Tracheostomy Tube Research Articles

Role of Therapeutic Bronchoscopy in Comparison to Standards of Care in Critically Ill Patients with Acute Respiratory Failure

Abstract Background Acute respiratory failure (ARF) is a sudden failure of oxygenation, carbon dioxide clearance or both, Hypoxic ARF is most commonly caused by pneumonia, cardiogenic or noncardiogenic pulmonary edema, or pulmonary haemorrhage, while the underlying causes of hypercapnic ARF include drug overdose, neuromuscular disease, chest wall abnormalities and severe obstructive airway disorders. Treatment for respiratory failure includes clearing the airways by suction, use of bronchodilators, tracheostomy and endotracheal tube with ventilator support. Additionally, the treatment regimen includes antibiotics for infections, anticoagulants for pulmonary thromboembolism, and electrolyte replacement for fluid imbalance. Objective To evaluate difference between use of therapeutic bronchoscope to standards of care, including open and closed suctioning (no bronchoscopy) regarding patient outcome. Patients and Methods Study included 80 patients who were divided by alternation into two groups: Group A: 40 patients were subjected to traditional standards of care including chest percussion, closed and open suctioning. Group B: 40 patients were subjected to therapeutic bronchoscope (fibreoptic bronchoscopy) with endobronchial washing and suctioning in addition to traditional standards of care. Results Regarding ABG significant improvements were observed, (in terms of PaCO2, PaO2 and PaO2/FiO2 ratio) in group B (fibreoptic bronchoscopy) in comparison with group A (traditional standards of care) at all follow up periods (P < 0.05). Regarding the radiological improvement, in this study we observed significant improvement after 3 days, after 8 days and total improvement were observed in group B (fibreoptic bronchoscopy) compared to group A (traditional standards of care) (P < 0.05). Regarding the patient’s ICU length of stay, both groups demonstrated insignificant differences (8.24±3.06 in group A versus 6.78±4.09 in group B) (P > 0.05). Conclusion The current study revealed that fibreoptic bronchoscopy was associated with significant improvement compared to traditional standards of care, in ARF cases in terms of ABG parameters as well as radiological findings. However, ICU length of stay and duration of mechanical ventilation seemed to be comparable.

Effectiveness of Training: Airway Management of Tracheostomized Pediatric Patients by Pediatric Residents and Anesthesiology Residents.

To evaluate the effect of training on increasing baseline knowledge of pediatrics and anesthesia residents about airway management of pediatric patients with tracheostomy. It is a prospective, descriptive, before and after survey study. A questionnaire was conducted to measure the baseline knowledge of pediatrics and anesthesia residents about airway management in patients with pediatric tracheotomy. The same questionnaire was repeated after the education. Of the 63 participants, 42 were pediatric residents and 21 were anesthesiology residents. While the number of participants who answered the cuff part, inner cannula part, obturator part and balloon part of the tracheostomy tube correctly before the training was 27, 4, 10, and 12, respectively, these numbers increased to 53, 52, 57, and 55 after the training. There was a statistically significant improvement after the training in the correct response of the cuff, inner cannula, obturator, and balloon sections. A statistically significant improvement was observed in the answers received after the training for all 7 questions regarding the clinical scenario of accidental decannulation and tracheostomy bleeding compared to the pre-training. There was a statistical improvement in part where the participants rated themselves. In conclusion, training increases the ability of healthcare professionals to cope with life-threatening complications related to pediatric tracheotomy. A standardized education program on pediatric tracheostomy should be included in the routine programs of associated departments such as emergency medicine, anesthesia, and pediatrics residencies.

A retrospective analysis of COVID-19 tracheostomies: Early versus late tracheostomy.

To assess the impact of early tracheostomy (ET) versus late tracheostomy (LT) placement on mortality and decannulation rates of COVID patients. A retrospective chart review was performed of all patients infected with COVID-19 who underwent tracheostomy tube placement in an Ochsner-affiliated hospital from March 2020 to May 2022. Patients were identified using the electronic medical record and data was collated using the "Epic SlicerDicer" tool. Descriptive statistics were gathered and compared between patients who underwent ET placement and those who underwent LT placement. Patient demographics, previous medical history, tracheostomy procedural details, arterial blood gases, complications, and outcomes including time to wean from the ventilator, and time to decannulation were recorded. Two-hundred nineteen patients were included in the study. There were no statistically significant differences in liberation from mechanical ventilation rates between early and LT (62% vs. 55%, p = .19), or in decannulation rates (40% vs. 32%, p = .14). The mean duration of time to liberation from mechanical ventilation for early trach was 13.88 versus 18.17 days for late trach, however, no statistically significant difference was found (p = .12). Similarly, mean duration of time to decannulation was 41.17 days for early versus 47.72 for late trach (p = .15). Contrary to some studies in the literature, the results presented here suggest ETs are not associated with hastened liberation from mechanical ventilation or increased decannulation rates. Further prospective studies may be warranted in assessing the impact of early versus LT in the COVID patient population. III.

