Term Tracheostomy Research Articles

A study of submental intubation for anaesthesia in patients with faciomaxillary injuries

<p class="abstract"><strong><span lang="EN-US">Background: </span></strong>Surgical repair of faciomaxillary trauma requires intraoperative occlusion of teeth that precludes orotracheal intubation. Airway management options in these patients are either nasotracheal intubation or tracheostomy. However nasal intubation is contraindicated in nasal bone fractures, skull base fractures. Tracheostomy, being a morbid procedure is not always a good option. Submental intubation allows a safe alternative in such patients.</p><p class="abstract"><strong><span lang="EN-US">Methods: </span></strong>25 Patients were studied with faciomaxillary trauma where submental intubation was indicated. After standard anesthesia induction patients were intubated with reinforced endotracheal tube (ETT), which is converted to submental route by a paramedian incision. At the end of the procedure, all patients had inter-maxillary wiring, were shifted to recovery room. Once they are recovered from the neuromuscular blockade ETT was removed through the submental tunnel.</p><p class="abstract"><strong><span lang="EN-US">Results: </span></strong>This was a prospective observational study in 25 adult patients undergoing faciomaxillary surgeries requiring submental intubation. The mean apnoea time was 1.28±0.38 minutes and induction to submental intubation time was 9.68±1.82 minutes. In one case there was damage to the pilot balloon while pulling the tube through the submental tunnel. Two patients had right endobronchial migration of the ETT. On postoperative follow up, one patient had infection at the submental incision site. </p><p class="abstract"><strong><span lang="EN-US">Conclusions: </span></strong><span lang="EN-US">Submental intubation is a safe, effective, alternative for short term tracheostomy in faciomaxillary sugeries. Careful handling of the ETT is must to avoid damage while passing through the submental tunnel. Avoid extra length of the tube introrally to prevent endobronchial migration of the ETT.</span></p>

Management of tracheomalacia in an infant with Tetralogy of Fallot.

Most infants with tracheomalacia do not need specific therapy as it usually resolves spontaneously by the age of 1–2 years. Severe forms of tracheomalacia characterized by recurrent respiratory infections require active treatment which includes chest physiotherapy, long term intubation or tracheostomy. Aortopexy seems to be the treatment of choice for secondary and even primary forms of severe tracheomalacia. Itentails tracking and suturing the anterior wall of the aorta to the posterior surface of the sternum. Consequently, the anterior wall of the trachea is also pulled forward preventing its collapse. A 3-month-old girl baby who was on ventilatory support for 2 months due to severe tracheomalacia associated with a cyanotic congenital heart disease underwent intracardiac repair and aortopexy along with Lecompte's procedure as all the conservative measures to wean off the ventilator failed. The baby was extubated on the third post-operative day and the post-operative period was uneventful.

Which percutaneous tracheostomy method is better? A systematic review.

The aim of this study was to assess the different methods of percutaneous tracheostomy in terms of successful performance of the tracheostomy as well as safety. Tracheostomy is the most common procedure performed on the airway for patients in ICUs. Lately, several methods of percutaneous tracheostomy (multiple dilator, progressive dilator, forceps dilation, screw-like dilation, balloon dilation, and translaryngeal) have been described, with theoretical advantages, but there is no consensus about which is better. A systematic review with critical appraisal of the literature was done. Literature in multiple databases was searched. Randomized controlled trials comparing different tracheostomy methods were selected. Clinical and methodological characteristics were assessed. A meta-analysis using fixed effect models was planned for statistically homogeneous outcomes. Fourteen randomized controlled trials were included, most of them with small sample sizes and with comparisons of multiple methods. Blue Rhino methods were less difficult for surgeons (risk difference of 14.7% [95% CI 8-21.5]) and had more minor bleeding events (risk difference of -6.3% [95% CI -13.58 to 0.8]). There were no differences in major bleeding events. Statistically, heterogeneity and lack of data impede comparison with other outcomes. The Blue Rhino method is less difficult and has more minor bleeding events, but physicians also have more experience with this technique. However, trials are underpowered to define the best method.

P179 Nebulised 7% Hypertonic Saline as an Adjunct to Airway Clearance Can Be Commenced Safely in a Supervised Environment Without the Need For a Formal Bronchoconstriction Trial

BackgroundNebulised Hypertonic Saline (HTS) has been shown to increase water content of airway surface liquid, enhance mucociliary clearance, reduce exacerbation frequency and improve quality of life in Cystic Fibrosis (CF)...

