Presence Of Tracheostomy Research Articles

Balloon Laryngoplasty for Pediatric Subglottic Stenosis: A 5-year Experience.

The objective of this study was to present our experience and evaluate our results of endoscopic balloon laryngoplasty (BL) in children with subglottic stenosis (SGS) at a pediatric tertiary center over a 5-year period. This study reviewed 41 pediatric patients diagnosed with acquired SGS who had undergone BL as the primary course of treatment. Cases were analyzed for details including patient demographics, SGS grade and length, timing and the type of surgery, presence of tracheostomy, comorbidities, postoperative management, complications and outcomes of balloon dilatation. Forty-one children (22 girls and 19 boys) who had undergone BL at a mean age of 26 months (range, 1 month to 14 years) were included in the study. Nineteen (46.3%) were diagnosed with acute SGS (12 thin stenosis, 7 thick stenosis) and 22 (53.7%) with chronic SGS (9 thin stenosis, 13 thick stenosis). The success rate of BL was 100% in patients with acute and chronic thin membranous stenosis. The effectiveness of BL was significantly higher in patients with acute thick stenosis than in patients with chronic thick stenosis (p=0.016). This study confirms that BL in patients presenting with acquired SGS with thin membranous stenosis, regardless of whether acute or chronic, can have a good prognosis. However, the results are less promising in cases of chronic thick stenosis.

Difficult to Treat Proteeae strains in high risk Romanian hospital departments

Abstract Introduction: Resistance to first-line antibiotics of the Proteeae strains within the difficult-to-treat (DTR) phenotype is a cause of limitation of therapeutic options. The study aimed to characterize these strains, to identify the factors that influence their acquisition and the predictive factors for the patient’s evolution. Material and methods: Between July 2017 and January 2019, 400 of Proteeae strains were isolated from samples of patients admitted to intensive care units (ICUs) and surgical wards of a university hospital in Romania. The identification and testing of antibiotic sensitivity was performed using the Vitek 2 Compact system. The DTR phenotype was defined as the resistance (or intermediate resistance) to all categories of β-lactams, carbapenems and fluoroquinolones. Results: Out of 400 Proteeae strains, 21% were of the DTR type, most of them from the species Providencia stuartii and Proteus mirabilis, identified predominantly on the ICUs. The excess fatality in the DTR subsample compared to the non-DTR subsample was 16.37%. The multivariate analysis identified as independent risk factors: the number of antibiotics administered, the number of days of urinary catheterization, the presence of tracheostomy, nasogastric nutrition, respectively belonging to the species P. stuartii. The probabilities of survival were reduced by the presence of the central venous catheter (CVC), tracheostomy, by the increase of the number of hospitalization days respectively of the number of antibiotics administered. Conclusion: The DTR phenotype in the case of Proteeae strains has been associated especially with the species P. stuartii, with invasive exogenous factors and with an increased fatality.

Cumulative Efficacy of Longitudinal Repeat Salivary Gland OnabotulinumtoxinA Injection: A Retrospective Study.

We hypothesized that repeat onabotulinumtoxinA (BTX-A) injections to salivary glands would have a cumulative effect on drooling, leading to prolonged efficacy duration. We retrospectively reviewed medical records and conducted a telephone survey of individuals treated with BTX-A to the salivary glands to investigate ongoing efficacy or adverse effects. Outcome measures were duration of decrease in drooling and adverse events. The main independent variable was the number of injections. We identified 52 consecutive individuals (26 females) with cerebral palsy with an average age of 9 yrs, 3 mos ± 5 yrs 2 mos, who had received BTX-A for sialorrhea. Linear regression analysis showed that each additional injection resulted in the duration of efficacy being 0.68 mos longer (P < 0.001, R2 = 0.47). Age, sex, Gross Motor Function Classification System level, presence of tube feeding, presence of tracheostomy, gastroesophageal reflex, seizures, and concurrent intramuscular injections seizures were not significant contributors to the association between injection number and efficacy duration (F (6, 45) = 1.01, P = 0.431). There may be a cumulative effect of BTX-A injections to the salivary glands, resulting in longer periods of efficacy with consecutive injection.