Use of the G8 Geriatric Screening Tool in Surgical Head and Neck Cancer Patients Requiring Rehabilitation: A Multisite Investigation.

The G8 is a well-validated screening test for older cancer patients. The current study was undertaken to determine whether the G8 is predictive of short-term post-operative outcomes after head and neck cancer (HNC) surgery. Consecutive patients aged 65 years or more and referred for a preoperative assessment by a speech-language pathologist were consecutively screened by clinicians at 2 academic medical centers using the G8. The G8 was used to screen for vulnerability prior to surgery. Patients were deemed vulnerable if they had a total G8 score ≤14 according to published guidelines. Data were also collected on demographic characteristics, tumor staging, post-operative course, and tracheostomy and feeding tube (FT) status. Ninety patients were consecutively screened during the study period. Using the G8, 64% of the patients were deemed vulnerable. Vulnerable patients differed significantly from non-vulnerable patients with regard to age, health, tumor stage, and baseline dysphagia, and underwent more extensive surgery. Postoperatively, vulnerable patients had a significantly longer hospital length of stay (LOS; 10.17 vs 5.50 days, respectively, P < .001), were less likely to discharge home (76% vs 94%, P = .044), and were more likely to be FT dependent for over a month (54% vs 21%, P = .006) compared to non-vulnerable patients. In regression models, controlling for T-stage and surgical variables, the G8 independently predicted 2 post-operative outcomes of interest, namely LOS and FT dependency. The G8 may be a useful screening tool for identifying older adults at risk of a protracted postoperative medical course after HNC surgery. Future research should aim to identify the optimal screening protocol and how this information can be incorporated into clinical pathways to enhance the post-operative outcomes of older HNC patients.

One-Year Outcomes of Patients Requiring Tracheostomy Placement Due to Severe Acute Respiratory Syndrome Coronavirus 2 Infection.

What are the characteristics of patients who develop the need for tracheostomy due to SARS-CoV-2 with acute respiratory distress syndrome (ARDS)? What is their 90-day and 1-year survival and are there any identifiable risk factors for mortality and ventilator dependency? Retrospective, follow-up cohort study of adult patients with COVID-19 infection and ARDS who required tracheostomy placement in a large healthcare system. One hundred sixty-four consecutive patients with SARS-CoV-2 admitted to ICUs for ARDS who required tracheostomy placement between March 2020 and March 2021 were identified. One hundred nine (66.5%) were male. Average age was 63.5 years. The most common comorbidities were obesity, hypertension, diabetes mellitus, congestive heart failure, chronic kidney disease, chronic obstructive pulmonary disease (COPD), atrial fibrillation, and asthma. The most common complications during hospitalization were delirium, secondary infections, acute kidney injury, pneumothorax, and venous thromboembolism. Ninety-day and 1-year mortality were 29.9% and 44.5%, respectively. Ninety-six patients (58.5%) were liberated from the ventilator, and 84 (51.2%) had the tracheostomy tube decannulated. Asthma, COPD, atrial fibrillation, and renal replacement therapy requirement in the ICU correlated with increased risk of ventilator dependency. Among survivors at 1 year, 71 patients (43.3%) were residing at home and 20 patients (12.2%) remained in a skilled nursing facility. COVID-19 has resulted in a significant burden of acute critical illness and acute respiratory failure with the need for tracheostomy. A significant percentage of patients with SARS-CoV-2 requiring tracheostomy were alive and at home 1 year after tracheostomy placement. Long-term care support, including tracheostomy, beyond 90 days appears to be beneficial in this patient population and warrants further investigation.

Evaluation of Early-term Results of Cuffed/Non-cuffed Tracheostomy Tubes in Infants and Children for Tracheostomy Procedure

Evaluation of Early-term Results of Cuffed/Non-cuffed Tracheostomy Tubes in Infants and Children for Tracheostomy Procedure

Thematic Analysis of Psychosocial Stressors and Adaptive Coping Strategies Among Informal Caregivers of Patients Surviving ICU Admission for Coma.

