Insertion Of Tracheostomy Tube Research Articles

Healthcare Utilization and Supportive Care Timing in South Korean People Living With Amyotrophic Lateral Sclerosis: A Single-Center Retrospective Study.

Despite the growing demands and challenges faced by patients with amyotrophic lateral sclerosis (ALS) in accessing healthcare services, our understanding of this access remains poor. This study aimed to investigate the healthcare utilization patterns and timing of nutritional and respiration support in patients with ALS in South Korea. A retrospective cohort study was conducted on patients diagnosed with ALS at a single tertiary hospital between 2016 and 2019 and followed up for 2 years. We evaluated patient characteristics, healthcare utilization (hospital admissions, outpatient visits, and emergency department [ED] visits), and the timing of nutritional and respiration support (noninvasive positive pressure ventilation [NIPPV], tracheostomy, gastrostomy, and nasogastric tube) at 6-month intervals from the first outpatient visit. Among the 143 included patients, 73.4% were admitted at least once, 18.9% experienced unplanned admissions, and 30.1% visited the ED at least once during the study period. The most-common reason for ED visits was neurological symptoms during the first 6 months (59.1%), followed by respiratory symptoms. One fifth of patients who visited the ED underwent tracheostomy (20.9%) or NIPPV (20.9%). Two years after the first visit, 32.2% used a ventilator, and 13.3%, 26.6%, and 6.3% had undergone tracheostomy, gastrostomy, and nasogastric tube insertion, respectively. During the 2 years following their first outpatient visit, 20% of patients with ALS experienced unplanned admissions and 30% visited the ED. An active and prompt supportive-care program should be implemented to ensure timely functional support in order to reduce these risks of unplanned admissions.

Outcomes in Severe COVID-19 Patients Following Percutaneous Versus Open Surgical Tracheostomy: An Analysis of Clinical and Prognostic Indicators.

Background and objective Tracheostomy in coronavirus disease 2019 (COVID-19) patients can be performed in casesof prolonged intubation or in patients with a known difficult airway. Tracheostomy is usually performed by two main approaches: open surgery or percutaneous endoscopic insertion. However, few studies have compared these two techniques in severe COVID-19 patients. The objective of the present study was to compare the efficacy of the two main methods of tracheostomyamong patients with severe COVID-19 infection. We also aimed to investigate the impactof various lab data and medications on patientoutcomes. Materials and methods We included all symptomatic severe COVID-19 patients in need of prolonged mechanical ventilation. We examined the patients' past medical history, arterial blood gas(ABG) analysis, laboratory workups, and medication history. We calculated the PaO2/FiO2ratio as an index to evaluate the severity of acute respiratory distress syndrome(ARDS). Results During the study period, 72 patientswith severe COVID-19underwent tracheostomy tube insertion. The average age of participants was 58.93 ±15.27 years; 44 (61.1%) were male and 28 (38.9%) were female. Of note, 54 (75.0%)patients passed away and only 18 (25.0%)survived. Among the survivors, 13 (29.5%) were men and five (17.9%) were women. The study showed a significantly higher mortality rate (23, 92.0%) among patients who underwent open surgery compared to those who received percutaneous surgery (31, 65.9%) (p=0.01). Conclusion Based on our findings, percutaneous endoscopic tracheostomy seems to be the superior approach compared to open tracheostomy. Other predictive factors associated with patient outcomes included levels of HCO3, FiO2, PaCO2, and PaO2/FiO2 ratio.

Numerical investigation of the effect of tracheostomy on flow and particle transport characteristics in human airways

