Tracheostomy Procedure Research Articles

Implementing a Bedside Percutaneous Tracheostomy and Ultrasound Gastrostomy Team Reduces Length of Stay and Hospital Costs Across Multiple Critical Care Units in a 1500 Bed Tertiary Care Center.

Thousands of critically ill patients every year in the United States receive tracheostomy and gastrostomy procedures. Recent research has investigated the benefits of a combined team approach to these procedures, with associated decreases in length of stay (LOS) and hospital costs. This study's objective was to determine if implementing a bedside percutaneous tracheostomy and percutaneous ultrasound gastrostomy (PUG) team would reduce LOS and hospital costs. Design and Methods: This retrospective chart review compares the impact of implementing an ICU bedside percutaneous tracheostomy and PUG service team to the hospital's previous workflow (ie, pre-implementation). Inclusion criteria were adult patients with Ventilator Dependent Respiratory Failure (VDRF), a clinical indication for both procedures while admitted to the ICU and received both tracheostomy and gastrostomy procedures while admitted to the hospital. Pre- and post-implementation groups were compared across patients' demographics, clinical characteristics, and outcomes. ICU LOS, hospital LOS and total hospital costs were the primary outcome measures. Results: A total of 101 adult critically ill patients were included in the analysis; 49 patients were in the pre-implementation group and 52 patients in the post-implementation group (ie, PUG group). Patients in the PUG group had a significantly shorter mean ICU LOS and hospital LOS, 10.9- and 14.7-day reductions respectively (p = 0.010, p = 0.006). PUG group patients also had a significant reduction in total hospital costs, a per patient cost savings of $34 778 (p = 0.043). Conclusions: This study supports implementing a bedside percutaneous tracheostomy and PUG team to reduce LOS and total hospital costs in patients with VDRF.

Prospective Study of Contamination Spread Produced During Open Surgical vs Conventional Percutaneous vs Novel Percutaneous Tracheostomy During COVID-19 Era in a Pig Model.

Because of concerns about provider contamination during tracheostomy procedures in a pandemic such as COVID-19, it is essential to objectively evaluate aerosol generation in all tracheostomy approaches, including newly developed tracheostomy procedures. We performed open surgical tracheostomy (OST), conventional percutaneous tracheostomy (CPT), and novel percutaneous tracheostomy (NPT), a modification of CPT designed to reduce contamination spread, in pig models and then compared the degree of contamination to providers using Glo Germ (Glo Germ, Moab, UT, USA). Six Yorkshire pigs were used for data collection. Either OST, CPT or NPT was performed on the pigs by the same team including a surgeon, anesthesiologist, and respiratory therapist. A mixture of Glo Germ and water was administered via atomizer into the oral cavity to the tracheal bifurcation before each procedure, and additionally dispersed via an aersolizer in the trachea and lungs through the endotracheal tube before and throughout the procedure. Before and immediately after each procedure, pre-specified body parts of the providers were photographed and two independent examiners blindly evaluated the photographs to determine degree of Glo Germ contamination using a 3-point Likert scale. Total contamination among provider team average score (min. 0, max. 2), was significantly lower for OST than CPT (0.29 ± 0.59 vs 0.63 ± 0.65; P<0.01) or NPT (0.29 ± 0.59 vs 0.59 ± 0.66; p <0.01). No significant difference was seen in overall contamination of any provider between CPT and NPT (0.63 ± 0.65 vs 0.59 ± 0.66; p =0.92). Our results suggest that OST causes significantly less aerosol contamination to providers than either CPT or NPT.