Predictors of Tracheostomy Decannulation in Adult Laryngotracheal Stenosis.

Predictors of tracheostomy decannulation in patients with laryngotracheal stenosis are not fully known, making prognosis difficult. The aim was to identify predictors of tracheostomy decannulation in adult patients with acquired stenosis of the larynx and/or trachea who were tracheostomy dependent. Case series. Academic teaching hospital. A total of 103 consecutive adult patients with laryngotracheal stenosis who were tracheostomy dependent and seen by the otolaryngology clinic from January 1, 2013, to August 2, 2018, were included. Exclusion criteria included age <18 years, history of laryngeal cancer or head and neck radiation, or history of laryngeal fracture. The primary outcome was the presence of tracheostomy at last follow-up. The patients' etiology of stenosis, comorbid conditions, and characteristics of the stenosis were analyzed to determine if there was a statistically significant relationship with decannulation. A total of 103 patients were included: 67% of patients were women and the average age was 53.5 years. Sixty-four patients (62%) were successfully decannulated. In multivariate analysis, patients who were successfully decannulated presented to the otolaryngology clinic earlier after tracheostomy was performed, were more likely to have been intubated due to trauma, and were less likely to have gastroesophageal reflux disease. In patients with subglottic or tracheal stenosis, those with granulation tissue without firm scar were more likely to be decannulated, and those who underwent rigid dilation were less likely to be decannulated. Early evaluation by an otolaryngologist may increase the likelihood of tracheostomy decannulation in patients with laryngotracheal stenosis. Patient comorbidities may assist in predicting which patients will be successfully decannulated.

Factors Related to Extralaryngeal Spread in Juvenile Recurrent Respiratory Papillomatosis.

To identify factors associated to increased risk of extra-laryngeal spread in pediatric patients with recurrent respiratory papillomatosis (RRP). Retrospective chart review. A retrospective study was conducted evaluating the clinical charts of patients younger than 16 years with histopathologically confirmed RRP treated between January 2014 and December 2018. Characteristics of patients with and without extra-laryngeal disease dissemination were compared. Odds ratios were calculated and multivariate logistic regression analysis was performed. Data from 82 patients were analyzed. Mean age at symptom onset was 42 months. Fifteen (18.29%) patients had extra-laryngeal spread (ELS) at time of diagnosis and in four, the disease continued to spread to other sites. Of 67 patients with disease restricted to the larynx, 17 (25.37%) developed ELS during the disease course. Human papilloma virus (HPV) typing was performed in 49 (59.8%) patients; in 28 (57.1%) HPV subtype 6 was identified and in 21 (42.9%) HPV subtype 11. ELS was found in 11 patients with serotype 11 (52.38%) and in seven patients with serotype 6 (25%) (P=.048). Statistically significant differences for ELS were also found for age at diagnosis younger than 5 years (P=.045), presence of tracheostomy (P=.031), and need for adjuvant therapy (P=.010). Age at diagnosis of RRP younger than 5 years and presence of tracheostomy were factors related to ELS. A statistically significant association between infection with HPV subtype 11 and ELS were also observed. Adjuvant medication might be considered a protective factor against ELS. Laryngoscope, 131:1652-1656, 2021.

Mechanism of Dysphagia after Acute Traumatic Cervical Spinal Cord Injury.

