Term Tracheostomy Research Articles

Provider moral distress in caring for tracheostomy and ventilator dependent children: A single institution cross-sectional evaluation.

To determine levels of moral distress in a pediatric unit caring for patients with tracheostomy/ventilator dependence. Moral distress will be significant in a dedicated pediatric trach/vent unit. The Moral Distress Survey-Revised (MDS-R) is a 21-question survey measuring moral distress in pediatrics. The MDS-R was anonymously distributed to medical degree/doctor of osteopathy(MD/DOs), advanced practice practitioners (APPs), registered nurses(RNs), and respiratory therapists (RTs) in a unit caring for tracheostomy/ventilator dependent patients. Descriptive statistics, bivariate and multivariate analysis were performed. Response rate was 48% (61/127). Mean MDS-R score was 83 (range 43-119), which is comparable to reported levels in the pediatric intensive care unit (ICU). APPs had the highest median rate of moral distress (112, interquartilerange[IQR], 72-138), while MD/DOs had the lowest median score (49, IQR, 43-77). RNs and RTs had MDS-R scores between these two groups (medians of 91 and 84, respectively). Moral distress levels in a unit caring for long term tracheostomy and ventilator dependent patients are high, comparable to levels in pediatric ICUs. APPs.APPs had higher levels of distress compared to other groups. This may be attributable to the constant stressors of being the primary provider for complex patients, especially in a high-volume inpatient setting.

Tracheostomy among Children Admitted in the Pediatric Intensive Care Unit of a Tertiary Care Centre.

Tracheostomy is commonly performed for upper airway obstruction, prolonged mechanical ventilation and tracheo-bronchial toileting. Pediatric tracheostomy differs from adult tracheostomy in terms of surgical procedure, post-operative care and recovery. The tracheostomized patients may either be decannulated, discharged with tube-in-situ or the patient may expire. The aim of this study was to find out the prevalence of tracheostomy in patients admitted to the Pediatric intensive care unit of a tertiary care centre. A descriptive cross-sectional study was performed among children admitted to the Pediatric intensive care unit of a tertiary care centre from 1 May 2017 to 31 August 2022 after obtaining ethical approval from the Institutional Review Committee. A convenience sampling method was used. The point estimate was calculated at 95% Confidence Interval. Among 1472 patients, tracheostomy was done in 65 (4.41%) (3.37-5.47, 95% Confidence Interval). A total of 33 (50.76%) underwent tracheostomy for prolonged ventilation whereas 32 (49.23%) were tracheostomized for airway obstruction. Among them, 41 (63.07%) patients were successfully decannulated, 9 (13.84%) were discharged with tracheostomy tubes in situ whereas 15 (23.07%) patients deceased. The most common complication was tracheostomy tube blockage reported in 5 (7.69%). The prevalence of tracheostomy among the children of the pediatric intensive care unit was found to be lower than in other studies. mechanical ventilation; complication; pediatric; tracheostomy.

Recurrent acute-onset of chronic inflammatory demyelinating polyneuropathy after COVID-19 vaccination

This is the case of 54-year-old male with a past medical history of Chronic Inflammatory Demyelinating Polyneuropathy (CIPD) who was found to have an acute exacerbation of CIPD shortly after receiving his 1st COVID 19 booster (3rd dose of vaccination series) and was successfully treated with intravenous immunoglobulin (IVIG) and then was found to have another acute exacerbation of CIDP 6 months later after receiving his 2nd COVID 19 booster (4th dose of vaccination series) that required intubation and long term tracheostomy. CIPD is an acquired immune-mediated polyneuropathy that mainly affects the peripheral nerve roots nerves. It typically presents with relapsing/remitting, or progressive symmetrical muscle weakness and sensory involvement and can cause decreased respiratory effort. COVID-19 is mainly a respiratory disease, but it has been associated with a wide variety of neurological conditions. Although there have been several findings of acute inflammatory demyelinating polyneuropathy in association with COVID-19, CIDP exacerbation as a result of COVID-19 has rarely been seen in the literature. Furthermore, CIDP exacerbation as a result of COVID-19 vaccination is even less frequently seen.

