Percutaneous Tracheostomy Placement Research Articles

Tracheal ulcer development from high volume, low-pressure cuffed endotracheal tubes

IntroductionIatrogenic injury to the larynx, particularly the vocal cords from prolonged intubation, has been well-studied; however, tracheal injuries are rarely reported. This study investigates the effectiveness of cuffed, high-volume, low-pressure endotracheal tubes in preventing the development of tracheal ulcers in intubated subjects. MethodsA retrospective, IRB-approved review was performed on 1355 subjects who underwent percutaneous tracheostomy from 2002 to 2018. The presence and severity of tracheal ulcers were collected using documentation and photos during percutaneous tracheostomy placement. Primary outcome measures included: the length of time on a ventilator until tracheostomy (LOVT), length of hospitalization (LOH), and mortality in relationship to the severity of the tracheal injury. Data was reported as n (%) and median (IQR). The differences in means between groups were analyzed by ANOVA and Chi-square test with an alpha of 0.05. Results206 subjects met the inclusion criteria; 65 subjects had an absence of tracheal injury, and 141 subjects developed tracheal ulcers. Subjects with tracheal ulcers were grouped by the following severity scale: no ulcer; mild ulcer (minimal mucosal erosion with exudate); moderate ulcer (mucosal erosion); and severe (tracheal ring exposure). There were no statistically significant differences in age (p = 0.99), gender (p = 0.83), BMI (p = 0.44), LOH (p = 0.88), LOVT (p = 0.93), and mortality (p = 0.306) between subjects with differing severity of ulcers. The average annual incidence of clinically significant ulcers (moderate and severe) was 2.2 %. ConclusionsThe lack of statistical correlation between the duration of intubation and tracheal ulcer severity, along with a low annual incidence of tracheal ulcers, supports the improved safety of high-volume, low-pressure cylindrical, cuffed endotracheal tubes. This study is among the first to specifically focus on injuries at the level of the cuff and tip of endotracheal tubes with implications in preventive measures and potential product design changes.

Usos del videolaringoscopio C-MAC en una Unidad de Cuidados Intensivos. Estudio prospectivo, observacional

ObjectiveTo describe the main uses of the C-MAC video laryngoscope (VL) in an Intensive Care Unit (ICU) during a period of 29 months. Material and methodsProspective, observational study during a period of 29 months. All patients admitted to our ICU where the VL C-MAC was used were included. Indications, efficacy, and complications were recorded. ResultsThe VL C-MAC has been used 297 times in 250 patients. The mean age of the patients was 68 ± 13 years. The most frequent use of the VL C-MAC was orotracheal intubation (IOT), in 103 (34.7%) cases. 86.4% of the patients were intubated at the first attempt. Intubation with the VL C-MAC accounted for 60.6% (103/170) of all IOTs performed during the study period. The VL C-MAC was used in 76 (25.6%) cases to review the pharynx-larynx area, and in 68 (22.9%) cases to facilitate the introduction of the transesophageal echocardiography (TEE) probe. Other uses were facilitating percutaneous tracheostomy placement (10.1%), nasogastric tube placement (3%), orotracheal tube exchange (3.4%) and Sengstaken balloon placement (0.3%). ConclusionsThe IOT, the review of the pharynx-larynx area and the introduction of the TEE probe were the most frequent uses of the VL C-MAC in our ICU. The use of VL C-MAC in an ICU is broader than tracheal intubation and can facilitate the management of critical patients.

Cognitive Task Analysis: Bringing Olympic Athlete Style Training to Surgical Education.

Surgical training is changing and evolving as time, pressure, and legislative demands continue to mount on trainee surgeons. A paradigm change in the focus of training has resulted in experts examining the cognitive steps needed to perform complex and often highly pressurized surgical procedures. To provide an overview of the collective evidence on cognitive task analysis (CTA) as a surgical training method, and determine if CTA improves a surgeon's performance as measured by technical and nontechnical skills assessment, including precision, accuracy, and operative errors. A systematic literature review was performed. PubMed, Cochrane, and reference lists were analyzed for appropriate inclusion. A total of 595 surgical participants were identified through the literature review and a total of 13 articles were included. Of these articles, 6 studies focused on general surgery, 2 focused on practical procedures relevant to surgery (central venous catheterization placement), 2 studies focused on head and neck surgical procedures (cricothyroidotomy and percutaneous tracheostomy placement), 2 studies highlighted vascular procedures (endovascular aortic aneurysm repair and carotid artery stenting), and 1 detailed endovascular repair (abdominal aorta and thoracic aorta). Overall, 92.3% of studies showed that CTA improves surgical outcome parameters, including time, precision, accuracy, and error reduction in both simulated and real-world environments. CTA has been shown to be a more effective training tool when compared with traditional methods of surgical training. There is a need for the introduction of CTA into surgical curriculums as this can improve surgical skill and ultimately create better patient outcomes.