Swallowing dysfunction, which may cause aspiration pneumonia, is one of the most important complications of treatment of traumatic cervical spinal cord injury (CSCI); however, the mechanism of dysphagia is not well understood. No previous studies have reported the association between morphological changes of the soft tissue and dysphagia. We aimed to determine the factors associated with severity of dysphagia after CSCI and elucidate its mechanism. We conducted a prospective analysis of patients with acute traumatic CSCI who were admitted within 2 weeks of the injury. Dysphagia was evaluated using the Dysphagia Severity Scale (DSS) 2 weeks after the injury. The widths of the retropharyngeal and retrotracheal spaces were measured to assess soft tissue damage owing to the injury using sagittal images of computed tomography. We also assessed age, surgery of the injured cervical spine, presence of tracheostomy, osteophyte behind the pharynx, level of injury, and motor score 2 weeks after the injury. A total of 136 persons met our criteria. Given that 44 persons were categorized under grades <5 of the DSS, which were defined as different types of aspirations, the incidence of aspiration was 32%. The multiple regression analysis revealed that age, motor score, tracheostomy, and retropharyngeal space were significantly associated with DSS. Severe paresis, tracheostomy, old age, and swelling of the retropharyngeal space were significantly affected by dysphagia after CSCI. Morphological changes in the pharynx, situated right behind the larynx, after the injury affects the mechanism of dysphagia.

Correlation between surgical site infection and classification of early onset scoliosis (C-EOS) in patients managed by rib-based distraction instrumentation.

The aim of this study is to determine risk factors for infection among EOS patients treated by rib-based distraction instrumentation, and to further assess the incidence of infection among C-EOS categories and sub-types. Despite the heterogonous nature of early onset scoliosis, the classification of early onset scoliosis (C-EOS) has proven to have excellent reliability across its major categories. C-EOS's reliability has been verified; however, little data exist on the utility of this categorization in clinical decision-making and risk assessment. After institutional review board approval, data for EOS patients treated by rib-based distraction instrumentation were collected between 2013 and 2017 in a single institution. Data collection included: major categories of early onset scoliosis classification (etiology, major curve and kyphosis), BMI, height, weight, procedure type, site of procedure, presence of tracheostomy, and bowel/urinary incontinence. 156 EOS patients underwent 843 rib-based distraction instrumentation procedures. 22.4% of patients (35/156 patients, 42 procedures) developed infections, 30/35 requiring irrigation and debridement. Type of procedure was significantly associated with infection rate, with rib-based distraction instrumentation insertion corresponding with the highest incidence of infection, as compared to instrumentation revisions or expansions (p = 0.006). Infection rates were also more common in shorter and lighter weight children (p = 0.001 and 0.03; respectively). Patients with a neuromuscular etiology had the highest rate of infection in comparison to congenital, syndromic, and idiopathic (5.7% vs, 4.9%, 4.7%, and 2.6%; respectively). Notably, high infection rates occurred neuromuscular hyper-kyphotic subjects (M+), occurring in all major curve C-EOS subgroups and at a rate of 8.3% for all procedures. Neuromuscular, larger magnitude major curve, and larger magnitude kyphotic angle C-EOS categories appear to be at a higher risk of infection. Such information potentiates the usefulness of C-EOS in surgical decision-making and in the informed consent process. Level III therapeutic.

Acute pediatric tracheitis: Distinguishing the disease by tracheostomy status

ObjectivesTracheitis is an upper airway infection that often presents in patients with tracheostomies and can potentially cause airway obstruction. This study aims to use a nationwide database to identify a large cohort of pediatric patients admitted with tracheitis to elucidate the management and resource utilization associated with the disease both with and without tracheostomies. MethodsThe Kids’ Inpatient Database (KID) 2012 was used to identify 2394 weighted discharges with acute tracheitis, with or without obstruction, as the primary diagnosis. Data on prior tracheostomy status, demographics, hospital characteristics, management, and resource utilization were obtained. Two groups of interest, based on presence of prior tracheostomy, were studied. Linear regression was performed to determine independent predictors of total charges. ResultsThe mean age was 5.52 years (SD: 5.54), mean length of stay (LOS) was 6.37 days (SD: 10.18), and mean total charges were $60,996.61 (SD: 107,798.41). Patients with prior tracheostomy had lower rates of endoscopy and endotracheal intubation than patients without (p < 0.0005). There was no significant difference in LOS (p = 0.076) or total charges (p = 0.210) between the groups based on prior tracheostomy status. ConclusionPediatric tracheitis should be differentiated on the basis of tracheostomy status. We propose that tracheitis diagnosis codes should be distinguished by the presence of tracheostomy as “open” and the absence of tracheostomy as “closed.”