Timing of tracheostomy and patient outcomes in critically ill patients requiring extracorporeal membrane oxygenation: a single-center retrospective observational study

BackgroundExtracorporeal membrane oxygenation (ECMO) is an integral method of life support in critically ill patients with severe cardiopulmonary failure; however, such patients generally require prolonged mechanical ventilation and exhibit high mortality rates. Tracheostomy is commonly performed in patients on mechanical ventilation, and its early implementation has potential advantages for favorable patient outcomes. This study aimed to investigate the association between tracheostomy timing and patient outcomes, including mortality, in patients requiring ECMO.MethodsWe conducted a single-center retrospective observational study of consecutively admitted patients who were supported by ECMO and underwent tracheostomy during intensive care unit (ICU) admission at a tertiary care center from April 2014 until December 2021. The primary outcome was hospital mortality. Using the quartiles of tracheostomy timing, the patients were classified into four groups for comparison. The association between the quartiles of tracheostomy timing and mortality was explored using multivariable logistic regression models.ResultsOf the 293 patients treated with ECMO, 98 eligible patients were divided into quartiles 1 (≤ 15 days), quartile 2:16–19 days, quartile 3:20–26 days, and 4 (> 26 days). All patients underwent surgical tracheostomy and 35 patients underwent tracheostomy during ECMO. The complications of tracheostomy were comparable between the groups, whereas the duration of ECMO and ICU length of stay increased significantly as the quartiles of tracheostomy timing increased. Patients in quartile 1 had the lowest hospital mortality rate (19.2%), whereas those in quartile 4 had the highest mortality rate (50.0%). Multivariate logistic regression analysis showed a significant association between the increment of the quartiles of tracheostomy timing and hospital mortality (adjusted odds ratio for quartile increment:1.55, 95% confidence interval 1.03–2.35, p for trend = 0.037).ConclusionsThe timing of tracheostomy in patients requiring ECMO was significantly associated with patient outcomes in a time-dependent manner. Further investigation is warranted to determine the optimal timing of tracheostomy in terms of mortality.

Comparison of percutaneous tracheostomy methods in ICU patients: Conventional anatomical landmark method versus ultrasonography method - A randomised controlled trial.

ABSTRACTBackground and Aims:Percutaneous dilational tracheostomy (PDT) is a common procedure in intensive care unit (ICU) patients requiring long-term mechanical ventilation. PDT has gradually replaced surgical tracheostomy because it is associated with minimal invasiveness, reduced bleeding and simplicity in technique.This study was conducted to compare ultrasound-guided PDT versus conventional tracheostomy in terms of duration of the procedure, number of passes and immediate peri-procedural complications.Methods:A total of 72 patients with clinical indications of tracheostomy were recruited. A total of 12 patients met the exclusion criteria. The remaining were randomly assigned into two groups of 30 each: Group A (Landmark) with traditional anatomical landmark and Group B (USG) with real-time ultrasound guidance. Puncture positions were recorded with bronchoscopy. Midline deviation was captured on a bronchoscopy image using a protractor. Data on procedural safety and efficacy were also collected.Results:Group B had significantly fewer cases of midline deviation (11.33 ± 9.51) in comparison to Group A (16.60 ± 12.31). Trials > 2 were equal to 11 in Group A and 2 in Group B. However, the duration of the procedure was higher in Group B (20.07 ± 3.25 min) as compared to Group A (15.20 ± 3.71 min). Peri-procedural and post-procedural complications were also higher in the Landmark group.Conclusion:Ultrasound-guided PDT showed superiority over landmark PDT in terms of less number of trials, midline puncture and fewer complications. However, it took a little longer to perform USG-guided PDT.

Early versus Late Tracheostomy in Patients with Acute Brain Injury: Importance of SET Score.

