Insertion Of Tracheostomy Research Articles

Effect of Percutaneous Tracheostomy on Optic Nerve Sheath Diameter [TONS Trial

Elective percutaneous tracheostomy [PCT] is the widely performed procedure in neurocritically ill patients as an airway management choice in neurocritical care unit [NICU]. Intracranial pressure [ICP] is a vital parameter to be monitored in these patients while undergoing any surgical procedure including PCT. Optic nerve sheath diameter [ONSD], being a surrogate of ICP, can be done bedside and carries less complications than invasive ICP monitoring. The aim of our study was to assess the effect of PCT on ONSD at different stages of PCT. A total of 158 patients with various intracranial pathologies scheduled for PCT in NICU were screened for eligibility in our study. We assessed mean values of ONSD, HR, MBP, and SpO2 for changes over various time points during PCT using generalized estimating equation (GEE). A p value of <0.05 was considered significant. A total of 135 patients who underwent PCT were analyzed for the study. The values of ONSD changed significantly at different stages of PCT procedure compared to baseline. The baseline ONSD value was 0.39 ± 0.05 cm. ONSD rose significantly to 0.40 ± 0.06 cm during positioning, 0.41 ± 0.06 cm during skin incision, 0.42 ± 0.07 cm during dilatation of tract, 0.41 ± 0.07 cm during insertion of tracheostomy, and 0.41 ± 0.06 cm at the end of the procedure. PCT leads to a significant rise of ONSD values during all stages of PCT. The available evidences point toward detrimental rise in ICP during PCT. ICP can be monitored noninvasively by measuring ONSD using bedside ultrasound. Kapoor I, Wanchoo J, Mahajan C, Singhal V, Roy H, Kumar S, et al. Effect of Percutaneous Tracheostomy on Optic Nerve Sheath Diameter [TONS Trial]. Indian J Crit Care Med 2021;25(4):382-387.

Association between post-sternotomy tracheostomy and deep sternal wound infection: a retrospective analysis

Tracheostomy has traditionally been used as a means of facilitated mechanical ventilation in patients requiring respiratory management following cardiac surgery. However in the clinical setting, the advantages of tracheostomy has been questioned by concerns surrounding evidence of its association with increased risk of deep sternal wound infections (DSWI). The present study sought to evaluate retrospectively our experience with post-sternotomy tracheostomy among cardiac surgery patients and association with DSWI. Between July 2003 and June 2013, 11,795 patients underwent open cardiac surgery via sternotomy in our department. Among these, 225 underwent post-sternotomy tracheostomy. Data were obtained by reviewing and analyzing the Cardiac Surgical and Cardiac Intensive Care Unit (ICU) databases for adult cardiac patients. Out of the 11,795 sternotomy patients analyzed, 225 (1.9%) underwent tracheostomy. The overall mortality rate for post-sternotomy tracheostomy patients was 21.3%. DSWI developed in 23 patients (10.2%) of the tracheostomy group. Seven of these 23 patients had DSWI after insertion of tracheostomy. DSWI was significantly higher in tracheostomy versus no-tracheostomy patients (10.2% vs. 0.48%; P<0.001). DSWI was also associated with higher mortality rates compared to non-DSWI patients (11.4% vs. 2.3%; P<0.001). The present study demonstrated that tracheostomy was an independent risk factor for post-sternotomy DSWI, and that DSWI was a predictor of mortality. For tracheostomy patients, coronary artery bypass grafting (CABG) procedures and longer durations of tracheostomy were strong predictors of DSWI. Across all sternotomy patients, tracheostomy, diabetes, urgency status and blood transfusions were significant risk factors for DSWI. As such, the decision for tracheostomy post-sternotomy should be carefully considered on a case by case basis.

Balloon Dilatation of Pediatric Subglottic Laryngeal Stenosis during the Artificial Apneic Pause: Experience in 5 Children

Introduction. Balloon dilatation is a method of choice for treatment of laryngeal stenosis in children. The aim of procedure in apneic pause is to avoid new insertion of tracheostomy cannula. Patients and Methods. The authors performed balloon dilatation of subglottic laryngeal strictures (SGS) in 5 children (3 girls and 2 boys) without tracheotomy. Two of them with traumatic and inflammatory SGS had a tracheal cannula removed in the past. The other 3 children with postintubation SGS had never had a tracheostomy before. The need for tracheostomy due to worsening stridor was imminent for all of them. Results. The total of seven laryngeal dilatations by balloon esophagoplasty catheter in apneic pause was performed in the 5 children. The procedure averted the need for tracheostomy placement in 4 of them (80%). Failure of dilatation in girl with traumatic stenosis and concomitant severe obstructive lung disease led to repeated tracheostomy. Conclusion. Balloon dilatation of laryngeal stricture could be done in the absence of tracheostomy in apneic pause. Dilatation averted threatening tracheostomy in all except one case. Early complication after the procedure seems to be a negative prognostic factor for the outcome of balloon dilatation.