Bacterial flora of the respiratory tract in patients with long term tracheostomy--colonization of the lower respiratory tract by Pseudomonas aeruginosa

Throat secretions (TS) and bronchial secretions aspirated from tracheostomy sites (TSTA) from six subjects with long term tracheostomy were simultaneously collected and then cultured every two weeks from January, 1990, to December, 1992. Isolated bacteria were mainly alpha-streptococci (96.2%) and Neisseria (69.6%) in TS, and Pseudomonas aeruginosa (75.7%) in TSTA. In all cases, P. aeruginosa was isolated from and colonization of the lower respiratory tract by this organism was apparent 24.4 months, on average, after tracheostomy. There were ten episodes of respiratory infection in five cases, eight of which occurred after colonization. P. aeruginosa was the causative organism in seven of these episodes. Findings in patients with long term tracheostomy indicated separate colonization of the upper and lower respiratory tracts and that P. aeruginosa colonized the lower respiratory tract. The colonization of the lower respiratory tract by P. aeruginosa would thus appear to be an important factor inducing respiratory infection.

Midline submental orotracheal intubation in maxillofacial injuries: A substitute to tracheostomy where postoperative mechanical ventilation is not required

Maxillofacial fractures present unique airway problems to the anaesthesiologist. Nasotracheal intubation is contraindicated due to associated Lefort I, II or III fractures. The requirement for intraoperative maxillomandibular fixation (MMF) to re-establish dental occlusion in such cases precludes orotracheal intubation. Tracheostomy has a high complication rate and in many patients, an alternative to the oral airway is not required beyond the perioperative period. Hernandez1 in 1986 first described "The submental route for endotracheal intubation". Later some workers faced difficult tube passage, bleeding, and sublingual gland involvement with this approach. They modified this to strict midline submental intubation and there were no operative or postoperative complications in their cases.67&8. Therefore we used mid line approach for submental orotracheal intubation in this study to demonstrate its feasibility and reliability and that it can be used as an excellent substitute to short term tracheostomy. PATIENTS #ENTITYSTARTX00026; We used midline submental intubation in 25 cases selected out of 310 consecutively treated patients with maxillofacial trauma over a 3 year period. After induction orotracheal intubation was done with spiral re-inforced tube. A 1.5-2.0 cm skin incision was made in the submental region in the midline 2.0 cm behind the symphysis and endotracheal tube was taken out through this incision in all the cases. At the end of the surgery the procedure was reversed, the submental wound was stitched; all the patients could be extubated & none of them required post-operative mechanical ventilation. There were no significant operative or postoperative complications. Postoperative submental scarring was acceptable([6]). We conclude that midline submental intubation is a simple and useful technique with low morbidity. It can be chosen in selected cases of maxillofacial trauma and is an excellent substitute to tracheostomy where postoperative mechanical ventilation is not required.

Early and Late Tracheostomy after Decompressive Craniectomy for Severe Traumatic Brain Injury

Objective: The purpose of the study was to retrospectively compare the early and late tracheostomy in terms of ventilator days, intensive care unit (ICU) days, pneumonia, and clinical outcomes in patients with a severe traumatic brain injury (TBI) who underwent a decompressive craniectomy. Methods: Patients who had a TBI and a Glasgow Coma Scale (GCS) score ≤8, and were treated with a unilateral or bilateral decompressive craniectomy were enrolled. Between January 2006 and December 2008, 37 patients were enrolled in the retrospective study. Percutaneous tracheostomies were performed by trained residents. According to the timing of the tracheostomy, the subjects were classified as the early (≤7 days; n=20) or late group (>7 days; n=17). Results: The average time of the tracheostomy was 3.2±1.4 days in the early group and 9.7± 0.9 days in the late group. There was no statistically significant difference between the early and late groups with respect to total days of mechanical ventilation, ICU stay, Glasgow Outcome Score (GOS), and pneumonia incidence. The duration of antibiotic administration for the treatment of pneumonia was shorter in the early group (p=0.04). Klebsiella species were the most common pathogens in both groups. Conclusion: Early tracheostomy decreased the antibiotic period for the treatment of pneumonia in patients with severe TBI who underwent decompressive craniectomy. Early tracheostomy did not reduce total time of mechanical ventilation, ICU stay, pneumonia incidence, and GOS. (J Kor Neurotraumatol Soc 2009;5:89-92)

