Tracheostomy In Patients Research Articles

523 Retrospective Outcomes Analysis of Tracheostomy in Paediatric Burn Population

Abstract Introduction For decades, controversy has raged regarding the placement of tracheostomy in severe paediatric burns. Numerous variables including extent of smoke inhalation injury, % TBSA burned, age of the patient, and co-morbidities among others complicate reaching consensus. Furthermore, paediatric patients are particularly susceptible to complications including inadvertent loss of airway and long-term swallowing and other anatomic issues. Additionally, previous analysis of the efficacy of tracheostomy in paediatric burn patients appears to be hindered by a lack of nationwide analysis. The aim of this study was to explore the efficacy of tracheostomy in the general paediatric burn patient population. Methods De-identified patient data was obtained from the TriNetX Research Network database. Two cohorts were identified: paediatric burn patients with tracheostomy (cohort A) and paediatric burn patients without tracheostomy (cohort B). Burn patients were identified using the ICD-10 codes T20-T25 & T30-T32. Tracheostomy was identified using the ICD-10 codes 1005887, 1014613, 31600, 31601, 31603, 31604, 31610, and Z93.0. A total of 132 patients were identified in cohort A in 23 HCOs and 83,117 patients were identified in cohort B in 38 HCOs. Infection, hypovolemia, pulmonary injury, laryngeal injury, pneumonia, and death were compared between the cohorts. Results Cohort A had a mean age of 11 (SD=5) and Cohort B had a mean age of 9 (SD=5). Paediatric burn patients with tracheostomy had a higher risk for death, infection, hypovolemia, pulmonary injury, laryngeal injury, and pneumonia when compared to their non-tracheostomy counterparts. The risk ratios for these outcomes were 62.452, 4.713, 9.267, 26.483, 116.163, and 18.154, respectively. Conclusions The analysis of the longitudinal outcomes of pediatric burn patients with tracheostomy as compared to those without tracheostomy demonstrated the tracheostomy cohort suffered much worse mortality and morbidity across several metrics. The potential benefits of tracheostomy placement in pediatric burn patients should be weighed against these outcomes.

Tracheostomy before 14 Days: Is It Associated with Better Outcomes in Pediatric Patients on Prolonged Mechanical Ventilation?

IntroductionWith the advancement of pediatric critical care services across India, many children require prolonged mechanical ventilation (MV), and tracheostomy is recommended to them. However, many pediatric intensivists have concerns regarding the safety, feasibility, and outcome of tracheostomy.We aimed to analyze clinical characteristics, indication, duration, and outcome of tracheostomized children with respect to timing of tracheostomy.Materials and methodsWe conducted a retrospective study from the hospital clinical database of consecutive patients below 12 years who had undergone tracheostomy after admission into the pediatric intensive care unit (PICU) for prolonged ventilation (≥96 hours) from January 2015 to December 2019. The study was approved by the Institutional Ethics Committee. Patients were divided into two groups: tracheostomies done within 14 days of MV (early tracheostomy) and patients with tracheostomies performed after 14 days (late tracheostomy). Patients’ age, sex, indications, complications, decannulation rate, length of MV, PICU, and hospital stay were analyzed.ResultsOf the 1,425 patients on invasive MV, 87 (6.1%) patients required tracheostomy after a mean 13.37 days of MV. The most common indication was encephalopathy 32 (36.7%) followed by acute respiratory distress syndrome 20 (22.9%). Factors like higher pediatric logistic organ dysfunction score, vasoactive inotrop score, incidence of pretracheostomy ventilator-associated pneumonia, and difficulty in obtaining parental consent were associated with late tracheostomy. The early tracheostomy group had a higher decannulation rate (odds ratio, 5.17; p, 0.01) and weaning rate (odds ratio, 5.94; p, 0.032). The late tracheostomy group needed a longer duration of MV, PICU, and hospital stay. Complications of tracheostomy were less in the early tracheostomy patients (odds ratio, 2.95; p, 0.03).ConclusionEarly tracheostomy was associated with lower complications, higher successful weaning rates, and less utilization of intensive care facilities in patients receiving prolonged MV.Clinical significanceIn the context of scarcity of data on the timing of tracheostomy in children with prolonged ventilation (≥96 hours) the study shows that early (<14 days) tracheostomy is associated with a better outcome.How to cite this articleSarkar M, Roychowdhoury S, Bhakta S, Raut S, Nandi M. Tracheostomy before 14 Days: Is It Associated with Better Outcomes in Pediatric Patients on Prolonged Mechanical Ventilation? Indian J Crit Care Med 2021;25(4):435–440.