Introduction:Patients with acute brain injury presents are unique subset of neurocritical care patients with its long-term functional prognosis difficult to determine. They often have long intensive care unit (ICU) stay and presents as challenge to decide when to transfer out of ICU. This prospective study aims to assess the benefits of early tracheostomy in terms of ICU-length of stay (ICU-LOS), number of days on ventilator (ventilator days), incidence of ventilator-associated pneumonia (VAP), and mortality rates.Materials and Methods:After institutional ethical clearance, 80 patients were randomized into two groups: Group A, early tracheostomy group (tracheostomy within 3 days of intubation) and Group B, standard of care group (tracheostomy after 10 days of intubation: late tracheostomy). A cutoff of 10 in the SET score was used in predicting need of early tracheostomy; both groups were compared with respect to ICU-LOS, number of ventilator days (ventilation time), need of analgesia and sedation, incidence of VAP, and mortality data.Results:Both the groups were comparable in terms of demographic profile and various disease severity scores. ICU-LOS was 14.9 ± 3.6 days in Group A and 17.2 ± 4.6 in Group B. The number of days on ventilator and incidence of VAP was significantly lower in Group A as compared to Group B. There was significantly lower mortality in Group A subset of patients in ICU.Conclusion:SET score is a simple and reliable score with fair accuracy and high sensitivity and specificity in predicting need of tracheostomy in neurocritical patients. A cutoff of 10 in the score can be reliably used in predicting need of early tracheostomy as in few other studies. Early tracheostomy is clearly advantageous in neurocritical patients, but has no advantage in terms of long-term mortality rates.

Decannulation protocol for short term tracheostomy in pediatric head and neck tumor patients

BackgroundWhile the majority of pediatric tracheostomies are performed in the setting of chronic and complex medical comorbidities, perioperative tracheostomies following head and neck tumor ablation are generally short-term. Deliberate planning is required for decannulation in this setting and no published protocols currently exist. Our study outlines a management strategy for short-term tracheostomy in pediatric patients following head and neck surgery. MethodsA retrospective study of pediatric head and neck tumor patients undergoing tracheostomy was performed at a quaternary children's hospital from February 1, 2016 to December 31, 2018. Charts were reviewed for demographics, surgical operation, relevant tracheostomy-related complications, and time to decannulation. ResultsEleven patients with a mean age of 10.4 years (st.dev. 6.7, range: 0.5–23) underwent tracheostomy during their primary ablative/reconstructive surgery. Trans-tracheal pressure monitoring helped direct the need for tracheostomy downsizing and readiness for capping trials. All patients were decannulated before hospital discharge after a mean of 12.8 days (st.dev. 2.5, range: 9–18) and were discharged after a mean of 14.8 days (st.dev. 2.5, range: 11–20). ConclusionPediatric head and neck surgery patients can be quickly and safely decannulated with an instructive protocol and multidisciplinary care.

English

BACKGROUND The term tracheostomy refers to forming an opening in the trachea.1,2 Its advantages include easy and direct access to lower respiratory tract, reduced risk of aspiration, faster weaning from ventilation support and improved physical and psychological comfort. But a common problem in tracheostomised patients is increased risk of colonisation of lower respiratory tract by exogenous bacteria because of direct exposure.1,3 This study was done to recognise pathogens in tracheal secretions collected from tracheostomised patients and their antibiotic sensitivity to treat them with appropriate antibiotics. METHODS This prospective study was done in 138 tracheostomised patients from October 2020 to March 2021 in intensive care unit (ICU) of Chettinad Hospital and Research Institute. Under sterile aseptic precautions, Day 0 and Day 7 cultures posttracheostomy was obtained and their antibiotic sensitivity was studied. Data was analysed using Statistical Package for Social Sciences (SPSS version 19) and presented in proportion, mean and standard deviation (Descriptive statistics). RESULTS In this study, of the 56 cases who had growth in their culture and sensitivity reports on day 0, the most common organism was Pseudomonas aeruginosa (33.9 %) sensitive to imipenem (94.7 %) followed by klebsiella (25 %) sensitive to teicoplanin, vancomycin, amikacin, cefoperazone/tazobactam, linezolid and piperacillin/tazobactam. On day 7, the growth of organisms isolated in tracheal culture got reduced from 56 cases to 16 cases. The prevalence of Pseudomonas reduced to 18.8 % in day 7 whereas Klebsiella pneumonia and Acinetobacter remained almost same from day 0 to day 7. CONCLUSIONS This study concludes the predominant pathogen as Pseudomonas aeruginosa with sensitivity to imipenem followed by Klebsiella with sensitivity to teicoplanin, vancomycin, amikacin, cefoperazone/tazobactam, linezolid and piperacillin/tazobactam on day 0 with reduction in the number of organisms on day 7 due to the fact that all our patients were admitted in ICU several days prior to tracheostomy and were started on antibiotics soon after admission as per choice of the treating physician. Hence, a clear understanding of bacterial colonisation post tracheostomy and its change in course is essential for timely intervention with empirical antibiotics for reducing the incidence of lower respiratory tract infections after tracheostomy in future. KEY WORDS Tracheostomy, Lower Respiratory Tract Infections, Pseudomonas Aeruginosa, Empirical Antibiotics.