Improvement of Swallowing Function After Surgical Treatment of Diffuse Idiopathic Skeletal Hyperostosis: Our Experience

To investigate the swallowing improvement in patients who underwent a transcervical prevascular retrovisceral approach for symptomatic cervical diffuse idiopathic skeletal hyperostosis (DISH), by means of the 10-item Eating Assessment Tool (EAT-10) questionnaire. Retrospective observational study of 21 patients treated with a transcervical anterior prevascular retrovisceral approach for symptomatic DISH with dysphagia as the primary symptom. All patients underwent videofluoroscopic study of swallowing before surgery and the EAT-10 questionnaire before and after the surgical procedure. A statistically significant (P < 0.001) improvement in the postoperative EAT-10 score was reported. Sixteen out of 21 patients (76.2%) had their symptoms completely resolved, with an EAT-10 score less than 3. These results were not influenced by age and sex nor by presence of tracheostomy. The preoperative EAT-10 score was consistently related to postoperative outcome. Patients with mild and moderate dysphagia had better Δ in EAT-10 scores than patients with severe and very severe dysphagia (P= 0.02). Surgical management seems to be effective in resolving swallowing disorders related to this disease in a consistent percentage of patients. This evidence is supported by the statistically significant improvement in EAT-10 scores after treatment. Moreover, it might be postulated that early intervention can guarantee a higher success rate because patients with severe and very severe dysphagia had significantly smaller improvement.

Neurological and neurosurgical early rehabilitation in Lower Saxony and Bremen

We analyzed the delivery of healthcare services among patients in neurological and neurosurgical early rehabilitation programmes in the German states of Lower Saxony and Bremen. Patients´applications and admissions for neurological and neurosurgical early rehabilitation in Lower Saxony and Bremen were recorded during a period of two weeks both in November 2015 as well as 2016. The proportion of patients admitted to early rehabilitation within a six-week-period after disease onset was calculated. In addition, factors influencing the probability of admission were investigated. Only 45 % of all patients transferred from a primary neurological / neurosurgical unit to an early rehabilitation facility in Lower Saxony / Bremen were successfully admitted. The probability of admission fell when patients were colonized with multi-drug resistant bacteria (21 % in comparison), in particular Methicillin-resistant Staphylococcus aureus (MRSA) with an admission rate of only 13 %. Deleterious effects were also observed in patients dependent on hemodialysis (20 %), or those with a primary diagnosis of polyneuropathy / Guillain-Barré-Syndrome (33 %) or hypoxic brain damage (37 %), as well as patients on mechanical ventilation (37 %). Patients had a higher probability of being admitted with the primary diagnoses of subarachnoid hemorrhage (52 %) or stroke (51 %). Age, Early Rehabilitation Index (ERI), monitoring, presence of tracheostomy, dysphagia, orientation or behavioral disturbances had no influence on the probability of admission, as well as other primary diagnoses or the number of admissions in one or more rehabilitation centers. Over one-half of the patients applying for admission to neurological / neurosurgical early rehabilitation facilities in Lower Saxony and Bremen were not admitted. Apparently, the capacity of early rehabilitation treatment in these two German states is not optimal.

Circular tracheal resection for acquired tracheal stenosis: evaluation of early and long-term outcomes