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Introduction: Early tracheostomy has been used in many ICUs to help weaning patients from mechanical ventilation. A recent publication of a randomised controlled trial casted doubt about the effectiveness of this strategy [1]. We carried out a meta-analysis of the available published data on the insertion of an early tracheostomy to assess the impact on mortality, duration of mechanical ventilation, duration of sedation and the incidence of ventilator-associated-pneumonia when compared to prolonged endotracheal intubation. Methods: We included only randomised controlled trials in the meta- analysis – cross-over and quasi-randomised designs were not permitted. We searched the MEDLINE, EMBASE and CINAHL databases from 1946 to 2013. Our outcome measures included the duration of mechanical ventilation, 28d mortality, 28d incidence of VAP and duration of sedation. We used Mantel-Haenszel method with random effects model for the dichotomous data and inverse variance method with random effects model for the continuous variables. Results: We have identified 8 eligible trials with 1860 recruited patients. Duration of mechanical ventilation was not significantly different in the two groups and despite being in favour of early tracheostomy, and the I2 test suggests significant heterogeneity (-3.20 95%CI -7.15, 0.76 days, respectively; I2=91%). We observed similar results when assessed duration of sedation and duration of ICU stay. 28 day mortality was also not significantly different between the two groups (RR 0.84 95%CI 0.67, 1.04; I2=31%). Similarly, the incidence of VAP was not statistically different in the two groups, with large heterogenity observed between the studies (RR 0.92 95%CI 0.76, 1.11; I2=73%). Conclusions: Despite hypothesised and plausible clinical benefits, early tracheostomy does not appear to carry any benefit in a heterogeneous patient population. This finding is further compounded by the problem of significant heterogeneity of the studies. We believe possible explanations for the negative findings are: Early tracheostomy was thought to be beneficial when our sedation practices were very different. Most of the early studies lacked sedation scoring, sedation breaks and adequate analgesia. This change in clinical practice might explain the negative results in the more recent trials. The other common limiting factor in all of these studies was the clinicians ability to predict the length of mechanical ventilation needed and therefore the inability to accurately predict, which patients would benefit from such an intervention. We recommend that further studies are carried out with strict sedation protocol and a clear definition of early tracheostomy and prolonged endotracheal intubation. Reference: 1. Young D, et al Journal of the American Medical Association May 2013;309(20):2121–2129.

A 10 year retrospective review on the management of upper airway obstruction in children with pierre robin sequence: the success of the nasopharyngeal airway

Introduction Pierre Robin Sequence (PRS) is a congenital anomaly presenting with micrognathia, glossoptosis and a cleft palate. Although significant upper airway obstruction is common, especially during sleep, there isn9t a general consensus about its management. In most centres, mandibular distraction surgery or insertion of tracheostomy is the recommended management for children with PRS not responding to conservative management such as positioning. The objective of this study was to present our experience with the use of nasopharyngeal airway in these patients as a possible alternative to surgery by retrospectively reviewing its use in our department over the last 10 years. Methods This study was conducted jointly between the respiratory and otolaryngology departments. Only the children with all three characteristics of this condition have been included. The data collected included the method of airway management and oximetry data pre and post intervention. Results Data was collected on 104 Pierre Robin patients referred to us from 2000 to 2010. Most of patients (64/104) were less than 4 weeks of age at referral. In this referred group, the airway symptoms were managed conservatively in 27 (25.9%), with nasopharyngeal airway (NPA) in 63 (60.6%) and tracheostomy in 14 (13.4%) patients. The duration of NPA use varied from 3 weeks to 27 months, the average being 7.9 months. There was an objective improvement on oximetry in all 63 patients with NPA. NPA did not improve symptoms subjectively or objectively in 14 patients who underwent a tracheostomy. There were no NPA related complications in this study. In this study 86.5% (90/104) PRS patients were successfully managed either conservatively or with the help of nasopharyngeal airway for few months. Conclusion In majority of children (86.5%), the airway obstruction can be managed by conservative measures or nasopharyngeal airway for few months. A small number of children need to be managed with a tracheostomy. Although oximetry studies are not the most accurate tool to diagnose obstruction in itself, they were accurate enough to show objective improvement post insertion of NPA.