Tracheostomy is a typical surgical procedure that has been widely practiced to address airway-related difficulties, such as airway obstruction or chronic conditions, that require long-term supportive ventilation. However, it may result in symptoms that detrimental to respiratory system. Computational fluid dynamics (CFD) is a noninvasive and efficient approach for observing the effects of tracheostomy. In this study, we introduced a CFD framework that can reveal the effects of tracheostomy tube insertion based on a comparison with the airflow of a normal airways. An automatic transformation method was developed using a patient's anatomical information to combine subject-specific airways with an artificial tracheostomy tube geometry and an idealized upper airway geometry for later comparison of characteristics of airflow and particle transport. The CFD scheme used for flow simulation in lungs was employed to achieve the behaviors of airflow. The tracheostomy tube generates a jet flow, resulting in twice greater wall shear stress (WSS) and 30 times greater viscous dissipation in the trachea compared to normal airway. The tracheostomized airway induces an intense turbulent jet, which enhances chaotic motion of the particles therein and allows particles to deposit more frequently on the surface. Subsequently, an increase in particle deposition is observed on the central airway's surface. The variation of pressure between inspiration and expiration phase was twice greater and the airflow resistance was also significantly higher compared to normal airway, implying the greater work of breathing. The novel framework could evaluate the efficiency and potential complications in performing tracheostomy beforehand by observing airflow behaviors.

Double-Staged Sleeve Resection of Laryngotracheal Tumor of Papillary and Follicular Thyroid Carcinoma.

Advanced thyroid carcinoma involving the upper aerodigestive tract confers a poor prognosis mainly due to airway complications. The management of thyroid carcinoma with infiltration to the aerodigestive tract has been widely discussed with no consensus regarding the best surgical technique. Complete surgical resection is the aim of the surgery. However, it has high morbidity if the postsurgical care is compromised, which will lead to airway obstruction, bleeding, infection, and anastomotic dehiscence. In our center, complete resection was achieved through cricotracheal window resection with partial closure and tracheostomy tube insertion. This procedure was chosen due to the time-sensitive nature of surgery in these patients with airway compromise and postoperative limitation of intensive care unit (ICU) bed availability. In our case series, we present six cases of papillary and follicular thyroid carcinoma complicated with intraluminal laryngotracheal infiltration and discuss its management and outcome.

Evaluation of Post-Thyroidectomy Complications in Autoimmune Thyroid Diseases versus Nodular Thyroid Diseases

Abstract Background: Thyroid surgery had been and was the most common endocrine surgical operations. An accurately per-formed operation on thyroid gland requires both experience and technical ability and is considered by many to be at the zenith of endocrine surgery. When thyroid operations are performed without sufficient interest, training, or experience the incidence of preventable complication is high. The mortality rate of thyroidectomy as reported in several large series approaches zero. The morbidity of thyroidectomy, however continues to be a matter of concern. Recent research suggests that surgeons may differ in their ability to perform this refined surgery with sufficient care. Aim of Study: The aim was to to evaluate of post-thyroidectomy complications in autoimmune thyroid diseases versus nodular thyroid diseases. Patients and Methods: The study was a prospective randomized study which was done over 100 patients suffering from thyroid disease into two groups, group (I) 50 patients presented with autoimmune thyroid diseases, group (II) 50 patients presented with nodular thyroid diseases. The patients was subjected to total thyroidectomy under general anesthesia which was performed in General Surgery Department of Faculty of Medicine, Menofia University in the period from April 2019 to May 2020. Operative time was reported from start of skin incision till closure of the wound. The two groups were followed-up for one month post-operative which is the end point of the study. Results: In cases of group (I); during operations there was difficulty dissection in 30 cases (30/50, 60%), excessive bleeding in 35 cases (35/50, 70%), nerve damage in 5 cases (5/50, 10%), tracheal damage in one case (1/50, 2%). While in group (II) difficulty dissection in 5 cases (5/50, 10%), excessive bleeding in 2 cases (2/50, 4%), nerve damage only in one case (1/50, 2%). And statistical analysis revealed the predominance of operative difficulties and complications in group (I) than in group (II) (p=0.01).In group (I), two cases needed to be reopened for hemos-tasis and bleeding control due to excessive bleeding (2/50, 4%) and two cases need the insertion of tracheostomy tube for either nerve damage or tracheal damage (2/50, 4%). While in group (II) only one case needed insertion of tracheostomy tube due to tracheomalacia with huge swelling (1/50, 2%). And the statistical analysis revealed a significant increase in early post-operative complications than in group (A) than in group (A) (p=0.024). Conclusion: From our study we can concluded that surgery in autoimmune thyroid swelling is more dangerous than in multinodular goiter this is because excessive fibrosis that leads to excessive and vigorous dissection that leads to bleeding and mare traumatic complications.

