurs frequently among children with craniofacial anomalies. The presence of a craniofacial anomaly is a common reason for tracheotomy in the pediatric population. Because of the complications associated with tracheotomy, however, numerous other methods have been proposed to alleviate severe airway obstruction in this patient population. Nonsurgical management of airway obstruction remains the initial treatment option in children with craniofacial abnormalities; however, a significant number of patients fail to respond to this management strategy. Perhaps the most significant recent alternative airway management technique is the use of distraction osteogenesis to advance the mandible and maxilla. This technique has been used both to achieve early decannulation and to avoid a tracheotomy in infants and children with craniofacial anomalies. Multiple options exist for relieving upper airway obstruction in craniofacial patients, and the application of these treatment strategies is dependent on the patient's disease and the philosophy of the treating institution. Future research into the management of airway obstruction in children with craniofacial anomalies will need to focus on predicting which children will benefit from conservative management and which children will need distraction osteogenesis or a tracheotomy.

Decannulation and survival following tracheostomy in an intensive care unit.

We investigated the long-term outcome of patients requiring tracheostomy in an intensive care unit (ICU) in an attempt to identify risk factors that would indicate a low probability of early decannulation. A retrospective study was conducted of a consecutive series of 106 patients who underwent tracheostomy in the period between January 1, 2001, and December 31, 2001, during their admission to the ICU at the Royal Melbourne Hospital, Melbourne, Australia. There were 61 male and 39 female patients with a median age of 65 years. The indications for tracheostomy were prolonged mechanical ventilation (47), tracheobronchial toilet or risk of aspiration (45), and an unstable or obstructed airway (8). Thirty-seven patients died during the study period. All surviving patients were successfully decannulated (median cannulation time, 25 days). Patients with tracheostomies inserted for an unstable or obstructed airway had a significantly shorter cannulation time (median time of 13 days) as compared to the other two indications (mechanical ventilation, 25 days; risk of aspiration, 33 days; log-rank test, chi2(2) = 14.62 and p = .0007). Multivariate analysis showed that the effect of an unstable or obstructed airway was independent of the remaining group variables. We conclude that ICU patients who need a tracheostomy have a high mortality rate. Only the indication for tracheostomy insertion predicts early decannulation, and other patient variables are not significant predictors.

喉頭癌T3例の再建の工夫

A reconstructive procedure was performed after subtotal laryngectomy due to T3 supraglottic carcinoma. An osteomuscular flap was designed to reconstruct the defective larynx in order to preserve the laryngeal function. In the patient, the contralateral hyoid bone, along with the sternohyoid muscle, was used to reconstruct the resulting defect. This osteomuscular flap provided bulk for the posterior glottic to prevent aspiration, while the maintenance of the glottic remnant preserved an adequate airway and phonation. Mobilized pyriform sinus mucosa and neck skin flap covered a new glottis. Early decannulation and satisfactory voice quality were archived in this case. Conservative laryngectomy means complete resection of the tumor and reconstruction of the essential laryngeal function (sphincteric, phonatory, and respiratory). The method of maintaining one movable arytenoid and one normal vocal cord during surgical treatment of T3 supraglottic carcinoma achieves the goal of satisfactorily reconstructing the essential laryngeal function.

Modified supracricoid partial laryngectomy with cricohyoidopexy: Series report and analysis of results

Aiming to improve voice quality and to facilitate swallowing rehabilitation, we modified the supracricoid partial laryngectomy with cricohyoidopexy by preserving the posterior segment of the true vocal cord on the less involved side of the larynx. Between 1983 and 1994, 13 patients with supraglottic cancer were treated with this modified procedure. The possibility of incomplete tumor excision was eliminated by careful patient selection and intraoperative reconfirmation of tumor extent with frozen sections. Our results have been promising, with a 76.9% 3-year survival rate and a 69.2% laryngeal preservation rate. There were 7 recurrences, 3 local (2 at the superior border of the cricoid and 1 at the cricoarytenoid region) and 4 nodal, in 5 patients. Distant metastases developed in another patient. Three patients, 2 with local and nodal recurrence and 1 with distant metastases, died of disease. Functional outcomes were also good, with all patients achieving normal swallowing by the end of the first year, although 5 patients required temporary gastrostomy for transient swallowing impairment. Early decannulation and satisfactory voice quality were achieved in all cases. We believe that with proper patient selection this modified procedure is effective both for tumor control and for preserving a more functional larynx. (Otolaryngol Head Neck Surg 2000;123:288–93.)

Distraction osteogenesis for obstructive apneas in patients with congenital craniofacial malformations.

Infants with congenital craniofacial malformations often have associated severe mandibular hypoplasia causing obstruction of the hypopharynx by retroposition of the base of the tongue into the posterior pharyngeal airway. Management depends on the severity of the airway obstruction. Most cases can be managed by prone positioning until the infant outgrows the problem at 3 to 6 months of age. In more critical cases, monitoring of oxygen saturation, temporary placement of a nasopharyngeal tube, and placement of an endotracheal tube will be useful procedures. Tracheotomy is an effective method for more severe cases, but longstanding tracheotomies result in high morbidity and occasional mortality. Mandibular distraction was performed in seven patients, ranging in age from 1 to 18 months, with critical obstructive apnea secondary to mandibular hypoplasia characterized by an apnea/hypopnea index greater than 20 apneas per hour and oxygen saturation below 80 percent. Two patients were tracheotomized previously. Mandibular lengthening, from 16 to 25 mm on the left side and from 10 to 22 mm on the right, was achieved in 21 to 25 days. Improvement of airway obstruction parameters was measured on polysomnograms and lateral cephalograms. Mandibular lengthening by gradual distraction is a successful method for young patients with severe mandibular hypoplasia causing critical obstructive apneas. Avoidance of tracheotomy or early decannulation in previously tracheotomized patients is a great advantage for patients with congenital craniofacial malformation.

Early decannulation with bilateral mandibular distraction for tracheostomy-dependent patients: Williams JK, Maull D, Grayson BH, et al. Plast Reconstr Surg 103:48, 1999

Early decannulation with bilateral mandibular distraction for tracheostomy-dependent patients: Williams JK, Maull D, Grayson BH, et al. Plast Reconstr Surg 103:48, 1999