Family caregivers of patients with severe acute brain injury (SABI) admitted to intensive care units (ICUs) with coma experience heightened emotional distress stemming from simultaneous stressors. Stress and coping frameworks can inform psychosocial intervention development by elucidating common challenges and ways of navigating such experiences but have yet to be employed with this population. The present study therefore sought to use a stress and coping framework to characterize the stressors and coping behaviors of family caregivers of patients with SABI hospitalized in ICUs and recovering after coma. Our qualitative study recruited a convenience sample from 14 US neuroscience ICUs. Participants were family caregivers of patients who were admitted with ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, traumatic brain injury, or hypoxic-ischemic encephalopathy; had experienced a comatose state for > 24h; and completed or were scheduled for tracheostomy and/or gastrostomy tube placement. Participants were recruited < 7days after transfer out of the neuroscience ICU. We conducted live online video interviews from May 2021 to January 2022. One semistructured interview per participant was recorded and subsequently transcribed. Recruitment was stopped when thematic saturation was reached. We deductively derived two domains using a stress and coping framework to guide thematic analysis. Within each domain, we inductively derived themes to comprehensively characterize caregivers' experiences. We interviewed 30 caregivers. We identified 18 themes within the two theory-driven domains, including ten themes describing practical, social, and emotional stressors experienced by caregivers and eight themes describing the psychological and behavioral coping strategies that caregivers attempted to enact. Nearly all caregivers described using avoidance or distraction as an initial coping strategy to manage overwhelming emotions. Caregivers also expressed awareness of more adaptive strategies (e.g., cultivation of positive emotions, acceptance, self-education, and soliciting social and medical support) but had challenges employing them because of their heightened emotional distress. In response to substantial stressors, family caregivers of patients with SABI attempted to enact various psychological and behavioral coping strategies. They described avoidance and distraction as less helpful than other coping strategies but had difficulty engaging in alternative strategies because of their emotional distress. These findings can directly inform the development of additional resources to mitigate the long-term impact of acute psychological distress among this caregiver population.

Utilization of Training Dolls to Enhance Caregiver Education for Pediatric Tracheostomy Care.

Caregivers of tracheostomized children must learn and demonstrate multiple tracheostomy care skills. At our hospital, caregiver education is provided through a combination of written instructions, classroom sessions, hands-on practice with a manikin, and bedside demonstration. As part of a quality improvement initiative, caregivers were provided a training doll to practice skills. A training doll was provided to caregivers of children within the first week of tracheostomy placement to practice skills. Two questionnaires were utilized during the education process to evaluate utility of the training dolls, skills practiced, and confidence in performing skills. The first questionnaire was completed at the time of the classroom session and the second questionnaire after training was completed. A chart review was conducted to compare outcomes for children whose caregivers did and did not receive a training doll. Caregivers of 33 children with a tracheostomy received training dolls, and 28 were not provided dolls. The majority of caregivers felt the training doll was helpful for practicing skills (initial 93%, second questionnaire 85%). Some caregivers reported a lack of confidence in changing the tracheostomy tube (47%) and using a self-inflating bag (21%) in the initial questionnaire. Confidence increased for all skills in the second questionnaire. Few caregivers reported not using the training doll (initial 21%, second 11%). There were no significant differences in hospital length of stay (LOS) (P = .21) or time to complete training (P = .21) for children whose caregivers were and were not provided a doll. The majority of caregivers utilized the training doll to practice tracheostomy skills and found it helpful for training. The training doll did not significantly impact hospital LOS or time to complete training. Use of a training doll to practice tracheostomy skills is an additional tool to assist caregivers with learning required skills prior to discharge home.

CO2 Stunning in Pigs: Physiological Deviations at Onset of Excitatory Behaviour.