Percutaneous Dilatational Tracheostomy: Experience of 100 Cases at a Tertiary Care Centre

Tracheostomy has been accepted as standard of care for patients requiring prolonged mechanical ventilation. There has been a shift from the era of open surgical tracheostomy to percutaneous tracheostomy. Some studies have reported certain advantages of percutaneous tracheostomy over open tracheostomy, yet some centres debate about its effectiveness and, hence, have not adopted it as a routine technique. We present our centre’s experience of performing 100 bedside percutaneous tracheostomies, including those in 27 patients of cervical spine injury. The aim of the study is to demonstrate the safety and efficacy of percutaneous tracheostomy such that it can be embraced as a routine technique. One hundred consecutive neurosurgical patients requiring tracheostomy for prolonged ventilation were included in the study. Patients requiring emergency tracheostomy were excluded. A prospective database was created which included demographic profile of the patient, diagnosis and related indications, procedure time and complications. Ciaglia multiple dilator technique was used for performing percutaneous tracheostomy using Cook set. Time taken was measured from skin incision to insertion of tracheostomy tube. All related complications were noted. Mean duration of procedure was 7.92 ± 0.17 min and 7.14 ± 0.1 min in patients of cervical spine injury. Cannula misplacement occurred in 5 patients and minor bleeding occurred in 4 patients, including 3 complications in patients of cervical spine injury(2 had bleeding while 1 had cannula misplacement corrected during the procedure). Conversion to open procedure was required in one patient. Percutaneous tracheostomy is a safe and effective alternative to open tracheostomy. It can be considered the first line of care in patients requiring tracheostomy, especially in patients of cervical spine injury.

The Outcome Analysis and Complication Rates of Tracheostomy Tube Insertion in Critically Ill Neurosurgical Patients; A Data Mining Study.

Objectives:To assess the impact, timing, the intra and early post-operative complications and the survival outcome of tracheostomy in critically ill neurosurgery patients.Methods:This study was a retrospective data mining where data was collected from hospital records from 175 consecutive patients who underwent tracheostomy in the department of Neurosurgery at the Narayna Medical College Hospital, Nellore, India from Jan 2016 to April 2018. A proforma was used to note down the details on the patient status before and after tracheostomy: Glasgow coma scale (GCS), procedure and intra and post-operative complications, type of tracheostomy cannula, details of decannulation, respiration difficulties, and problems with wound, swallowing difficulties, and voice difficulties, stay in intensive care unit (ICU) and hospital and survival status of the patient.Results:In our series, mean age of TBI cases was 47.42±16.62; mean hospital stay and ICU stay was 18.81±10.22 and 12.58±7.36 days respectively. In all age groups, more tracheostomy was needed in cranial injury cases and surgery was major intervention. Commoner complications were mucous deposition (6.86%), blockage of tracheostomy canula (6.29%), bleeding from multiple attempts (6.06%), excessive bleeding (2.94%). Cranial injury needed tracheostomy more in all age groups and more done at operation theatre without significant improvement of GCS score. Survival was statistically higher after tracheostomy irrespective of GCS status or venue of intervention.Conclusion:Tracheostomy should be considered as soon as the need for airway access is identified during intervention of the critically ill neurosurgical patients.

Transhepatic PEG Tube Placement

A 50-year-old man was successfully treated for severe acute respiratory distress syndrome from adenovirus pneumonia with venovenous extracorporeal membrane oxygenation. Because of the inability to wean from the ventilator, tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube insertion were performed. During PEG tube insertion, 1:1 finger movement was visualized; however, transillumination was not. A percutaneously placed guidewire was grasped endoscopically from the gastric lumen and brought out through the mouth, where the PEG tube was attached and inserted orally through to the skin in a single pass. Eight days after PEG insertion, hemoglobin decreased significantly, and computed tomography scan revealed a spontaneous thigh hematoma caused by anticoagulation. The PEG tube was incidentally noted to pass through the lateral tip of the left lobe of the liver, without intra-abdominal bleeding (Figure A, green circle). A surgical consultation was obtained, but no intervention was recommended. The patient’s swallowing progressively improved, and the PEG tube was successfully removed after 6 months of use. The internal bumper was snared and removed endoscopically to prevent transhepatic passage of the bumper, after freeing by cutting the external portion of the tube. This adverse event may be prevented by performing the safe track technique or by surface ultrasound-guided landmarking.