High-Flow Oxygen Therapy in Tracheostomized Subjects With Prolonged Mechanical Ventilation: A Randomized Crossover Physiologic Study.

High-flow oxygen therapy via tracheostomy (HFT) can be used in tracheostomized patients during ventilator disconnection. The physiologic effects of this technique are unknown. We hypothesized that HFT would reduce inspiratory effort and improve breathing pattern compared to conventional oxygen therapy via T-tube. This study aimed to evaluate the physiologic effects of HFT compared to conventional O2 in patients with prolonged mechanical ventilation. A randomized crossover physiologic study was conducted in adult tracheostomized patients who experienced temporary periods of ventilator disconnection. Subjects were ventilated with pressure support ventilation (PSV) for 15 min and were then randomly assigned to HFT or conventional O2 via T-tube for 30 min. After a washout period, subjects were switched to the other system. Esophageal pressure (Pes), breathing frequency, blood pressure, heart rate, [Formula: see text], and transcutaneously measured pressure of carbon dioxide ([Formula: see text]) were recorded. The primary outcome was inspiratory effort as determined by the simplified esophageal pressure-time product (sPTPes). Secondary outcomes were Pes swing, breathing frequency, heart rate, mean arterial pressure, [Formula: see text], and [Formula: see text] between groups. Twenty-two subjects were enrolled: sPTPes per minute was significantly higher with HFT and conventional O2 compared to PSV (153.5 ± 97.9, 163.5 ± 111.3, and 86.8 ± 51.1 cm H2O × s/min, respectively, P = .001), but it was not different between HFT and conventional O2 (P = .72). Breathing frequency increased significantly after switching from PSV to HFT and conventional O2 (23 ± 4 vs 26 ± 6 and 23 ± 4 vs 27 ± 5 breaths/min, respectively, P = .001). [Formula: see text] was higher with conventional O2 compared to HFT (P = .02). No differences in [Formula: see text], mean arterial pressure, or heart rate were observed between HFT and conventional O2. Inspiratory effort and breathing frequency increased significantly during unassisted breathing compared to PSV in tracheostomized subjects, but HFT via tracheostomy provided no measurable additional physiologic benefit compared to O2 therapy via T-tube.

Abstract P273: Hospitalization Costs for United States Stroke Patients Receiving Tracheostomy

Introduction: Stroke patients who receive tracheostomy often undergo prolonged ventilation and have long, complicated ICU stays. Little is known about the hospitalization costs for these patients. Methods: We used the National Inpatient Sample from 2008-2017 to identify patients with a primary diagnosis of acute ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage. We identified individuals who received tracheostomy based on procedure codes. We used cost-to-charge ratios to calculate hospitalization costs for each patient and adjusted costs to 2017 US dollars using the Medical Consumer Price Index. We examined differences in hospitalization costs based on age, sex, race, Elixhauser score, length of stay, and early tracheostomy placement (≤7 days). We calculated overall average annual hospitalization costs for all patients with stroke and tracheostomy in the US and compared to the total US acute stroke population inpatient costs. Results: We identified an estimated 61,322 acute stroke patients in the US receiving tracheostomy from 2008 to 2017, representing 1.1% of all US acute stroke patients. Stroke patients with tracheostomy had a mean age of 61 years (SD=13.8); 46% were female, 29% black, 12% Hispanic, and 13% rural. Among tracheostomy patients, the mean Elixhauser score was 4.7 (SD=2). The mean hospitalization cost for tracheostomy patients was $117,492 (median $97,063; IQR $64,887-$145,419). Costs were greater for younger patients, females, and those from urban locations. There was no difference in costs for white compared to minority patients. Each additional hospital day accounted for $2,023 in hospitalization costs, and those with early tracheostomy (22% of tracheostomy patients) had lower hospitalization costs (mean $89,811 vs. $125,318; p&lt;0.001). Total US hospitalization costs for acute stroke patients receiving tracheostomy are estimated at $720.4 million per year, which represents 8.1% of total acute stroke hospitalization costs in the US. Conclusion: Acute stroke patients who receive tracheostomy account for 1% of all stroke patients, but 8% of all hospitalization costs for stroke in the US.