Stunning by carbon dioxide (CO2) inhalation is controversial because it is associated with vigorous movements and behaviours which may or may not be conscious reactions. Furthermore, it is unknown whether some behaviours might indicate the transition into unconsciousness. Our study objective was to investigate the loss of consciousness during CO2 stunning by linking physiological variables (in particular pH, PaO2 and PaCO2) to the onset of observed behaviours. A total of 11 cross-bred pigs were studied. A tracheostomy tube, venous and arterial cannulae were placed under sevoflurane anaesthesia. After recovery from this, and a "wash out" period of at least 30 min, arterial blood samples were taken (and baseline values established) before 90-95% CO2 in medical air was administered through the tracheostomy tube. Subsequent behaviours were video-recorded and key physiological variables were evaluated using an anaesthetic monitor and the frequent sampling of arterial blood (albeit with inconsistent inter-sample intervals). After the study, behaviours were classified in an ethogram. At the onset of behaviours categorised as "vigorous movement extremities", "opisthotonos" and "agonal gasping" pH values (range) were: 6.74-7.34; 6.66-6.96 and 6.65-6.87, while PaCO2 (kPa) was 4.6-42.2, 24.4-51.4 and 29.1-47.6. Based upon these values, we conclude that the pigs were probably unconscious at the onset of "opisthotonos" and "agonal gasping", but some were probably conscious at the onset of "vigorous movements".

Subacute prognosis of oral nutrition (SPOON): Development of a multivariable prognostic model for complete oral intake in tube-fed subjects with acquired brain injury

Enteral feeding is very common following an acquired brain injury. However, no prognostic models for oral food intake have been developed for subacute rehabilitation. The aim of this study was to develop a prognostic model and online tool, coined "subacute prognosis of oral nutrition" (SPOON), for complete oral intake in tube-fed subjects with acquired brain injury. The model was developed using routinely gathered clinical data from a cohort of 1233 adult patients who were tube-fed at admission for sub-acute inpatient rehabilitation. Candidate predictors were included based on scientific evidence and their availability in the medical records within the first days following admission. The outcome was time until achieving complete oral food intake without any tube-feeding supplements. Time until complete oral intake was analyzed by discrete time-to-event analysis with logit-link and presented as daily odds ratios (OR) with 95% confidence intervals (CI). The following predictors of complete oral intake were included in the model: age, diagnosis, cuffed tracheostomy tube, days from injury to admission for rehabilitation, and the Early Functional Abilities (EFA) sum score. Multiple adjusted analyses were performed stratified by cuffed tracheostomy tube status. Some of the strongest predictors of complete oral intake were age 18-40 years, OR 1.99 (95%CI: 1.53; 2.59); 0-2 weeks since injury, OR 3.75 (95%CI: 2.72; 5.16); and EFA 61-100 (slight/no disturbance in function), OR 5.81 (95%CI: 4.47; 7.55). The online prognostic tool SPOON was evaluated in a usability study. Based on feedback from clinicians, the tool was further refined to enable extraction of data for prediction directly from medical records. The objective of SPOON is to complement the planning of rehabilitation initiatives and inform discussions to determine if a percutaneous endoscopic gastrostomy (PEG) tube should be inserted. SPOON is being implemented locally, but external validation based on appropriate data modeling is warranted before further clinical implementation.

Hassle with the tracheostomy tube

Hassle with the tracheostomy tube

High-flow via a tracheostomy tube and speaking valve during weaning from mechanical ventilation and tracheostomy.

Weaning from mechanical ventilation and tracheostomy after prolonged intensive care consume enormous resources with optimal management not currently well described. Restoration of respiratory flow via the upper airway is essential and early cuff-deflation using a one-way valve (OWV) is recommended. However, extended OWV use may cause dry airways and thickened secretions which challenge the weaning process. High-flow therapy via the tracheostomy tube (HFT-T) humidifies inspired air and may be connected via an in-line OWV (HFT-T-OWV) alleviating these problems. We aim to provide clinical and experimental data on the safety of HFT-T-OWV along with a practical guide to facilitate clinical use during weaning from mechanical ventilation and tracheostomy. Data on adverse events of HFT-T-OWV were retrieved from a quality register for patients treated at an intensive care rehabilitation center between 2019 and 2022. Benchtop experiments were performed to measure maximum pressures and pressure support generated by HFT-T-OWV at 25-60 L/min flow using two different HFT-T adapters (interfaces). In simulated airway obstruction using a standard OWV (not in-line) maximum pressures were measured with oxygen delivered via the side port at 1-3 L/min. Of 128 tracheostomized patients who underwent weaning attempts, 124 were treated with HFT-T-OWV. The therapy was well tolerated, and no adverse events related to the practice were detected. The main reason for not using HFT-T-OWV was partial upper airway obstruction using a OWV. Benchtop experiments demonstrated HFT-T-OWV maximum pressures <4 cmH2 O and pressure support 0-0.6 cmH2 O. In contrast, 1-3 L/min supplemental oxygen via a standard OWV caused pressures between 84 and 148 cmH2 O during simulated airway obstruction. Current study clinical data and benchtop experiments indicate that HFT-T-OWV was well tolerated and appeared safe. Pressure support was low, but humidification may enable extended use of a OWV without dry airway mucosa and thickened secretions. Results suggest the treatment could offer advantages to standard OWV use, with or without supplementary oxygen, as well as to HFT-T without a OWV, for weaning from mechanical ventilation and tracheostomy. However, for definitive treatment recommendations, randomized clinical trials are needed.