Penetrating Neck Injuries: from ER to OR.

Neck contains several vital structures, in a small close space, in complex relationship to each other, and unprotected by any bony framework. Any injury to this crucial region, hence mostly becomes an acute emergency. Appropriately managing the same has always been a point of constant discussion amongst head and neck surgeons. The basic aim of the study was to discuss the management, comorbidities, prognosis and associated complications encountered in a series of patients with penetrating neck trauma (piercing platysma), presenting to the emergency over a period of 1year. Combat injuries and patients declared as brought dead at the time of first examination were excluded. This was a retrospective study of patients with cut throat injury, managed at a tertiary center of northern India from June 2014 to September 2015. Following management in the ER as per ATLS guidelines, all patients were then operated for specific injuries. Graph pad software was used for statistical analysis. Of the 15 patients studied in total, 11 (73.3%) were males. The mean patient age was 33.67years. Mean duration of presentation was 20.85h. 60% patients had homicidal injuries. Tracheostomy and Ryle's tube insertion was done in 8 (53.3%) patients. Exploration and surgical repair was done in all patients without any mortality. 4 patients developed post-operative complications. Mean duration of hospital stay was 9.2days. Immediate resuscitation followed by exploration and primary repair is a must in all patients of penetrating neck injury.

Inadvertent passage of a tracheostomy tube through Murphy's eye during percutaneous tracheostomy tube insertion

SummaryPercutaneous tracheostomies are commonly performed at the bedside in Critical Care Units. The use of bronchoscopy during the procedure is variable. We describe a case of inadvertent cannulation of Murphy's eye with a tracheostomy which initially went unrecognised. Recommendations from the NCEPOD report “On the right Trach” related to the use of bronchoscopy during percutaneous tracheostomy insertion and awareness of the nuances of different endotracheal tubes may have prevented this complication.

The experience of adult patients who have tracheostomy tubes in situ: A systematic review

Background: There is a wide range of conditions requiring a patient to have tracheostomy tube insertion. The use of tracheostomy tubes in hospitals has increased among patients with both stable and critical conditions. Respiratory illness may make it necessary for patients to have an alternative breathing system (apart from the mouth or nose) whether as a temporary or permanent procedure. Patients have different experiences of tracheostomy tube insertion. Aims: This study aims to perform a systematic review of qualitative research into the experiences of patients treated with a tracheostomy tube. Objective: The objective of this study is to systematically appraise qualitative evidence on the experience of adult patients having a tracheostomy tube in situ. The report seeks to answer the following question: What are the experiences faced by adult patients with a tracheostomy tube in situ? Inclusion Criteria: Types of Participants: This review included any research that used qualitative methods to investigate the experiences of adult patients with tracheostomy tube insertion. Phenomenon of Interest: The phenomenon of interest was the experience of patients with a tracheostomy tube in situ either as a temporary or permanent procedure, either in hospital or in the community. Types of Studies: This review deliberated on studies that concentrated on qualitative data. The review included all study designs; for instance, phenomenology, action research, grounded theory, feminist research, and ethnography. Search Strategy: The review included all relevant studies published in Arabic and English obtained from the following databases: CINAHL, Cochrane Library, EMBASE, MEDLINE (PubMed), and Scopus and reference lists. There was no limitation on year of publication, and reference list items were searched along with keywords in the heading, abstract, and topic descriptors. Methodological Quality: The methodological quality of each study was assessed by applying the Joanna Briggs Institute's Qualitative Assessment and Review Instrument. Data Collection: The study included adult patients treated with a tracheostomy tube. The research literature was searched using the standard methodology of qualitative research. The two reviewers then applied inclusion and exclusion criteria to the studies and evaluated the findings that met the inclusion criteria on the same subject. Data Synthesis: Synthesis of all data enabled a statement to be created that explains the experiences of adult patients with a tracheostomy tube in situ in the hospital or community. The data were then characterized according to the quality of findings and the similarity of meaning. Results: Four studies met the study selection criteria and were included in the systematic review that determined the experience of patients with a tracheostomy tube in situ. There were 18 findings extracted from the included studies. These were synthesized and then grouped into seven categories in relation to similarity of meaning. The seven categories remaining were then synthesized in a meta-synthesis that produced four outcomes linked to the experiences of participants having a tracheostomy tube in situ: (i) Communication is fundamental. (ii) The experience has both physical and psychological impacts. (iii) There are long-term consequences. (iv) Staff and patients work together to achieve positive outcomes. Conclusions: In the studies appraised by the reviewers, the importance of understanding the experiences of adult patients with tracheostomy tubes in situ was clarified. Patients have a right to experience correct practices that may help them to adapt to a new lifestyle with a tracheostomy. Implications for Practice: Patients should be given support physically, psychosocially, and emotionally after tracheostomy tube insertion. In addition, nurses' awareness about patients' educational needs regarding tracheostomy care, before discharge from hospital, needs to be increased. Implications for Further Research: Further research is required to identify the ways to reduce patients' negative experiences after having a tracheostomy tube in situ.