Percutaneous tracheostomy placement with external laser light transillumination identifies proper tracheal orientation and improves surgeon insertion confidence

Complications of percutaneous tracheostomy include bleeding, loss of airway control, inadvertent injury to surrounding structures, and equipment damage, all of which can be attributed to poor visualization and inaccurate orientation. Initially, we performed percutaneous tracheostomy in the intensive care unit setting using the single-dilator technique with video bronchoscopy without external transillumination. During our first 30 procedures, the video bronchoscope was damaged in four instances, requiring costly repairs each time. To decrease the potential for uncertainty, loss of airway control, and equipment damage, the investigators developed a technique incorporating an external laser light source to transilluminate the trachea to accurately identify the correct and appropriate orientation. Since integration of the external transillumination technique, no additional video bronchoscopes have been damaged in 100 subsequent procedures. We conclude transillumination using an external laser light source is useful in identifying the tracheostomy insertion site. This tool decreases instrument damage and improves surgeon confidence during percutaneous tracheostomy placement.

The use of cognitive task analysis to improve the learning of percutaneous tracheostomy placement

Objective The purpose of the current study was to determine the effectiveness of using cognitive task analysis (CTA) to develop a curriculum to teach the behavioral skills and the cognitive strategies of a percutaneous tracheostomy (PT) placement. Methods Postgraduate 2, 3, and 4 general surgery residents were randomly assigned to either the CTA group (N = 9) or the control group (N = 11). The CTA group was taught percutaneous tracheostomy placement using the CTA curriculum. The control group received the traditional curriculum. Results The CTA group performed significantly higher on the PT procedure at 1 month (CTA: 43.5 ± 3.7, control 35.2 ± 3.9, P = .001) and at 6 months post-instruction (CTA: 39.4 ± 4.2, control: 31.8 ± 5.8, P = .004). In addition, the CTA group demonstrated superior cognitive strategies than the control group (CTA: 25.4 ± 5.3, control: 19.2 ± 2.0, P = .004). Conclusions The use of CTA was effective in improving the cognitive processes and technical skills of performing a PT for surgical residents.

Repeat Percutaneous Tracheostomy in the Neurocritically Ill Patient

Percutaneous tracheostomy is a widely used and accepted method for long-term mechanical ventilation and airway protection. Neurocritically ill patients sometimes require repeat tracheostomy, which is traditionally considered a relative contraindication for percutaneous procedure. The aim of this study was to determine the safety of repeat percutaneous tracheostomy in neurocritically ill patients with a history of previous tracheostomy. In the 16-bed academic neurointensive care unit, we prospectively enrolled patients who needed new tracheostomy placement for airway protection or prolonged mechanical ventilation and had previously undergone percutaneous tracheostomy placement. We collected data on indications, procedure, periprocedural complications, and outcome of repeated tracheostomy. Between January 2001 and October 2005, we enrolled 12 consecutive patients (mean age 35.4 +/- 7.0 years) who underwent repeat percutaneous tracheostomy. Head injury was the most common underlying diagnosis (seven patients, 58%). Tracheostomy tube placement was easy and successful in all patients, and none of the patients needed conversion to surgical tracheostomy. In three patients, ultrasound-guided needle aspiration was used before the procedure to confirm the position of the trachea. No patients died or experienced serious complication related to the procedure. Two patients (17%) had a minor periprocedural bleeding, which was controlled with local compression. Long-term outcome was poor, with only two patients alive and off the ventilator at hospital discharge, both with serious disability. Repeat percutaneous tracheostomy can be performed safely in neurocritically ill patients who have undergone previous tracheostomy.

Accuracy of blind placement of percutaneous tracheostomy

Accuracy of blind placement of percutaneous tracheostomy

A cadaver study appraising accuracy of blind placement of percutaneous tracheostomy.

An attempt was made to place a percutaneous catheter between the first and second cartilaginous rings of the trachea in 20 cadavers presenting for postmortem examination. Only nine of the catheters entered the trachea in the intended space. All catheters which were noted to be difficult to place entered the trachea higher than intended. One third of all catheters punctured the thyroid isthmus.