Comparing decannulation failures and successes in pediatric tracheostomy: An 18-year experience.

There is a paucity of published literature identifying patients at higher risk of decannulation failure. The purpose of this study is to evaluate patient factors that may predict successful decannulation of pediatric tracheostomy patients and analyze factors contributing to tracheostomy decannulation failures. A retrospective chart review of tracheostomy outcomes was conducted at a pediatric referral hospital. Successful and failed decannulations were compared using the following patient variables: age at tracheostomy, sex, ethnicity, gestational age and weight, the primary indication for tracheostomy, comorbidities, age at decannulation attempt, polysomnography data, and status of airway before decannulation as assessed endoscopically by airway team. Four hundred thirty-nine tracheostomies were performed over the 18-year period with 173 decannulation attempts. The overall rate of successful decannulation on the first attempt was 91.9% (159of 173), with an eventual decannulation success rate of 97.1% (168of 173). Compared with failed decannulations, the patients with successful decannulations had a shorter duration of tracheostomy and no medical comorbidities. Gestational age and weight approached, but did not achieve, statistical significance. After 25 months with a tracheostomy, approximately 50% of patients are decannulated with very few decannulations occurring after 75 months. The overall mortality rate in this cohort was 18.6% (78 of 420) with a tracheostomy-related mortality rate of 0.95% (4 of 420). The decannulation protocol at this institution is successful nearly 92% of the time. Fewer medical comorbidities, shorter duration of tracheostomy placement, and older gestational age may improve the likelihood of successful decannulation. Future studies are needed to determine the optimal timing and workup to evaluate patients for decannulation.

Swallowing and Voice Outcomes in Patients Hospitalized With COVID-19: An Observational Cohort Study

ObjectiveTo evaluate the presentations and outcomes of inpatients with coronavirus disease 2019 (COVID-19) presenting with dysphonia and dysphagia to investigate trends and inform potential pathways for ongoing care. DesignObservational cohort study. SettingAn inner-city National Health Service Hospital Trust in London, United Kingdom. ParticipantsAll adult inpatients hospitalized with COVID-19 (N=164) who were referred to Speech and Language Therapy (SLT) for voice and/or swallowing assessment for 2 months starting in April 2020. InterventionsSLT assessment, advice, and therapy for dysphonia and dysphagia. Main Outcome MeasuresEvidence of delirium, neurologic presentation, intubation, tracheostomy, and proning history were collected, along with type of SLT provided and discharge outcomes. Therapy outcome measures were recorded for swallowing and tracheostomy pre- and post-SLT intervention and Grade Roughness Breathiness Asthenia Strain Scale for voice. ResultsPatients (N=164; 104 men) aged 56.8±16.7 years were included. Half (52.4%) had a tracheostomy, 78.7% had been intubated (mean, 15±6.6d), 13.4% had new neurologic impairment, and 69.5% were delirious. Individualized compensatory strategies were trialed in all and direct exercises with 11%. Baseline assessments showed marked impairments in dysphagia and voice, but there was significant improvement in all during the study (P<.0001). On average, patients started some oral intake 2 days after initial SLT assessment (interquartile range [IQR], 0-8) and were eating and drinking normally on discharge, but 29.3% (n=29) of those with dysphagia and 56.1% (n=37) of those with dysphonia remained impaired at hospital discharge. A total of 70.9% tracheostomized patients were decannulated, and the median time to decannulation was 19 days (IQR, 16-27). Among the 164 patients, 37.3% completed SLT input while inpatients, 23.5% were transferred to another hospital, 17.1% had voice, and 7.8% required community follow-up for dysphagia. ConclusionsInpatients with COVID-19 present with significant impairments of voice and swallowing, justifying responsive SLT. Prolonged intubations and tracheostomies were the norm, and a minority had new neurologic presentations. Patients typically improved with assessment that enabled treatment with individualized compensatory strategies. Services preparing for COVID-19 should target resources for tracheostomy weaning and to enable responsive management of dysphagia and dysphonia with robust referral pathways.