Safety and tolerability of continuous inhaled iloprost in critically ill pediatric pulmonary hypertension patients: A retrospective case series.

Inhaled iloprost (iILO) has shown efficacy in treating patients with hypoxic lung disease and pulmonary hypertension, inducing selective pulmonary vasodilation and improvement in oxygenation. However, its short elimination half-life of 20-30 min necessitates frequent intermittent dosing (6-9 times per day). Thus, the administration of iILO via continuous nebulization represents an appealing method of drug delivery in the hospital setting. The objectives are: (1) describe our continuous iILO delivery methodology and safety profile in mechanically ventilated pediatric pulmonary hypertension patients; and (2) characterize the initial response of iILO in these pediatric patients currently receiving iNO. Continuous iILO was delivered and well tolerated (median 6 days; range 1-94) via tracheostomy or endotracheal tube using the Aerogen® mesh nebulizer system coupled with a Medfusion® 400 syringe pump. No adverse events or delivery malfunctions were reported. Initiation of iILO resulted in an increase in oxygen saturation from 81.4 ± 8.6 to 90.8 ± 4.1%, p < 0.05. Interestingly, prior iNO therapy for >1 day resulted in a higher response rate to iILO (as defined as a ≥ 4% increase in saturations) compared to those receiving iNO <1 day (85% vs. 50%, p = 0.06). When the use of iILO is considered, continuous delivery represents a safe, less laborious alternative and concurrent treatment with iNO should not be considered a contraindication. However, given the retrospective design and small sample size, this study does not allow the evaluation of the efficacy of continuous iILO on outcomes beyond the initial response. Thus, a prospective study designed to evaluate the efficacy of continuous iILO is necessary.

Extrinsic tracheotomy tube compression in a patient with upper airway obstruction: A case series

Extrinsic tracheotomy tube compression in a patient with upper airway obstruction: A case series

Predictors of postoperative performance status after surgical management of infratemporal fossa malignancies.

Infratemporal fossa (ITF) tumors are difficult to access surgically due to anatomical constraints. Moreover, aggressive ITF carcinomas and sarcomas necessitate aggressive treatment strategies that, along with tumor-related symptoms, contribute to decreases in patient performance status. To assess factors that predict postoperative performance in patients undergoing surgery for ITF tumors. We reviewed medical records for all patients surgically treated for an ITF malignancy between January 1, 1999, and December 31, 2017, at our institution. We collected patient demographics, preoperative performance, tumor stage, tumor characteristics, treatment modalities, pathological data, and postoperative performance data. The 5-year survival rate was 62.2%. Higher preoperative Karnofsky Performance Status (KPS) score (n = 64; p < 0.001), short length of stay (p = 0.002), prior surgery at site (n = 61; p = 0.0164), and diagnosis of sarcoma (n = 62; p = 0.0398) were predictors of higher postoperative KPS scores. Percutaneous endoscopic gastrostomy (PEG) (n = 9; p = 0.0327), and tracheostomy tube placement (n = 20; p = 0.0436) were predictors of lower postoperative KPS scores, whereas age at presentation (p = 0.72), intracranial tumor spread (p = 0.8197), and perineural invasion (n = 40; p = 0.2195) were not. Male patients and patients with carcinomas showed the greatest decreases in KPS scores between pretreatment and posttreatment. Higher preoperative KPS score and short length of stay were the best predictors of higher postoperative KPS scores. This work provides treatment teams and patients with better information on outcomes for shared decision-making.

Functional and quality-of-life outcomes following salvage surgery for recurrent squamous cell carcinoma of the head and neck: a systematic review and meta-analysis.