To present single-center experience and results of surgical treatment of acquired tracheal stenosis. There were 99 patients with acquired tracheal stenosis for the period from January 2008 to December 2017. Median age was 39 (28; 55) years (range 19-79 years), male/female ratio - 64/35. There were 59 patients with tracheostomy-related stenosis, 31 - post-intubation injury, 6 - posttraumatic stenosis, malignant and idiopathic stenosis was observed in 2 and 1 patients, respectively. Single-stage circular tracheal resection or staged surgical approach were preferred depending on localization and severity of stenosis, respiratory function at admission, severity of concomitant diseases and possibility of prolonged head adduction, presence of tracheostomy and cervical tissues inflammation, functional state of laryngeal structures. Single-stage circular tracheal resection was applied in 44 (44.4 %) out of 99 cases. In 55 (55.6%) patients staged approach was preferred: Montgomery T-tube placement followed by tracheoplasty after 6-12 months - 27 patients; tracheoplasty on prefabricated endotracheal stent - 8 patients; staged endotracheal treatment (including Dumon prosthesis deployment) - 12 patients. In 11 cases circular resection was done as a final stage of treatment. There was no in-hospital mortality after circular tracheal resection. Morbidity included anastomotic dehiscence - 2 (3.6%), recurrent stenosis in 6 months after surgery - 1 (1.8%), granulation tissue growth followed by stenosis - 4 (7.3%), wound infection - 3 (5.5%) cases), postoperative pneumonia - 2 (3.6%) patients, respectively. Tracheal resection is preferred for tracheal stenosis management. Alternative techniques are life-saving procedures, but could potentially extent the length of stenosis and delay recovery of the patient.

Standard or individualized quality of life for larynx cancer patients?

Locally advanced larynx cancer benefits from curative surgery therapy. Clinical trials have been proposed for assessing the quality of life for patients with larynx malignant neoplasia who underwent radical surgery. The removal of the “voice box” is known to have great impact on the social reintegration of these patients as well as psychological distress. The presence of tracheostomy and voice impairment are two of the major issues that need to be thought of by patients that will have a total laryngectomy. The quality of life is a multi-dimensional subjective and personal concept which includes normal physical activity, looks, psychological status, somatic symptoms and, non the less, sexual activity. Cancer free survival intervals for patients with larynx cancer must be evaluated physical and psychological modifications with particular considerations to stress, anxiety and depression related symptoms and to functional rehabilitation adaptation regarding swallowing and speech. Oncology surgeons must consider that QoL is impaired in all patients with larynx cancer that benefit from total laryngectomy. However, there is evidence presented below that the difference in QoL parameters is small when comparing radical surgery, total laryngectomy, and larynx conservation by radio and chemotherapy.

Extensively drug-resistant Acinetobacter baumannii and Proteeae association in a Romanian intensive care unit: risk factors for acquisition.

PurposeThe purpose of this study was to identify risk factors for extensively drug-resistant (XDR) Acinetobacter baumannii (AB) and XDR Proteeae association in the largest intensive care unit (ICU) in Western Romania.Materials and methodsThis retrospective case-controlled study was conducted between January 2016 and December 2016 in the ICU of the “Pius Brînzeu” County Emergency Clinical Hospital of Timi oara. Data were collected, in strict confidentiality, from the electronic database of the Microbiology Laboratory and the hospital’s electronic medical records. Risk factors were ș investigated by logistic regression. Independent variables with P≤0.05 and OR >1 (95% CI >1) in the univariate analysis were entered into multivariate sequenced analysis.FindingsThe incidence density of coinfection with XDR AB and XDR Proteeae was 5.31 cases per 1,000 patient-days. Independent risk factors for the association of XDR AB and XDR Proteeae were represented by the presence of tracheostomy and naso-/orogastric nutrition ≥ 8 days. In addition, pressure ulcers were independent predictive factors for infections with all three infection types. Previous antibiotic therapy was an independent risk factor for the acquisition of XDR-AB strains, alone or in association, while the prolonged hospitalization in the ICU, blood transfusion, and hemodialysis appear as independent risk factors for single infections.ConclusionThis association of XDR AB and XDR Proteeae may well not be limited to our hospital or our geographical area.