Tracheostomy in patients with high suspicion or diagnosis of COVID-19: case series from two hospitals in Northwestern Mexico

Abstract OBJECTIVE. To describe the results of tracheostomy in a series of cases in patients with COVID-19 admitted to the intensive care unit in two hospitals in the Northwest Mexico. MATERIAL AND METHODS. A prospective, descriptive, longitudinal study was carried out on a series of cases from April 2020 to August 2020. Data such as age, sex, hospital of origin, risk factors for the development of severe COVID-19, ventilatory and gasometric parameters before and 72 hours after, the days of oro-tracheal intubation were taken into account. Descriptive statistics with frequencies and percentages were used for the qualitative variables, for the numerical measures of central tendency as the mean and the median, the distribution of the results. RESULTS. From April to August 2020, in the two Intensive Care Units (ICUs) of these hospitals, 134 COVID-19 cases were admitted. In 14 patients (10.4%) tracheotomies were performed, 13 (92.8%) were male, mean age 49.21 years, 85% tested positive. The mean duration of oro-tracheal intubation was 22.7. Obesity combined with diabetes and arterial hypertension represented a risk factor in 57.1% of the cases. In 10 patients, the procedure was performed in the ICU bed. There were changes in some ventilatory parameters before and 72 hours after the procedure. The average number of days after weaning from the ventilator was 5.5 days. There were 3 deaths in our series. CONCLUSION. The adequate and prudent selection of COVID-19 patients for tracheostomy makes it easier to choose with greater justification the patients with the best prognosis, avoiding unnecessary procedures in a patient and a greater risk of contagion in the personnel.

Tracheostomy and Improvement in Utilization of Hospital Resources During SARS-CoV-2 Pandemic Surge

The SARS-CoV-2 pandemic has affected millions across the world. Significant patient surges have caused severe resource allocation challenges in personal protective equipment, medications, and staffing. The virus produces bilateral lung infiltrates causing significant oxygen depletion and respiratory failure thus increasing the need for ventilators. The patients who require ventilation are often requiring prolonged ventilation and depleting hospital resources. Tracheostomy is often utilized in patients requiring prolonged ventilation, and early tracheostomy in critical care patients has been shown in some studies to improve a variety of factors including intensive care unit (ICU) length of stay, ventilation weaning, and decreased sedation medication utilization. In a patient surge setting, as long as adequate personal protective equipment (PPE) is available to minimize spread to healthcare workers, early tracheostomy may be a beneficial management of these patients. Decreasing sedative medication utilization may help prevent shortages in future waves of infection and improve patient-provider communication as patients are more alert. Tracheostomy care is easier than endotracheal intubation and may have decreased viral aerosolization risk, particularly if repeat intubation is necessary after a weaning trial. Additionally, tracheostomy patients can be monitored with less staff, decreasing total healthcare worker exposure to infection. To manage risk of exposure, coordination of ventilation controlled by an anesthesiologist or a critical care physician with a surgeon during the procedure can minimize aerosolization to the team. Risk management and resource allocation is of the utmost importance in any global crisis and procedures must be appropriately planned and benefits to patients, as well as minimized exposure to healthcare providers, must be considered. Early tracheostomy could be a beneficial procedure for severe SARS-CoV-2 patients to minimize long-term virus aerosolization and exposure for healthcare workers while decreasing sedation, allowing for earlier transfer out of the ICU, and improving hospital resource utilization.

Comparative Study Between Haemorrhage and Surgical Emphysema as Complication of Emergency Tracheostomy

Background: Emergency tracheostomy is the commonest surgical intervention performed as lifesaving procedure by ENT surgeons on patients in emergency room of ENT and ICU. Several operative and postoperative complications have been reported after tracheostomy including fatal hemorrhage. Massive subcutaneous neck emphysema occurred because ventilation started at the time when the hemorrhage was not completely managed and the tracheal tube was not fully secured.&#x0D; Objective: This study was conducted to compare haemorrhage and surgical emphysema as complication of emergency tracheostomy among patients admitted in Department of ENT and Head-Neck Surgery in Dhaka Medical College &amp; Hospital.&#x0D; Methods and Materials: This was a Cross Sectional Study conducted in the ENT and Head- Neck Surgery Department, Dhaka Medical College Hospital from July 2015 to June 2016. A total of 90 patients were included who fulfilled the selection criteria. Non probability convenient sampling was used to collect data. Statistical analysis was done by SPSS version 21.&#x0D; Results: Mean± SD of the study subjects was 49.84±17.4 years with most patients belonged to 40-79 years age group. 28.9% patients had habit of smoking and betel nut chewing. (48.9%) patients suffered from Ca larynx. Out of 90 tracheostomy patients, 40(44.4%) patients had had different complications including haemorrhage (13.3%), surgical emphysema (10%), haemorrhage with surgical emphysema (6.7%), tube blockage (3.3%), wound infection (3.3%) and injury to local tissue (2.2%). Haemorrhage occurs from anterior jugular vein, middle thyroid veins and thyroid gland and included peroperative haemorrhage (7.8%), immediate post- operative haemorrhage, &lt;24 hours, (4.43%) and late post-operative haemorrhage (1.2%).&#x0D; Conclusion: In this study, haemorrhage followed by surgical emphysema and haemorrhage with surgical emphysema were found as major complications following emergency tracheostomy,&#x0D; J Dhaka Medical College, Vol. 28, No.2, October, 2019, Page 159-163