Recurrent head and neck squamous cell carcinomas (HNSCC) are frequently managed with salvage surgery, but the impact these operations have on function and quality-of-life (QoL) is understudied. This review aimed to provide a quantitative and qualitative assessment of the functional and QoL effects of salvage surgical procedures. Systematic review and meta-analysis were conducted of studies reporting QoL and function following salvage HNSCC resections. The search identified 415 articles and 34 were selected for inclusion. Pooled random effects analysis revealed long-term feeding and tracheostomy tube rates of 18% and 7%. Pooled long-term feeding tube rates in open oral and oropharyngeal, transoral robotic, total and partial laryngectomy surgeries were 41%, 25%, 11% and 4%. Eight studies used validated QoL questionnaires. Functional and QoL outcomes from salvage surgery are acceptable, but appear to be worse following open procedures. Prospective studies measuring changes over time are needed to assess these procedures impact on patient well-being.

The Role of Methylene Blue Spray to Keep Parathyroid Gland and Recurrent Laryngeal Nerve Safe During Thyroidectomy.

Background: The main postoperative complications of thyroidectomy are hypoparathyroidism and recurrent laryngeal nerve (RLN) palsy. Methylene blue, which is a drug and dye, is safe and easy to get, and we can use it to avoid complications during thyroidectomy. Objectives: We aim to assess that we can spray Methylene blue to allow the identification of important structures intraoperative which are the parathyroid gland and recurrent laryngeal nerve. Also, to evaluate that this technique is safe, effective, technically feasible, and less dangerous than other techniques. Methods: Our study is a prospective cohort study of patients, patients who presented with simple nodular goiter, solitary thyroid nodule, controlled toxic goiter, and failed medical treatment with the indication for thyroidectomy, suspected malignancy, and retrosternal goiters at El-Demerdash Hospital from the period of August 2021 to August 2022. In the specified study period of 1 year from 1/8/2021 to 31/7/2022. Results: Sixty patients underwent thyroidectomy 54 underwent total while 6 only underwent hemithyroidectomy. The time taken to wash out the dye over the thyroid gland was 15 to 25 minutes, the parathyroid gland was 4 to 7 minutes and the recurrent laryngeal nerve (RLN) was almost 0 to 1 minute and this indicated that the RLN almost did not take the dye. In the controlled group, two patients had symptoms and signs of hypocalcemia only one of them had signs of tetany, 8 patients had laboratory hypocalcemia, two patients suffered from a change of voice and another two patients suffered difficulty breathing one of which needed temporary tracheostomy while in the interventional group, only one patient had symptoms and signs of hypocalcemia no one had signs of tetany, two patients had laboratory hypocalcemia, one patient suffered from the change of voice and another two patients suffered the difficulty of breathing but no one needed a tracheostomy tube. Conclusions: It is safe, useful, and suitable to use Methylene blue spraying to keep the parathyroid gland and RLN during thyroidectomy, which led us to reduce the percentage of incidence of postoperative complications. Also, it helped us to find the parathyroid gland and RLN during the surgery, despite some surgeons seeing that searching for the parathyroid and RLN can lead to harmful effects and increase the incidence of injury.

Aspiration of Fractured Tracheostomy Tube in a Prone Positioned COVID-19 Patient: A Case Report and Review of the Literature.

A 61-year-old male patient diagnosed with Coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS) was managed with tracheostomy and intermittent prone positioning in the intensive care unit. After a sudden deterioration, examination of tracheostomy tube (TT) and X-ray of the chest revealed that he had aspirated the fractured TT. The fractured tube was removed through the tracheostomy stoma using a rigid ventilating bronchoscope and forceps. Prone positioning is a beneficial postural therapy capable of improving patient oxygenation. However, it has some complications, like unplanned extubation and facial tissue injury. Percutaneous tracheostomy is also a valuable and safe procedure and has been increasingly performed in critical care patients, including those who suffer from COVID-19 ARDS. Fractures and aspiration of a tracheostomy tube can occur anytime after tracheostomy. We think prone positioning may contribute to the rupture and aspiration of the tracheostomy tube in this study.

Neurological Pupillary Index and Disposition at Hospital Discharge following ICU Admission for Acute Brain Injury.