An Overview of Outcomes Associated With Early Versus Late Tracheostomy From a National Standpoint.

Tracheostomy is a procedure that is commonly used in critically ill patients who require prolonged mechanical ventilation due to acute respiratory failure or airway problems. The best tracheostomy timing (early vs. late) and techniques (percutaneous dilatational, other new percutaneous procedures, open surgery) have been hotly debated. This research aimed to evaluate the outcome of early versus late tracheostomy in terms of in-hospital mortality, patient length of stay in the hospital, and cost after a detailed analysis and review using National Inpatient Survey (NIS) data. This study indicates that early tracheostomy greatly reduces in-hospital mortality, the need to transfer to skilled nursing facilities as well as direct variables, length of stay, and potentially overall hospital cost in the ICU.

Tips and Pearls for Tracheostomy during the Covid-19 Pandemic.

The number of critically-ill coronavirus disease 2019 (Covid-19) patients requiring mechanical ventilation is on the rise. Most guidelines suggest keeping the patient intubated and delay elective tracheostomy. Although the current literature does not support early tracheostomy, the number of patients undergoing it is increasing. During the pandemic, it is important that surgeons and anesthesiologists know the different aspects of tracheostomy in terms of indication, procedure, tube care and complications. A literature search was performed to identify different guidelines and available evidence on tracheostomy in Covid-19 patients. The purpose of the present article is to generate an essential scientific evidence for life-saving tracheostomy procedures.

P44 Posterior Tracheopexy in Severe Tracheobronchomalacia in Children

Tracheomalacia is a segmental or diffuse weakness of the trachea. If the main stem bronchi are involved, the term tracheobronchomalacia is used. At present, there is no structured approach for the assessment of paediatric tracheobronchomalacia. Surgically, it is a challenging substrate to deal with. Long term ventilation and tracheostomy is not the preferred approach due to obvious morbidity associated. Stent placement has issues with migration while aortopexy does not sort out posterior tracheal intrusion. Posterior Tracheopexy as primary intervention for severe tracheobronchomalacia was done for the first time in Australia, to the best of our knowledge.

Tracheostomy in the COVID-19 pandemic.

PurposeThe role of tracheostomy in COVID-19-related ARDS is unknown. Nowadays, there is no clear indication regarding the timing of tracheostomy in these patients.MethodsWe describe our synergic experience between ENT and ICU Departments at University Hospital of Modena underlining some controversial aspects that would be worth discussing tracheostomies in these patients. During the last 2 weeks, we performed 28 tracheostomies on patients with ARDS due to COVID-19 infection who were treated with IMV.ResultsNo differences between percutaneous and surgical tracheostomy in terms of timing and no case of team virus infection.ConclusionIn our experience, tracheostomy should be performed only in selected patients within 7- and 14-day orotracheal intubation.

Practices regarding the care of tracheostomy tube in the patients with long term tracheostomy

Practices regarding the care of tracheostomy tube in the patients with long term tracheostomy

Practices regarding the care of tracheostomy tube in the patients with long term tracheostomy

Practices regarding the care of tracheostomy tube in the patients with long term tracheostomy