Risk Factors for Dysphagia After a Spinal Cord Injury: A Systematic Review and Meta-Analysis

Systematic review and meta-analysis. To determine the risk factors predictive of dysphagia after a spinal cord injury (SCI). None. A comprehensive literature search was performed in five scientific databases for English articles that identified risk factors for dysphagia after a SCI in adult (≥19 years) individuals. Data extracted included: author name, year and country of publication, participant demographics, sample size, study design, method of dysphagia diagnosis, and risk factor percentages. Methodological quality of studies was assessed using the Newcastle–Ottawa Scale. For identified risk factors, risk percentages were transformed into risk ratios (RR) with 95% confidence intervals. Quantitative synthesis was performed for risk factors reported in two or more studies using restricted maximum-likelihood estimator random effects models. Eleven studies met inclusion criteria of which ten studies were of moderate quality (n = 10). Significant risk factors included: age, injury severity, level of injury, presence of tracheostomy, coughing, voice quality, bronchoscopy need, pneumonia, mechanical ventilation, nasogastric tubes, comorbid injury, and a cervical surgery. Results of the quantitative synthesis indicated that the presence of a tracheostomy posed a threefold greater risk of the development of dysphagia (RR: 3.67); while, cervical surgery posed a 1.3 times greater risk of the development of dysphagia (RR: 1.30). Knowledge of these risk factors can be a resource for clinicians in the early diagnosis and appropriate medical management of dysphagia post SCI.

Toxic epidermal necrolysis data from the CELESTE multinational registry. Part II: Specific systemic and local risk factors for the development of infectious complications

The aim of the study was to identify the most important systemic and local risk factors for the development of infectious complications in patients with toxic epidermal necrolysis (TEN). Material and methodologyThis is a multicentric study that included all patients with TEN who were hospitalized between 2000–2015 in specialized centres in the Czech Republic and Slovakia. The total catchment area included a population of over 12.5 million inhabitants.The actual implementation of the project was carried out using data obtained from the CELESTE (Central European LyEll Syndrome: Therapeutic Evaluation) registry, wherein specific parameters related to epidemiological indicators and infectious complications in patients with TEN were evaluated as a retrospective analysis. ResultsA total of 38 patients (97%) of the group were treated with corticosteroids. The comparison of patients with different doses of corticosteroids did not exhibit a statistically significant effect of corticosteroid administration on the development of infectious complications (p=0.421).There was no effect of the extent of the exfoliated area on the development of infectious complications in this area. The average extent of the exfoliated area was 66% TBSA (total body surface area) in patients with reported infectious complications and 71% TBSA (p=0.675) in patients without infectious complications.In the case of the development of an infectious complication in the bloodstream (BSI), the increasing effect of the SCORTEN (SCORe of Toxic Epidermal Necrosis) value was monitored during hospitalization. Within 5days from the beginning of the hospitalization, the average SCORTEN value was 2.7 in 6 patients with BSI and 3.0 in 32 patients without BSI (p=0.588). In the period after the 15th day of hospitalization, 7 patients with BSI had an average SCORTEN value of 3.4, and 16 patients without BSI had an average SCORTEN value of 2.5 (p=0.079).In the case of low respiratory tract infection (LRTI), the effects of the necessity for artificial pulmonary ventilation and the presence of tracheostomy were monitored. The statistically significant effect of mechanical ventilation on the development of LRTI occurred only during the period of 11–15days from the beginning of the hospitalization (p=0.016). The effect of the tracheostomy on the development of LRTI was proven to be more significant. ConclusionWe did not find any statistically significant correlation between the nature of immunosuppressive therapy and the risk of developing infectious complications. We failed to identify statistically significant risk factors for the development of BSI. Mechanical ventilation and tracheostomy increase the likelihood of developing LRTIs in patients with TEN.

Predictive value of the Hyodo score in endoscopic evaluation of aspiration during swallowing