Effect of early prone positioning among critically ill patients admitted with acute respiratory distress syndrome during the COVID-19 pandemic: A comparative retrospective observational study

Background and objective: COVID-19 has offered an opportunity to the clinicians to try and study various oxygenation enhancing maneuvers in the patients. These included lung protective measures and prone positioning of participants admitted to the ICU with acute respiratory distress syndrome. We aimed to identify the effects of early prone positioning on the length of stay, discharge rate, and frequency of tracheostomies in the ICU patients. Methodology: This retrospective study was conducted on critically ill patients needing mechanical ventilation with lung protective strategy, admitted to the Intensive Care Units of Al-Azhar University Hospitals between March 2020 to April 2022. All patients in the study were interpreted retrospectively by examining the patient's records. Group A (n = 39) included patients who had been early placed in prone positions within 24 h of intubation, and Group B (n = 31) included patients who had not been placed in prone positions. All patients received a lung protective strategy for ARDS. In both groups, PaO2, PaCO2, pH, SpO2, and PaO2/FiO2 ratio were checked initially and later every 24 h for 6 days. Data was evaluated for the total days of both hospital and ICU length of stay, number of successful discharges to home from the hospital, and the total number of tracheostomized patients. Results: After prone positioning, lower SOFA and APACHE II scores were noticed in the prone group. There was no significant difference in the rate of discharge between the two groups. We observed non-significant shorter hospital and ICU stays and higher frequency of tracheostomy procedures in the prone group. We noticed a significant improvement in PaO2/FiO2 ratios in the prone group starting from day 2 to day 6. We observed a significant improvement in PO2 in the prone group in comparison to the non-prone group. Conclusions: Early prone positioning of patients admitted to the ICU with acute respiratory distress syndrome during COVID-19 pandemic led to a significant improvement in both PaO2 and PaO2/FiO2 ratio with a non-significant decrease in both hospital and ICU length of stay as shown by the collected data over consecutive six days. Abbreviations: ARDS- acute respiratory distress syndrome; FiO2: The fraction of inspired oxygen; CPAP: Continuous Positive Airway Pressure; PaO2: Arterial oxygen partial pressure; PEEP: Positive End-Expiratory Pressure; SOFA- Sequential Organ Failure Assessment Keywords: Prone; Lung protective measures; ARDS; APACHI II; SOFA Citation: Seyam SHA, Ahmed IMA. Effect of early prone positioning among critically ill patients admitted with acute respiratory distress syndrome during the COVID-19 pandemic: a comparative retrospective observational study. Anaesth. pain intensive care 2024;28(4):626−632; DOI: 10.35975/apic.v28i4.2504 Received: February 12, 2024; Reviewed: May 14, 2024; Accepted: May 15, 2024

Advancements in Interventional Pulmonology: Harnessing Ultrasound Techniques for Precision Diagnosis and Treatment.

Medical ultrasound has emerged as an indispensable tool within interventional pulmonology, revolutionizing diagnostic and procedural practices through its non-invasive nature and real-time visualization capabilities. By harnessing the principles of sound waves and employing a variety of transducer types, ultrasound facilitates enhanced accuracy and safety in procedures such as transthoracic needle aspiration and pleural effusion drainage, consequently leading to improved patient outcomes. Understanding the fundamentals of ultrasound physics is paramount for clinicians, as it forms the basis for interpreting imaging results and optimizing interventions. Thoracic ultrasound plays a pivotal role in diagnosing conditions like pleural effusions and pneumothorax, while also optimizing procedures such as thoracentesis and biopsy by providing precise guidance. Advanced ultrasound techniques, including endobronchial ultrasound, has transformed the evaluation and biopsy of lymph nodes, bolstered by innovative features like elastography, which contribute to increased procedural efficacy and patient safety. Peripheral ultrasound techniques, notably radial endobronchial ultrasound (rEBUS), have become essential for assessing pulmonary nodules and evaluating airway structures, offering clinicians valuable insights into disease localization and severity. Neck ultrasound serves as a crucial tool in guiding supraclavicular lymph node biopsy and percutaneous dilatational tracheostomy procedures, ensuring safe placement and minimizing associated complications. Ultrasound technology is suited for further advancement through the integration of artificial intelligence, miniaturization, and the development of portable devices. These advancements hold the promise of not only improving diagnostic accuracy but also enhancing the accessibility of ultrasound imaging in diverse healthcare settings, ultimately expanding its utility and impact on patient care. Additionally, the integration of enhanced techniques such as contrast-enhanced ultrasound and 3D imaging is anticipated to revolutionize personalized medicine by providing clinicians with a more comprehensive understanding of anatomical structures and pathological processes. The transformative potential of medical ultrasound in interventional pulmonology extends beyond mere technological advancements; it represents a paradigm shift in healthcare delivery, empowering clinicians with unprecedented capabilities to diagnose and treat pulmonary conditions with precision and efficacy. By leveraging the latest innovations in ultrasound technology, clinicians can navigate complex anatomical structures with confidence, leading to more informed decision-making and ultimately improving patient outcomes. Moreover, the portability and versatility of modern ultrasound devices enable their deployment in various clinical settings, from traditional hospital environments to remote or resource-limited areas, thereby bridging gaps in healthcare access and equity.