Bronchoscopy Guided V.S Ultrasound Guided Percutaneous Tracheostomy

Abstract Introduction Percutaneous dilatational tracheostomy (PDT) is a widely utilized technique in the intensive care unit as it is a safe and cost effective technique. Bronchoscopy guided percutaneous dilatational tracheostomy has traditionally been used as a safety adjunctive tool in order to define the appropriate site for the tracheal puncture, to guide the real-time entrance of the needle into the trachea, avoiding tracheal posterior wall injuries, and confirming the endotracheal tube placement. By contrast, bronchoscopy might not precisely identify the cervical anatomical structures. Ultrasound has emerged as potentially useful tool in assisting percutaneous dilatational tracheostomy when factors that increase the technical difficulty of the procedure (morbid obesity, difficult anatomy & cervical spine precautions) are present. Several studies have demonstrated the value of pre-procedure cervical ultrasound in order to improve the safety of percutaneous dilatational tracheostomy. Objectives This review aimed at comparing bronchoscopy guided versus ultrasound guided percutaneous tracheostomy in terms of the detected complications resulting from each procedure. Design A randomized prospective comparative trial. Setting Critical care department, Ain Shams university hospital. Patients Forty adult patients, requiring elective PDT, and need to maintain a secure airway. Methods They were randomly assigned to 2 groups; fiber optic bronchoscopy PDT group I and Ultrasound guided PDT group II. Both groups used Blue Rhino technique for PDT. Post-operative complications were recorded. Results In group I, males were 11(55%) and females were 9(45%) while in group II, males and females were 14(70%) and 6(30%) respectively. Age in group I ranged from 37-67 with mean value of 52.4±10.89 and in group II ranged from 40-71 with mean value of 54.6±9.81. There was one puncture in 19 cases (95%) in group I, while one puncture in 17 cases (85%) in group II. Total time in group I was ranged from 3-9 with mean value 5.3±1.69 and in group II was ranged from 3-9 with mean value 6.2±1.79. Transient hypoxemia occurs in about 3 cases (15%) in the bronchoscopy guided PDT group in comparison to none in the ultrasound guided PCT group. Bleeding occurred in 2 patients (10%) in bronchoscopy guided PDT group versus one patient (5%) in Ultrasound guided PCT group. Misplacement of the tracheostomy tube was encountered in only two cases (10%) in US guided PDT group and non in the other bronchoscopy guided PDT group, which lead subsequently to pneumothorax in one case (5%). Conclusion Percutaneous dilatational tracheostomy is a bedside safe procedure with low rate of complications. US guided PDT and bronchoscopy guided PDT are effective, safe and associated with similar complication rate and clinical outcome. Bronchoscopy guidance during PDT offers the best vision decreasing the need for multiple punctures and the risk of misdirection or false passage of the tube. Ultrasound is a promising less invasive method to guide the percutaneous tracheostomy procedure.

Timing of Tracheostomy and Outcomes in Adults with Moderate and Severe Tetanus

Objective: This study aimed to evaluate the timing of tracheostomy and relationship to outcomes (length of hospital stay, length of mechanical ventilation, morbidity and mortality rate) in adults with moderate and severe tetanus. 
 Methods: 
 Design: Cross-Sectional Study
 Setting: Tertiary Government Training Hospital
 Patients: All adult patients (19 years old and above) diagnosed with moderate and severe stage tetanus from January 2015 to January 2018 were considered for inclusion.
 Results: There were 109 patients included in this study, majority were males (n=95) with a male to female ratio of 7:1. Most belonged to the 51-60 years age group (mean: 53.7 SD: +/-16.1). Based on Cole Tetanus staging, the majority presented with severe stage tetanus (67.9%; n=74). Only 35.8% (n=39) were admitted at the Intensive Care Unit. Early tracheostomy was performed in 56.0% (n=61) of the patients (mean 6.3 hours SD: +/- 4.61). Mortality rate was noted to be 52.3% (n=57). Overall, early tracheostomy among moderate to severe stage tetanus patients showed shorter length of hospital stay and length of mechanical ventilation than late tracheostomy (tracheostomy >24 hours) (p-value < .05). However, no significant difference was noted for timing of tracheostomy in terms of morbidity and mortality rate (p-value > .05).
 Conclusion: Early tracheostomy within less than 24 hours from time of admission for moderate and severe tetanus is associated with shorter length of hospital stay and mechanical ventilation than late tracheostomy, and may play a role in tetanus management.
 Keywords: tracheostomy; tetanus; hospital stay; mechanical ventilation; morbidity; mortality

Tracheostomy in Adult Intensive Care Unit: An ISCCM Expert Panel Practice Recommendations.