When a Safety-Valve Became a Ticking Time-Bomb: Fractured Tracheostomy Tube as a Tracheobronchial Foreign Body in a Child

AbstractTracheostomy Tube care is a part of respiratory rehabilitation in acquired brain injury but just tracheostomy tube insertion is not enough. Checking for Pre-requisites including manufacturing details, and regular follow – up is important. Here we present a rare case of fracturing of the tracheostomy tube in a traumatic brain injury which was managed timely.

Design of a Safer Tracheostomy Tube1

During a tracheotomy, the surgeon makes an incision through the front of the patient’s neck (the incision is known as a tracheostomy) to access the trachea and insert a tracheostomy tube (see Figure 1), which serves as an alternative airway to the mouth or nose. After insertion, a balloon is inflated to the diameter of the trachea, which fixes the tracheotomy tube in place, allows for positive pressure ventilation, and creates a seal to the walls of the trachea.

Supraglottoplasty outcomes in neurologically affected and syndromic children.

Supraglottoplasty (SGP) failure is frequently attributed to coexistent medical comorbidities, but studies specifically evaluating outcomes in these populations are lacking. To assess SGP outcomes in patients with neurologic and syndromic comorbidities and severe laryngomalacia (LM). Case series with retrospective review of medical records of 54 patients with neurologic and/or syndromic comorbidity and severe LM who underwent SGP between 2004 and 2012 at a tertiary care pediatric institution. Patients presented with severe LM that required SGP. Supraglottoplasty failure necessitated revision SGP, tracheostomy, or gastrostomy tube insertion, or LM and obstructive sleep apnea that required assisted ventilation (continuous positive airway pressure and bilevel positive airway pressure). Medical records were reviewed with a focus on patient factors, surgical timing, complications, and surgical and dysphagia outcomes. Patients were grouped based on their age at the time of SGP as infants (aged ≤12 months) and children (aged >12 months). Statistical comparisons were performed with SGP outcomes of infants with LM and no comorbidities. Fifty-four patients met the inclusion criteria. Thirty-one (13 infants, 18 children) had a neurologic condition and 23 (15 infants, 8 children) had syndromes. The overall success rate of SGP was 67% (36 of 54) in these populations. Neurologic (P = .003) and syndromic (P < .001) comorbidities were associated with significant reduction in SGP success rates vs no comorbidities. Among SGP failures (18 of 54 [33%]), 13% (7 of 54) required tracheostomy, 9% (5 of 54) needed assisted ventilation, 7% (4 of 54) required a postoperative gastrostomy tube, and 4% (2 of 54) required revision SGP. In the neurologic comorbidities group, patients with cerebral palsy had significantly higher tracheostomy rates compared with those who had other neurologic pathologies constituting comorbidities (2 of 11 [18%] vs 0 of 20; P = .049). In infants, acute airway obstruction was the most common indication for SGP in the neurologically comorbidity and syndrome populations (success rates, 69% and 67%, respectively). In children, obstructive sleep apnea was the most common indication for SGP in the neurologic comorbidity and syndrome populations (success rates, 78% and 50%, respectively). Supraglottoplasty remains useful and outcomes were better in patients with neurologic comorbidity than in patients with syndromic comorbidity.