We examined the associations between the Neurological Pupillary Index (NPi) and disposition at hospital discharge in patients admitted to the neurocritical care unit with acute brain injury (ABI) due to acute ischemic stroke (AIS), spontaneous intracerebral hemorrhage (sICH), aneurysmal subarachnoid hemorrhage (SAH), and traumatic brain injury (TBI). The primary outcome was discharge disposition (home/acute rehabilitation vs. death/hospice/skilled nursing facility). Secondary outcomes were tracheostomy tube placement and transition to comfort measures. Among 2258 patients who received serial NPi assessments within the first seven days of ICU admission, 47.7% (n = 1078) demonstrated NPi ≥ 3 on initial and final assessments, 30.1% (n = 680) had initial NPI < 3 that never improved, 19% (n = 430) had initial NPi ≥ 3, which subsequently worsened to <3 and never recovered, and 3.1% (n = 70) had initial NPi < 3, which improved to ≥3. After adjusting for age, sex, admitting diagnosis, admission Glasgow Coma Scale score, craniotomy/craniectomy, and hyperosmolar therapy, NPi values that remained <3 or worsened from ≥3 to <3 were associated with poor outcomes (adjusted odds ratio, aOR 2.58, 95% CI [2.03; 3.28]), placement of a tracheostomy tube (aOR 1.58, 95% CI [1.13; 2.22]), and transition to comfort measures only (aOR 2.12, 95% CI [1.67; 2.70]). Our study suggests that serial NPi assessments during the first seven days of ICU admission may be helpful in predicting outcomes and guiding clinical decision-making in patients with ABI. Further studies are needed to evaluate the potential benefit of interventions to improve NPi trends in this population.

Tracheoinnominate Artery Fistula After Tracheostomy: A Systematic Literature Review of Associations With Mortality

Tracheoinnomate artery fistulas (TIF) are a rare but deadly complication of tracheostomy. This study summarizes TIF cases in the literature and seeks to understand associations with mortality. MEDLINE was searched (up to May 2021) for studies reporting individual clinical and demographic characteristics of patients with TIFs after tracheostomy. Exclusion criteria were: no tracheostomy tube in place at the time of fistula or additional procedures performed at the tracheostomy site. This study was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 122 TIF patients from 18 case series and 46 case reports were included. The median age was 40.9 years (range: 4-85, interquartile range: 20.9-60.9 years) and 53.3% (64 of 120) were male. Trauma was the leading indication for tracheostomy (26.2%, 32 of 122), followed by head/neck cancer (20.5%, 25 of 122) and structural malformation (19.7%, 24 of 122). Mortality characteristics are summarized in the Table. Overall mortality rate was 64.8% (79 of 122), with a 15.4% higher rate in females than males (P = .077). There was no significant difference in the median number of days between tracheostomy and TIF detection between those who survived their TIF vs those who died (46 days vs 23 days, P = .077). There was a significant difference in mortality between cases that initially presented with vs without sentinel bleeding (50% [25 of 50] vs 75% [54 of 72], P = .005). The presence or absence of frank hemorrhage also showed a significant difference in mortality (59.6% [53 of 89] vs 78.8% [26 of 33], P = .035). Mortality differed in whether or not the tracheostomy cuff was overinflated for temporary hemostasis during resuscitation (52.2% [35 of 67] vs 80% [44 of 55], P < .001). A total of 27 cases received endovascular management, 2 of which ultimately needed open surgery. No difference in mortality was found between endovascular and surgical management, yet both of these were superior to no treatment (48.6% [36 of 74] vs 89.6% [43 of 48], P < .001). Of the 49 cases definitively managed with open surgery, there were 36 innominate artery resections, 15 tracheal reconstructions, and 12 innominate artery reconstructions. Mortality is a major concern and resuscitation paired with endovascular or surgical intervention is imperative. Investigating sentinel bleeds in a timely fashion and intervening upon hemorrhage with temporary cuff overinflation may lead to improved outcomes.TableMortality characteristicsMortalityP valueDied64.7 (79/122)Sex Male57.8 (37/64).077 Female73.2 (41/56)Age, groups in years 4-2563.8 (23/36).756 26-5061.4 (27/44) >5069.0 (29/42)Sentinel bleed Present50 (25/50).005 Absent75 (54/72)Hemorrhage Present59.6 (53/89).035 Absent78.8 (26/33)Cuff over inflation Performed52.2 (35/67)<.001 Not performed80 (44/55)Endovascular vs surgical management Endovascular48.0 (12/25).938 Surgical49.0 (24/49)Definitive treatment vs no treatment Endovascular or Surgical48.6 (36/74)<.001 No treatment89.6 (43/48)Values represented as percentage and count (condition present/total). Open table in a new tab