Background and AimCritically ill patients on mechanical ventilation undergo tracheostomy to facilitate weaning. The practice in India may be different from the rest of the world and therefore, in order to understand this, ISCCM conducted a multicentric observational study “DIlatational percutaneous vs Surgical tracheoStomy in intEnsive Care uniT: A practice pattern observational multicenter study (DISSECT Study)” followed by an ISCCM Expert Panel committee meeting to formulate Practice recommendations pertinent to Indian ICUs.Materials and methodsAll existing International guidelines on the topic, various randomized controlled trials, meta-analysis, systematic reviews, retrospective studies were taken into account to formulate the guidelines. Wherever Indian data was not available, international data was analysed. A modified Grade system was followed for grading the recommendation.ResultsAfter analyzing the entire available data, the recommendations were made by the grading system agreed by the Expert Panel. The recommendations took into account the indications and contraindications of tracheostomy; effect of timing of tracheostomy on incidence of ventilator associated pneumonia, ICU length of stay, ventilator free days & Mortality; comparison of surgical and percutaneous dilatational tracheostomy (PDT) in terms of incidence of complications and cost to the patient; Comparison of various techniques of PDT; Use of fiberoptic bronchoscope and ultrasound in PDT; experience of the operator and qualification; certain special conditions like coagulopathy and morbid obesity.ConclusionThis document presents the first Indian recommendations on tracheostomy in adult critically ill patients based on the practices of the country. These guidelines are expected to improve the safety and extend the indications of tracheostomy in critically ill patients.How to cite this articleGupta S, Dixit S, Choudhry D, Govil D, Mishra RC, Samavedam S, Tracheostomy in Adult Intensive Care Unit: An ISCCM Expert Panel Practice Recommendations. Indian J Crit Care Med 2020;24(Suppl 1):S31–S42.

77) Impact of a comprehensive education program for parents of children requiring long term tracheostomy

BACKGROUND/METHODS: The Pediatric Intensive Care Unit (PICU) at Kentucky Children’s Hospital (KCH) aimed to improve and standardize education to caregivers of patients with a fresh tracheostomy. The target population included all PICU patients with new tracheostomies. Incidence of readmission within one week or less after discharge, incidence of readmission within 8-30 days post discharge, the average number of admissions over the first three months after discharge, and length of stay (LOS) post tracheostomy placement were collected retrospectively (2014 –November 2015) and prospectively (December 2015 to March 2017). A …

(77) Impact of a comprehensive education program for parents of children requiring long term tracheostomy

(77) Impact of a comprehensive education program for parents of children requiring long term tracheostomy

Early vs. late tracheostomy in intensive care settings: Impact on ICU and hospital costs

IntroductionUp to 12% of the 800,000 patients who undergo mechanical ventilation in the United States every year require tracheostomies. A recent systematic review showed that early tracheostomy was associated with better outcomes: more ventilator-free days, shorter ICU stays, less sedation and reduced long-term mortality. However, the financial impact of early tracheostomies remain unknown. ObjectivesTo conduct a cost-analysis on the timing of tracheostomy in mechanically ventilated patients. MethodsWe extracted individual length of hospital stay and length of ICU stay data from the studies included in the systematic review from Hosokawa et al. We also searched for any recent randomized control trials on the topic that were published after this review. The weighted length of stay was estimated using a random effects model. Average daily hospital and ICU costs per patients were obtained from a cost study by Kahn et al. We estimated hospital and ICU costs by multiplying LOS with respective average daily cost per patient. We calculated difference in costs by subtracting hospital costs, ICU costs and total direct variable costs from early tracheotomy to late tracheotomy. 95% confidence intervals were estimated using bootstrap re-sampling procedures with 1000 iterations. ResultsThe average weighted cost of ICU stay in patients with an early tracheostomy was $4316 less when compared to patients with late tracheostomy (95% CI: 403–8229). Subgroup analysis revealed that very early tracheostomies (<4days) cost on average $3672 USD less than late tracheostomies (95% CI: –1309, 10,294) and that early tracheostomies (<10days but >4) cost on average $6385 USD less than late tracheostomies (95% CI: –4396–17,165). ConclusionThis study shows that early tracheostomy can significantly reduce direct variable and likely total hospital costs in the intensive care unit based on length of stay alone. This is in addition to the already shown benefits of early tracheostomy in terms of ventilator dependent days, reduced length of stays, decreased pain, and improved communication. Further prospective studies on this topic are needed to prove the cost-effectiveness of early tracheostomy in the critically ill population.