Tracheal Stoma Closure and Outcomes in Tracheotomy Patients

Tracheal Stoma Closure and Outcomes in Tracheotomy Patients

Early ventilator liberation and decreased sedation needs after tracheostomy in patients with COVID-19 infection

BackgroundSince the outset of the coronavirus disease 2019 (COVID-19) pandemic, published tracheostomy guidelines have generally recommended deferral of the procedure beyond the initial weeks of intubation given high mortality as...

Gaining Experience Over Time: The Family Caregivers' Perception of Patients with a Tracheostomy in Home Care.

Background:The transition of tracheostomy patients to the home poses many challenges for both the patient and the family. Identifying and understanding the experiences of family caregivers pave the road for discovering and meeting care needs. This study has been aimed to explain the experiences of family caregivers of patients with a tracheostomy about patient care at home.Materials and Methods:This qualitative study was conducted using a conventional content analysis approach from September 2018 to January 2019. Participants included nine family caregivers and one professional caregiver who were selected through purposive sampling method. The in-depth interviews were conducted at home or in health centers using field notes. Data were recorded manually and analyzed using the five-step method proposed by Granehim and Lundman.Results:The data led to the emergence of 1591 initial codes, 23 subcategories, and 6 categories. Categories include the need for training, the need for receiving care support, care challenges, care burden, gaining experience, hope, and inner satisfaction.Conclusions:In this study, the family caregivers faced with lots of challenges in caring patients with tracheostomy so that they were in needs of training and support from professionals. Although they got skillful in care and endure burden, they were so hopeful and satisfied with their attempts. Hence, there is a need for official nongovernmental organizations with the aim of maintaining care and protecting their families.

A Prospective Study of Voice, Swallow, and Airway Outcomes Following Tracheostomy for COVID-19.

The COVID-19 pandemic has led to unprecedented demands on healthcare with many requiring intubation. Tracheostomy insertion has often been delayed and the enduring effects of this on voice, swallow, and airway outcomes in COVID-19 tracheostomy patients are unknown. The aim of this study was to prospectively assess these outcomes in this patient cohort following hospital discharge. All COVID-19 patients who had undergone tracheostomy insertion, and were subsequently decannulated, were identified at our institution and followed up 2 months post-discharge. Patient-reported (PROMS) and clinician-reported outcome measures, endoscopic examination, and spirometry were used to assess voice, swallow, and airway outcomes. Forty-one patients were included in the study with a mean age of 56 years and male:female ratio of 28:13. Average duration of endotracheal intubation was 24 days and 63.4% of tracheostomies were performed at day 21 to 35 of intubation. 53.7% had an abnormal GRBAS score and 30% reported abnormal swallow on EAT-10 questionnaire. 81.1% had normal endoscopic examination of the larynx, however, positive endoscopic findings correlated with the patient self-reported VHI-10 (P = .036) and EAT-10 scores (P = .027). 22.5% had spirometric evidence of fixed upper airway obstruction using the Expiratory-Disproportion Index (EDI) and Spearman correlation analysis showed a positive trend between abnormal endoscopic findings and EDI scores over 50 (P < .0001). The preliminary results of this study reveal a high incidence of laryngeal injury among patients who underwent intubation and tracheostomy insertion during the COVID-19 pandemic. As these patients continue to be followed up, the evolution of these complications will be studied. 3 Laryngoscope, 131:E1918-E1925, 2021.