Predictors of Complete Oral Intake in Patients With Stroke After Tracheostomy.

Tracheostomy procedures inhibit swallowing, although details of subsequent recovery of oral intake remain unknown. This retrospective cohort study aimed to investigate factors influencing dysphagia improvement in patients with subacute stroke after tracheostomy. The study included 117 patients who underwent tracheostomy after subacute stroke, cerebral hemorrhage, or endogenous subarachnoid hemorrhage and received care at 2 convalescent rehabilitation wards in urban and suburban Japan between 2015 and 2022. The primary outcome measure was the achievement of complete oral intake. Patient demographics, Functional Independence Measure scores, body mass index, food intake level scale scores, and the presence of severe white matter hyperintensities on imaging were retrospectively collected from medical records. Statistical analysis involved univariate logistic regression to identify potential predictors and multivariate logistic regression to refine the model while accounting for multicollinearity. In total, 47% of patients achieved complete oral intake on discharge. Sex, days from onset to admission, Functional Independence Measure motor and cognitive scores, body mass index, food intake level scale scores, and severe white matter hyperintensities were identified as potential predictors in the univariate analysis. However, multivariate logistic regression identified only food intake level scale scores (odds ratio [OR], 3.687 [95% CI, 1.519-8.949]; P=0.004) and severe white matter hyperintensities (OR, 0.302 [95% CI, 0.096-0.956]; P=0.042) as significant predictors of complete oral intake. In patients with subacute stroke undergoing tracheostomy, the level of oral intake on admission and severe white matter hyperintensities on imaging may be better predictors of complete oral intake. However, prospective studies with larger sample sizes and more comprehensive data are warranted to confirm these findings.

The dragonfly technique for trachea closure in temporary tracheostomies. Surgical steps and clinical results.

To assess the effectiveness of a new suturing technique called Dragonfly for the closure of temporary tracheotomies. This technique involves placing two sutures during the tracheotomy procedure and leaving them loose and unknotted until the day of skin closure. Retrospective case control study. Monocentric study at a department of Otolaryngology and head and neck surgery at a tertiary centre in Italy. A total of 50 patients who underwent temporary tracheotomy between January 2017 and December 2021. Patients were divided into two groups based on the trachea closure method: traditional closure with sutures placed during the skin closure procedure (Group A) and the Dragonfly technique (Group B). The incidence of tracheal stenosis by Computed Tomography (CT), granulation tissue formation, bleeding, procedure duration, patient discomfort were evaluated. The incidence of tracheal complications and tracheal stenosis was reduced in Group B (6%) compared to Group A (24%). Procedure times (3min vs. 6min) durations was significantly shorter. No patients had symptoms of tracheal stenosis at the end of the procedures. The Dragonfly suturing technique is effective and safe for tracheotomy closure, reducing the incidence of tracheal stenosis and shortening hospitalization duration compared to the traditional method.

Tracheostomy Complications Over 5 Years: Decannulation Analysis.