Tracheal Re-Stenosis after Resection and Anastomosis of Complete Tracheal Stenosis

Tracheal Re-Stenosis after Resection and Anastomosis of Complete Tracheal Stenosis

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Introduction: 79 year old male presented with generalized weakness, slurred speech, altered mental status and labored breathing for several hours along with 20 pound weight loss over 6 months. Patient had three admissions at different hospital over the last 3 months for similar but milder presentation. Past work up included CT scan of the chest which was unrevealing and pulmonary function test (PFT) which showed restrictive lung disease with FEV1 of 48%, FVC of 44% of predicted and FEV1/FVC 84, though he was given the diagnosis of chronic obstructive pulmonary disease (COPD) as an explanation of his hyperbaric respiratory failure. Physical exam in the ED was pertinent for tachycardia, labored shallow breathing and lethargy. Auscultation of his chest demonstrated bilateral decreased breath sound. An arterial blood gas analysis showed pH of 7.04, PaCO2 of >130.00 mmHg and PaO2 of 218 mmHg on 100% oxygen. Chest x-ray and CT scan of the head were both unremarkable for acute process. Hypercarbia was initially attributed to possible COPD and obstructive sleep apnea (OSA). Patient's trachea immediately intubated and mechanical ventilation was begun. After borderline spontaneous breathing trial, patient was extubated next morning. Patient required bi-level noninvasive positive pressure mechanical ventilation (NIPPV) for moderate respiratory distress after extubation. A repeat physical examination was remarkable for impaired dorsiflexion of right ankle, tongue fasciculation and weak negative inspiratory force. There was no evidence of upper motor neuron dysfunction. Work up for neuromuscular weakness included antiacetylcholine receptor antibody, which was negative and electromyography, which demonstrated 2+ fasciculation and fibrillation potentials in >3 muscle groups. A diagnosis of progressive muscular atrophy (PMA) with early respiratory failure was made; it is believed to be a rare form of Amyotrophic Lateral Sclerosis (ALS). After discussing the merits and demerits of invasive mechanical ventilation via tracheostomy and gastrostomy tube insertion, he opted for comfort care. ALS is a neurodegenerative disease characterized by progressive muscular paralysis due to degeneration of lower and upper motor neurons in the primary motor cortex, brainstem, and spinal cord. Muscular paralysis is progressive and typically leads to death due to respiratory failure within 2-5 years of onset. However, only 3.0% of patients with ALS present with respiratory symptoms and 14% of this subpopulation requires mechanical respiratory support, a rare presentation of ALS. Clinical features of early respiratory failure like dyspnea on minor exertion, early morning headache, daytime fatigue and weight loss may be subtle and often overlooked. The classic form of ALS presents with both upper motor neuron (UMN) and lower motor neuron (LMN) findings, but it can be as in our case limited to LMN only and is referred to as PMA. Compared to ALS, patients with PMA are more likely to be males and live longer. Management of ALS in all of its forms is supportive, multidisciplinary and palliative. Early use of NIPPV in ALS patients prolong survival and improve quality of life. Invasive mechanical ventilation, implying the use of an endotracheal tube or a tracheostomy may be considered. Patient with bulbar dysfunction may need gastrostomy to support nutrition. A FVC of <50% of the predicted value has been shown to be associated with poor prognosis. Arriving to accurate diagnosis in timely manner is critical for health care team to expedited discussion with patient and family about management plan and encourage them to consider advanced directives regarding end of life. Patients should be provided with a realistic prognostication of the course of their disease and in the event of decline of full mechanical ventilation, patient and family should be provided with assurance that palliative care strategies can control symptoms in the terminal phase of illness.