ObjectiveThe Hyodo scoring system during the endoscopic procedure has been proposed as a new tool for evaluating oral intake feasibility. However, the effectiveness of the information obtained from this procedure in predicting aspiration is not fully elucidated. The aim of this study was to assess the significance of clinical factors, including Hyodo scores, for predicting the risk of aspiration. MethodsFive hundred and twenty-eight endoscopic swallowing examinations were performed. Clinical factors, including age, sex, disease type, history of aspiration pneumonia, cognitive function, presence of tracheostomy, presence of vocal cord paralysis, consciousness level on the Japan Coma Scale, ECOG Performance Status, serum albumin level and Hyodo score, were obtained for each examination. The relationship between each of these factors and the presence of aspiration during endoscopic procedure was evaluated. ResultsThree hundred and thirty-two patients (62.9%) were scored less than 5, 153 (29.0%) were scored between 5 and 8, and 43 (8.1%) were scored above 8. The number of patients with aspiration was 133 (25.2%). ROC analysis revealed that a cut-off point of 6 for Hyodo score was effective for predicting aspiration, with a sensitivity of 0.65 and a specificity of 0.86. History of aspiration pneumonia (OR 1.87, P<0.001), vocal cord paralysis (OR 2.23, P<0.001), PS≥3 (OR 2.47, P<0.001) and Hyodo score>6 (OR 9.08, P<0.001) were found to be independent predictive factors for aspiration. ConclusionThe Hyodo scoring method was easy for otolaryngologists to perform and the scores were useful for predicting aspiration with moderate sensitivity and high specificity. Hyodo score>6, history of aspiration pneumonia, vocal cord paralysis, and PS≥3 were independent predictive factors for aspiration and that a Hyodo score above 6 was the statistically strongest predictor for aspiration.

Frequency and Characterization of Tracheal Intubation Adverse Events in Pediatric Sepsis.

Intubation in critically ill pediatric patients is associated with approximately 20% rate of adverse events, but rates in the high-risk condition of sepsis are unknown. Our objectives were to describe the frequency and characteristics of tracheal intubation adverse events in pediatric sepsis. Retrospective cohort study of a sepsis registry. Two tertiary care academic emergency departments and four affiliated urgent cares within a single children's hospital health system. Children 60 days and older to 18 years and younger who required nonelective intubation within 24 hours of emergency department arrival. Exclusion criteria included elective intubation, intubation prior to emergency department arrival, presence of tracheostomy, or missing intubation chart data. Not applicable. The outcome was tracheal intubation adverse event as defined by the National Emergency Airway Registry Tool 4 KIDS. During the study period, 118 of 2,395 registry patients met inclusion criteria; 100% of intubations were successful. First attempt success rate was 57% (95% CI, 48-65%); 59% were intubated in the emergency department, and 28% were intubated in the PICU. First attempts were by a resident (30%), a fellow (42%), attending (6%), and anesthesiologist (13%). Tracheal intubation adverse events were reported in 61 (43%; 95% 43-61%) intubations with severe tracheal intubation adverse events in 22 (17%; 95 CI, 13-27%) intubations. Hypotension was the most common severe event (n = 20 [17%]) with 14 novel occurrences during intubation. Mainstem bronchial intubation was the most common nonsevere event (n = 28 [24%]). Residents, advanced practice providers, and general pediatricians in urgent care settings had the lowest rates of first-pass success. The rates of tracheal intubation adverse events in this study are higher than in nonelective pediatric intubations in all conditions and highlight the high-risk nature of intubations in pediatric sepsis. Further research is needed to identify optimal practices for intubation in pediatric sepsis.

Mitomycin C in the endoscopic treatment of tracheal stenosis: a prospective cohort study.

ABSTRACTObjective:To evaluate the efficacy of mitomycin C (MMC) in the endoscopic treatment of tracheal stenosis. Methods:Patients with laryngotracheal, tracheal, or tracheobronchial stenosis were treated with dilation and topical MMC. The inclusion criteria were as follows: being ineligible for surgery (for medical reasons) at the time of evaluation; membranous stenosis responding well to dilation; and postoperative stenosis at the anastomosis site. Etiology of stenosis and indication for treatment with MMC, as well as site, length, and percentage of stenosis, together with presence of tracheostomy and duration of follow-up, were analyzed. The outcomes evaluated were symptom-free interval ≥ 12 months, number of dilations with topical application of MMC, and complications. Results:Twenty-two patients (15 men and 7 women) were treated between 2003 and 2010. Stenosis was due to endotracheal intubation in 15 patients and surgery in 8. Pure tracheal stenosis was encountered in 13 patients, subglottic stenosis was encountered in 4, tracheobronchial stenosis was encountered in 3, and complex stenosis was encountered in 2. The length of stenosis ranged from 0.5 cm to 2.5 cm, and the percentage of stenosis ranged from 40% to 100%. Nine patients had undergone tracheostomy and had a Montgomery T-tube in situ. Treatment was successful in 14 patients, who remained free of symptoms for at least 12 months. The number of topical applications of MMC ranged from 1 to 5, and complications included fungal infection, keloid scarring, granuloma, and mediastinal emphysema. Conclusions:MMC appears to be effective in the endoscopic treatment of tracheal stenosis.