The pattern of hospital-community-home (HCH) nursing in tracheostomy patients with severe traumatic brain injury: Is it feasible?

Tracheostomy is very common in patients with severe traumatic brain injury (TBI), long-term nursing care are needed for those patients. We aimed to evaluate the effects of hospital-community-home (HCH) nursing in those patients. This study was a before-after study design. Patients were divided into control groups (traditional nursing care) and HCH group(HCH nursing care). Tracheostomy patients with severe TBI needing long-term care were included. All patients underwent a two-month long follow-up. Glasgow coma score (GCS), Karnofsky, Self-Anxiety Scale (SAS) from caregiver and Barthel assessment at the discharge and two months after discharge were evaluated. The tracheostomy-related complications were recorded and compared. A total of 60 patients were included. There were no significant differences between the two groups in the GCS, Karnofsky, SAS from caregiver and Barthel index at discharge((all P>.05); the GCS, Karnofsky and Barthel index were all significantly increased after two-month follow-up for the two groups (all P<.05), and the GCS, Karnofsky and Barthel index at two-month follow-up in HCH group were significantly higher than that of the control group(all P<.05), but the SAS from caregiver at two-month follow-up in HCH group was significantly less than that of the control group(P=.009). The incidence of block of artificial tracheal cannula and readmission in HCH group were significant less than that of control group (all P<.05). HCH nursing care is feasible in tracheostomy patients with severe TBI, future studies are needed to further evaluate the role of HCH nursing care.

Tracheostomy in 80 COVID-19 Patients: A Multicenter, Retrospective, Observational Study.

Background: The outbreak of coronavirus disease 2019 (COVID-19) has led to a large and increasing number of patients requiring prolonged mechanical ventilation and tracheostomy. The indication and optimal timing of tracheostomy in COVID-19 patients are still unclear, and the outcomes about tracheostomy have not been extensively reported. We aimed to describe the clinical characteristics and outcomes of patients with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia who underwent elective tracheostomies.Methods: The multi-center, retrospective, observational study investigated all the COVID-19 patients who underwent elective tracheostomies in intensive care units (ICUs) of 23 hospitals in Hubei province, China, from January 8, 2020 to March 25, 2020. Demographic information, clinical characteristics, treatment, details of the tracheostomy procedure, successful weaning after tracheostomy, and living status were collected and analyzed. Data were compared between early tracheostomy patients (tracheostomy performed within 14 days of intubation) and late tracheostomy patients (tracheostomy performed after 14 days).Results: A total of 80 patients were included. The median duration from endotracheal intubation to tracheostomy was 17.5 [IQR 11.3–27.0] days. Most tracheotomies were performed by ICU physician [62 (77.5%)], and using percutaneous techniques [63 (78.8%)] at the ICU bedside [76 (95.0%)]. The most common complication was tracheostoma bleeding [14 (17.5%)], and major bleeding occurred in 4 (5.0%) patients. At 60 days after intubation, 31 (38.8%) patients experienced successful weaning from ventilator, 17 (21.2%) patients discharged from ICU, and 43 (53.8%) patients had died. Higher 60 day mortality [22 (73.3%) vs. 21 (42.0%)] were identified in patients who underwent early tracheostomy.Conclusions: In patients with SARS-CoV-2 pneumonia, tracheostomies were feasible to conduct by ICU physician at bedside with few major complications. Compared with tracheostomies conducted after 14 days of intubation, tracheostomies within 14 days were associated with an increased mortality rate.