Care of adult patients with a temporary tracheostomy

The insertion of a temporary tracheostomy is a common procedure in the critical care environment. This article aims to explore the evidence relating to the nursing care required for a patient with a temporary tracheostomy in a critical care or acute ward setting. The article focuses on the insertion of a tracheostomy as a planned intervention to improve or enable patient recovery, rather than an emergency procedure for airway obstruction. The procedure is not without risk and aftercare is vital to ensure the patient remains safe and the procedure aids recovery and promotes comfort.

Safety of percutaneous tracheostomy in trauma patients

Percutaneous tracheostomy is a common procedure in many trauma ICUs. A concern about the safety of performing percutaneous tracheostomy in patients with no cervical spine clearance or cervical spine injury has limited its adoption for some surgeons. Most experts recommend the use of fiberoptic bronchoscopy during the insertion of percutaneous tracheostomy.

Sedation use before and after tracheostomy in ICU

Objective. To study the total amount of sedative drugs administered to patients in the intensive care unit (ICU) before and after tracheostomy. Design. Prospective observational study. Setting. Twelve-bedded general ICU that was expanded to an 18-bedded general ICU. Subjects. Twenty-two patients who had a tracheostomy inserted during their ICU stay. Interventions. None. End points. The total amount of sedative drugs administered to patients three days before and three days after insertion of tracheostomy. Measurements and main results. During the study period 447 patients were admitted to ICU, 27 (5.6%) had a tracheostomy. Four patients were excluded from the study because of the presence of hypoxic brain damage or a permanent tracheostomy prior to ICU admission. Twenty-three patients were studied. The median age was 65, median initial 24 h APACHE II score was 22, median length of stay was 36 days, and median time of performing the tracheostomy was 14 days. Twelve (52%) patients died and one patient was transferred to another centre the day after tracheostomy and was therefore not included in the comparison of sedation use before and after tracheostomy. Alfentanil, morphine, propofol and midazolam were used in 17 (77.3%), 8 (36.4%), 19 (86.4%) and 9 (40.9%) patients respectively. Overall, there was a significant reduction in the total amount of alfentanil (p=0.01) and propofol (p=0.01) administered before and after tracheostomy. One patient (4.5%) did not receive sedation before or after tracheostomy. Sedative drug use was reduced after tracheostomy in 13 (59%) patients and slightly increased in one (4.5%) patient. Sedative drugs were altered in 7 (31.8%) patients. Ten patients received only propofol and/or alfentanil for sedation. For these patients, there was a significant reduction in the use of both these agents after tracheostomy, p=0.02 and p<0.01 respectively. Conclusions. Tracheostomy results in a reduction in the amount of sedative drugs administered to patients in ICU, especially when propofol and alfentanil are used.

Sedation use before and after tracheostomy in ICU

AbstractObjective. To study the total amount of sedative drugs administered to patients in the intensive care unit (ICU) before and after tracheostomy. Design. Prospective observational study. Setting. Twelve-bedded general ICU that was expanded to an 18-bedded general ICU. Subjects. Twenty-two patients who had a tracheostomy inserted during their ICU stay. Interventions. None. End points. The total amount of sedative drugs administered to patients three days before and three days after insertion of tracheostomy. Measurements and main results. During the study period 447 patients were admitted to ICU, 27 (5.6%) had a tracheostomy. Four patients were excluded from the study because of the presence of hypoxic brain damage or a permanent tracheostomy prior to ICU admission. Twenty-three patients were studied. The median age was 65, median initial 24 h APACHE II score was 22, median length of stay was 36 days, and median time of performing the tracheostomy was 14 days. Twelve (52%) patients died and one patie...

Translaryngeal tracheostomy (TLT): UK clinical experience

Sub-cricoid dilation tracheostomy has gained popularity in intensive care units throughout the world during the past 10 years [1]. We describe our experience with a new and novel method for insertion of a percutaneous tracheostomy minimising the inherent risks of bleeding, misplacement and pneumothorax which have been described with other techniques.