Management of dysphagia following radiation therapy and tracheostomy

&lt;p class="abstract"&gt;&lt;span lang="EN-IN"&gt;Dysphagia (swallowing disorders) have been reported commonly following oral and laryngeal cancers. Patients undergoing radiation therapy usually complaint of deterioration in swallowing functions due to fibrosis. Also, presence of tracheostomy causes aspiration while swallowing by reducing the hyolaryngeal excursion and also leading to inadequate subglottic pressure and fixation of trachea. An 85 year old male with history of supraglottic carcinoma managed by radiation therapy and tracheostomy reported for swallowing assessment. Detailed assessment was performed using clinical swallow examination and instrumental assessment (modified barium swallow) using thin, thick and paste consistencies. Results revealed no overt signs of penetration on clinical swallow while modified barium swallow revealed severe intraswallow aspiration due to incomplete hyolaryngeal elevation on all consistencies (more for liquids). This clearly indicated silent aspiration. Swallowing therapy focused on hyolaryngeal elevation using protective maneuvers. Reassessment was performed following 7 sessions using the above mentioned protocol which revealed improvement in hyolaryngeal elevation (complete hyolaryngeal closure during swallow) and no aspiration on all consistencies. Dysphagia is a common complication following radiation therapy. An instrumental assessment is mandatory to rule out silent aspirations as seen in the present case. Swallowing intervention has an important role to treat dysphagia following radiation therapy and has shown to be effective in the present study and literature. Hence, patients who have indications for radiation therapy should undergo swallowing intervention in order to ensure safe oral intake.&lt;/span&gt;&lt;/p&gt;

The association between oral health status and respiratory pathogen colonization with pneumonia risk in institutionalized adults.

This study aimed to assess the oral health and the prevalence of pre-existing oral colonization with respiratory pathogens in dependent elderly, and whether these factors influence pneumonia development. Participants residing in a long-term care facility received bedside oral examinations, and information on their oral health (caries status, calculus index and debris index) was obtained. Samples from the tongue and teeth were collected at baseline and at time of pneumonia development. Sputum was collected at the time of pneumonia diagnosis. Samples were assessed for Haemophilus influenzae, Klebsiella pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus and Streptococcus pneumoniae by polymerase chain reaction. This was a 1-year longitudinal study of 60 dependent elderly (mean age: 64.2±14.1years). Seventeen patients (28.3%) developed pneumonia. The mean Decayed, Missing and Filled Teeth and Simplified Oral Hygiene Index were 22.8±9.2 and 4.0±1.0, respectively. At baseline, 48.3% were orally colonized with ≥1 respiratory pathogens. The presence of H.influenzae (P=.002) and P.aeruginosa (P=.049) in the sputum was significantly associated with their colonization on the tongue at baseline. In the bivariate analyses, pneumonia development was associated with naso-gastric feeding tube (P=.0001), H.influenzae (P=.015) and P.aeruginosa (P=.003) tongue colonization at baseline and calculus index (P=.002). Multivariate analyses revealed that calculus index (P=.09) and the presence of tracheostomy (P=.037) were associated with pneumonia. The calculus amount and tongue colonization with respiratory pathogens are risk factors for pneumonia development. Oral hygiene measures to remove tongue biofilm and calculus may reduce pneumonia development.