Difficult tracheostomy tube insertion rescued by an angiographic catheter

Difficult tracheostomy tube insertion rescued by an angiographic catheter

S-shaped tracheostoma in pediatric tracheostomy using three-dimensional sigma-plasty—A novel technique to possibly reduce procedure related complications

ObjectivesWe have designed a technique of tracheostomy in pediatric patients with S-shaped incision on the tracheal wall which we think, provides a larger cross-sectional area of stoma and facilitates easier insertion of tracheostomy tube and thus helped in reducing early and late complications associated with it in our series. TechniqueThe trachea was exposed in midline by a vertical skin incision. In order to make S-shaped tracheostoma, second tracheal ring was identified. The conventional vertical incision was made in second tracheal ring and then extended at both its ends laterally in the inter-cartilaginous space parallel to the tracheal cartilage in the opposite direction to make the incision S-shaped. The trachea was dilated with tracheal dilator and appropriate size of tracheostomy tube was then placed into the trachea. ResultsS-shaped tracheostomy was performed in 40 children with mean age of 6.36 years (age range is 2–12) required for airway maintenance or prolonged ventilatory support. The incidence of early complications was quite less in our patients (ranged from 0 to 5%). There was no incidence of excessive intra-operative bleeding or injury to surrounding structures causing subcutaneous emphysema or vocal cord palsy. One patient developing pneumothorax after the procedure was managed conservatively. There was no incidence of tracheo-esophageal fistula, suprastomal collapse or difficulty in decannulation on 9 months of follow up related to our technique. However, one of the patients developed early trachietis and cutaneous peristomal granulomas and 2 patients developed late trachietis which was treated conservatively. ConclusionS-shaped tracheoplasty, a new pediatric tracheotomy technique has resulted in a quantifiable reduction in the risk of the early and late complications in our series. Hence, we feel that this new technique is a better alternative to existing methods but larger randomized controlled studies are required before universal adoption of this technique.

Tracheo-Innominate Artery Fistula after Stroke

Tracheo-innominate artery fistula (TIAF) is rare, yet the most fatal complication after tracheostomy. In the absence of immediate diagnosis and surgical management, the mortality rate is very high, because the complication can lead to sudden massive tracheal hemorrhage. Tracheal obstruction and hypovolemic shock are the major life threatening conditions. The 46-year-old woman received tracheostomy tube insertion after stroke. Three months later, there was occurrence of active bleeding at the site of tracheostomy in the patient, who participated in comprehensive rehabilitation program. Immediately, the patient received an endotracheal tube insertion into the tracheostomy site and thus massive bleeding was controlled. The patient was transferred to the intensive care unit, where her breathing was maintained by mechanical ventilation. Based on computed tomography and laryngoscopy, no remarkable findings about TIAF were detected. Nevertheless, transfemoral angiography findings revealed that innominate artery made small luminal outpouching to trachea at the carotid artery and at the subclavian artery bifurcation level, based on which a diagnosis of TIAF was made. She had an operation for TIAF, tracheoplasty with bypass graft. Subsequently, she was discharged after 15 weeks. In the present report, we describe a case of TIAF, which can occur in the patients with tracheostomy tube during rehabilitation.

More than nothing: The lived experience of tracheostomy while acutely ill

While the physical sensations surrounding tracheostomy tube insertion have been reported within nursing and allied healthcare literature, the lived experience of these sensations is poorly described. This appears relevant given the imminent results of the Tracman study (2008). A purposive sample of three participants who had tracheostomy tubes previously within a critical care area or still in situ were recruited. They described their experiences in a face-to-face semi-structured interview that were audio taped. The interviews were transcribed verbatim and analysed using Giorgi's 5 concrete steps of the human scientific phenomenological method (1997). Findings revealed themes that drew attention to the fundamental aspects of the experience. These were: Practical recommendations draw attention to the organisational support required for staff expected to care for these patients in the ward environment. This involves the introduction of evidence based guidelines and competency based care to promote the acquisition of skills required to perform those essential tasks such as suction and stoma care to a high standard. Protected, formalised skills based teaching is seen as fundamental in this process. Patients' felt confident in nursing staff that were able to demonstrate proficiency with such tasks and this is seen as crucial when one considers that the tracheostomy tube is a new experience for patients.