Health literacy rates among pediatric tracheostomy caregivers

IntroductionAs health outcomes and disparities become more important in national healthcare, physicians must be aware of every patient's health literacy in order to deliver effective care. Our goal was to measure the health literacy rates in the caregivers of our pediatric tracheostomy population. These caregivers specifically have an immense responsibility that requires a certain capacity for understanding and learning complex skills. Thus far there have been no studies or surveys investigating the rates of health literacy in this population or tracheostomy patients in general. Caregivers' literacy rates were measured by administering a Test of Functional Health Literacy in Adults (TOFHLA). This test uses actual materials that patients might encounter in a typical clinic and consists of a reading comprehension and numeracy section. To assess impact of the complex care on caregiver quality of life, we simultaneously administered the Pediatric Tracheostomy Health Status Instrument (PTHSI), a validated caregiver quality of life measurement. MethodsCaregivers of children with tracheostomies were recruited and surveyed during the Pediatric Tracheostomy Clinic between July 2019–October 2019. Twenty - six caregivers completed the TOFHLA; 24 completed all three parts - the TOFHLA, the demographic survey, and the PTHSI. ResultsHealth literacy rates among patient families in the out-patient setting with experience with tracheostomy were deemed “adequate” in 85% of caregivers; the remaining 15% of caregivers scored “inadequate”. Overall adult literacy rates in the general population in this state are 26% “inadequate.” Approximately 80% of our caregivers rely solely on Medicaid for healthcare insurance and nearly half of participants reported an annual household income less than $5000. Ages of caregivers ranged from 20 to 61 years, with no significant correlation to health literacy. The average PTHSI score was 36 (SD 8.6), denoting a moderate level of caregiver burden but no correlation to the caregiver health literacy score was found. When comparing caregiver health literacy scores in relation to education level, caregivers with college and post-graduate education had higher literacy scores than those with a high school education, p = .0086. In addition, when comparing African American to white caregivers, white caregivers were found to have higher health literacy scores, p = .036. Notably, caregiver burden as measured by the PTHSI score did not differ significantly between caregivers in lower income and higher income levels, p = .91. ConclusionHealth literacy measurements for caregivers of children with complex medical conditions exceed the health literacy rates of the general population in our state, potentially biased by the intensive training provided to families during their prolonged hospitalization. Healthcare disparities may impact the medically complex child differently from the healthy child. Assumptions about health, wealth and caregiver burden may be inaccurate and warrant further evaluation. Assessing health literacy before institutionalization has occurred may enable us to more accurately design caregiver training programs to further augment literacy and health literacy.

Impact of Tracheal Tube on Swallowing in Post-Operative Head and Neck Cancer Patients: Scintigraphic Analysis

Dysphagia is common in tracheostomized patients who underwent head and neck surgery for cancer treatment. The objective of this study was to evaluate, by means of oropharyngoesophageal scintigraphy (OPES), the impact of an occluded tracheal tube (TT) on swallowing in patients treated for head and neck cancer before hospital discharge, to provide further information to the benefit of out-patient care management. From October 2018 to November 2019, we enrolled 19 tracheostomized patients (6 females and 13 males; mean age 61 years) who underwent primary surgical resection of head and neck tumor and swallowing rehabilitation during hospitalization. All subjects underwent a double-standard OPES, one with occluded tracheal tube and the other without TT, with their tracheal stoma being closed directly by a plaster. For each study, we assessed and compared the following quantitative parameters: oral transit time (OTTsec), pharyngeal transit time (PTTsec), esophageal transit time (ETTsec), oral retention index (ORI%), pharyngeal retention index (PRI%), esophageal retention index (ERI%), and aspiration percentage (AP%). The mean values of OTT, PTT, ORI%, PRI%, and ERI% were abnormal during OPES both with TT and without TT and did not statistically differ between the two tests (p > 0.05). Aspiration was detected in 4 cases out of 19 (21.05%) cases during OPES with TT and in 4/19 (21.05%) cases without TT who showed a mean AP% of 11.4% and 11.5% respectively (p > 0.05). Patients with abnormal AP% (> 0%) during OPES with TT showed aspiration signs without TT. Our study showed that the mere presence of a closed tracheal tube does not impact significantly the oropharyngeal transit of bolus during swallowing. This result suggests the possibility to maintain a small-diameter occluded tracheal tube in place for the postsurgical management of head and neck cancer patients.

Surveillance endoscopy in pediatric tracheostomy: A systematic review

ObjectivesTo systematically review the literature on the yield of surveillance airway endoscopy in pediatric patients with tracheostomies. MethodsA systematic search was performed according to PRISMA guidelines of the MEDLINE/Pubmed and Embase databases. Data were collected on the following outcomes of interest: abnormal airway findings in surveillance endoscopy performed in pediatric tracheostomy patients, frequency and nature of interventions performed during endoscopy, and predictive factors associated with abnormal airway findings. ResultsSeven studies were included in the review. The timing of endoscopy post-tracheostomy placement was variable and ranged from 1 to 24 months. All studies reported abnormal airway findings on initial endoscopic examination, with rates varying from 20 to 87%. Airway granulomas/granulation tissue was the most common finding, followed by airway stenosis and suprastomal collapse. Interventions performed to improve airway safety occurred in 18%–64% of patients undergoing surveillance endoscopy. The most commonly reported interventions were debridement of granulation tissue and dilation of subglottic stenosis. No endoscopy-related complications were reported across the studies. The presence of tracheostomy-related symptoms was the most consistently reported predictor of abnormal airway findings and airway interventions. ConclusionPediatric tracheostomy patients undergoing surveillance airway endoscopy have a high rate of abnormal airway findings and interventions. However, additional studies are needed before routine endoscopy can be recommended in asymptomatic patients.