Airway reconstruction in children

Aim/Background:Airway anomalies are infrequent but potentially life threatening in children. A program to care for these difficult children was set up at our institution, and this paper summarizes our experience.Methods:A total of 34 children were enrolled in the program over a period of three years. These children were evaluated as per the standard protocols. Treatment was individualized.Results:Of these 34 children, 28 had their airways restored and are doing well. Four children continue to remain on tracheostomy and two will require long term tracheostomy. There were two deaths. All children are under surveillance as there is a risk of recurrence.Conclusions:Airway anomalies are complex problems with significant morbidity and mortality. Current therapeutic modalities allow for good results. Most children were successfully decannulated and did well.

Perkutane Dilatationstracheotomie

Tracheostomy is a generally accepted procedure that assures free access to the airways in long-term lung ventilation. Apart from surgical tracheostomy, percutaneous dilational tracheostomy (PDT) has been increasingly employed in intensive care units. Presently, five dilatation methods are available, all equally allowing the performance of a secure and low-risk, bedside tracheostomy in the intensive care unit. Exact knowledge of the anatomy of the neck region and of the entire procedure are preconditions for a safe intervention. Percutaneous procedures offer advantages over surgical tracheostomy in terms of complications. To minimize the risks, expertise in airway management during PDT and knowledge of the particularities of cannula replacement in dilational tracheostoma, are compulsory. Endoscopic control assures that the tracheostoma can be placed correctly and that possible complications can be recognised early. The incidence of a serious tracheal stenosis after PDT is low.

LONG TERM USE OF LARYNGEAL MASK AIRWAY (LMA) IN NEONATES WITH ROBIN SEQUENCE.2121

Neonates with Robin sequence (micrognathia, cleft palate and glossoptosis) frequently have severe upper airway obstruction. Depending on the range of severity, treatment modalities include positioning the infants face down, inserting an oropharyngeal airway, endotracheal intubation or long term tracheostomy. Many of these infants may require intubation due to inadequacy of nasal CPAP in presence of a cleft palate. Intubation of these neonates may also be challenging and sometimes impossible. Long term tracheostomy may carry the risks of pneumonia, and impairment of speech development and pharyngeal growth. The use of a LMA (size #1) for anesthesia and in the aid for difficult intubation has been described. We present our experience with three cases of Robin sequence who were treated with long term use of a LMA to relieve upper airway obstruction and deliver CPAP.

Relation of bacterial flora between upper and lower respiratory tracts in patients with long-term tracheostomy

Throat secretions (TS) and bronchial secretions aspirated from tracheostomy (TSTA) were cultured at the same time in 9 subjects with long term tracheostomy every two weeks from January, 1990 to December, 1990. Total number of each examination in TS and TSTA were 200 times. Mean number of bacteria isolated by single culture were 2.9 strains in TS and 1.8 strains in TSTA. Isolated bacteria were mainly alpha-Streptococcus (84.8%) and Neisseria (69%) in TS, and Pseudomonas aeruginosa (53.5%) and Serratia marcescens (30%) in TSTA. Only 20% of P. aeruginosa or S. marcescens in TSTA were isolated from TS. In 8 cases of 9, P. aeruginosa in TSTA were isolated with every time or long term. There were 14 episodes of respiratory infections in 6 cases. P. aeruginosa were causative organisms in 7 episodes. It suggests that P. aeruginosa tended to colonize in lower respiratory tracts of the patients with long term tracheostomy and to become causative organisms in respiratory infections.

Endobronchial cryotherapy in the treatment of tracheal strictures

Modern advances in ventilatory support systems have introduced a patient population requiring long term endotracheal intubation or tracheostomy. The formation of tracheal strictures in such patients remains a very significant clinical problem despite new modifications in endotracheal tube design and materials. Dissatisfied with standard modalities of treatment for these lesions, we have explored the usefulness of endobronchial cryotherapy for the treatment of such stricture. Cervical tracheal strictures were produced in 11 sheep. In six animals a prototype cryosurgical probe was passed through the bronchoscope and these lesions frozen to −80°C. Respiratory epithelial regeneration was complete, but significant reduction in strictures was not noted. Utilizing the cryosurgical probe in conjunction with the endobronchial resection of tracheal strictures in three animals did, however, produce significant reduction in stricture size. Healing following cryonecrosis was associated with minimal fibrosis. Endobronchial cryotherapy is easily performed and has been well tolerated by these animals.