Determinants of the Need for Tracheostomy in Neurocritical Patients.

Background: Given the difficulties in predicting the need for prolonged intubation and the timing of tracheostomy, the stroke-related early tracheostomy score (SETscore) was developed, and this tool has demonstrated moderate accuracy in predicting intensive care unit (ICU) length of stay (LoS), ventilation duration, and need for tracheostomy. We aim to assess the usefulness of SETscore in a more heterogeneous population that includes trauma patients to whom this score has not yet been applied.Material and Methods: A retrospective consecutive analysis of all neurocritical patients who were admitted to our medical-surgical ICU between 2016 and 2018 and who required endotracheal intubation within 48 h of admission was performed in this study. Clinicodemographic data, as well as tracheostomy timing, imaging results, and SETscore were evaluated.Results: The medical records of 732 neurocritical patients were reviewed, but only 493 patients were included, 68 of whom were tracheostomized (TR). These TR patients presented longer LoS and ventilation and antibiotic duration, lower Glasgow Coma Scale (GCS) score at admission, and more respiratory comorbidities. Severity scores, including SETscore, were higher in the TR group. A SETscore of >10 demonstrated 92.6% sensitivity and 79.1% specificity in predicting the need for tracheostomy. The majority of patients were tracheostomized after the seventh day of ICU admission. No significant differences in SETscore as well as in severity scores, age, and gender were observed between the early and late TR groups. However, the need for tracheostomy was significantly associated with lower ICU death rate even after controlling for GCS at admission, gender, age, and duration of invasive mechanical ventilation.Conclusion: SETscore can be applied to a heterogeneous population. However, more data and prospective analyses are needed to validate their clinical usefulness on a daily basis. Nevertheless, the present data are expected to contribute to the management of neurocritical patients, particularly in the setting of ICUs managing a broad spectrum of critically ill patients.

Surgical strategy and optimal timing of tracheostomy in patients with COVID-19: Early experiences in Japan

ObjectiveTracheostomy is an important surgical procedure for coronavirus disease-2019 (COVID-19) patients who underwent prolonged tracheal intubation. Surgical indication of tracheostomy is greatly affected by the general condition of the patient, comorbidity, prognosis, hospital resources, and staff experience. Thus, the optimal timing of tracheostomy remains controversial. MethodsWe reviewed our early experience with COVID-19 patients who underwent tracheostomy at one tertiary hospital in Japan from February to September 2020 and analyzed the timing of tracheostomy, operative results, and occupational infection in healthcare workers (HCWs). ResultsOf 16 patients received tracheal intubation with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, five patients (31%) received surgical tracheostomy in our hospital. The average consultation time for surgical tracheostomy was 7.4 days (range, 6 - 9 days) from the COVID-19 team to the otolaryngologist. The duration from tracheal intubation to tracheostomy ranged from 14 to 27 days (average, 20 days). The average time of tracheostomy was 27 min (range, 17 - 39 min), and post-wound bleeding occurred in only one patient. No significant differences in hemoglobin (Hb) levels were found between the pre- and postoperative periods (mean: 10.2 vs. 10.2 g/dl, p = 0.93). Similarly, no difference was found in white blood cell (WBC) count (mean: 12,200 vs. 9,900 cells /µl, p = 0.25). After the tracheostomy, there was no occupational infection among the HCWs who assisted the tracheostomy patients during the perioperative period. ConclusionWe proposed a modified weaning protocol and surgical indications of tracheostomy for COVID-19 patients and recommend that an optimal timing for tracheostomy in COVID-19 patients of 2 - 3 weeks after tracheal intubation, from our early experiences in Japan. An experienced multi-disciplinary tracheostomy team is essential to perform a safe tracheostomy in patients with COVID-19 and to minimize the risk of occupational infection in HCWs.