Tracheostomy is a life-saving surgical intervention commonly performed in patients requiring prolonged mechanical ventilation. However, the decannulation process is associated with various complications that can affect patient outcomes. This study aimed to assess complications and their management during decannulation in a cohort of tracheostomy patients at a tertiary care hospital, considering the complexities introduced by prior intubation. A retrospective cohort study was conducted involving 450 patients who underwent tracheostomy during a stipulated timeframe. Data regarding demographic characteristics, complications, and management strategies during decannulation were analysed. Special attention was given to distinguishing between complications directly related to the tracheostomy procedure and those potentially influenced by previous intubation. Out of the 450 patients, 250 experienced minor complications such as localized bleeding, oxygen desaturation, and minor infections. Another 40 faced major complications including severe haemorrhage, tracheal damage, and stenosis. Increasing age and tracheostomy duration were identified as significant predictors of complications. Pharmacological treatments, surgical interventions, and respiratory therapy were among the management strategies employed. The differentiation between complications arising from tracheostomy and prior intubation highlighted the need for comprehensive patient evaluation. Complications associated with decannulation occur frequently with varying severity. Efficient recognition and management of these complications are vital for improving patient outcomes. The study provides important insights into the challenges experienced during the decannulation process and highlights the necessity of considering prior intubation history in the management of tracheostomy decannulation to refine patient care protocols.

Four-layer technique for tracheostomy scar treatment.

One important complication of the tracheostomy procedure is the depressed scar left after the tube is removed. A depressed tracheostomy scar can be aesthetically and functionally unacceptable. Tracheostomy scar treatment aims to fill lost soft tissue volume and correct tracheal skin tug. There are various techniques described to manage post-tracheostomy scars, including the use of autologous tissue or allogenic material and the creation of muscle flaps. In this article, the authors introduce a surgical method using four layers: the scar, the strap muscles, the platysma muscle, and the skin. This procedure has been used in two patients with depressed scar after prolonged tracheostomy placement. The tracheal tug was eliminated in each patient, and an imperceptible cutaneous scar remained. In each case, patient satisfaction was complete. The authors recommend this technique as a simple and effective method of closure for these troublesome tracheostomy scars.

Tracheostomy-related data from an intensive care unit for two consecutive years before the COVID-19 pandemic.

Tracheostomy is commonly used in intensive care unit (ICU) patients who are expected to be on long-term mechanical ventilation or suffer from emergency upper airway obstruction. However, some studies have conflicting findings regarding the optimal technique and its timing and benefits. To provide evidence of practice, characteristics, and outcome concerning tracheostomy in an ICU of a tertiary care hospital. This was a retrospective cohort study including adult critical care patients in a single ICU for two consecutive years. Patients' demographic characteristics, severity of illness (APACHE II score), level of consciousness [Glasgow Coma Scale (GCS)], comorbidities, timing and type of tracheostomy procedure performed and outcome were recorded. We defined late as tracheostomy placement after 8 days or no tracheotomy. Data of 660 patients were analyzed (median age of 60 years), median APACHE II score of 19 and median GCS score of 12 at admission. Tracheostomy was performed in 115 patients, of whom 63 had early and 52 late procedures. Early tracheostomy was mainly executed in case of altered level of consciousness and severe critical illness polyneuromyopathy, however there were no significant statistical results (47.6% vs 36.5%, P = 0.23) and (23.8% vs 19.2%, P = 0.55) respectively. Regarding the method selected, early surgical tracheostomy (ST) was conducted in patients with maxillofacial injuries (50.0% vs 0.0%, P = 0.033), whereas late surgical tracheostomy was selected for patients with goiter (44.4% vs 0.0% P = 0.033). Patients with early tracheostomy spent significantly fewer days on mechanical ventilation (15.3 ± 8.5 vs 22.8 ± 9.6, P < 0.001) and in ICU in general (18.8 ± 9.1 vs 25.4 ± 11.5, P < 0.001). Percutaneous dilatation tracheostomy (PDT) vs ST was preferable in older critical care patients in the case of Central Nervous System underlying cause of admission (62.5% vs 26.3%, P = 0.004). ST was the method of choice in compromised airway (31.6%, vs 7.3% P = 0.008). A large proportion of patients (88/115) with tracheostomy managed to wean from mechanical ventilation and were transferred out of the ICU (100% vs 17.4%, P < 0.001). PDT was performed more frequently in our cohort. This technique did not affect mechanical ventilation days, ventilator-associated pneumonia (VAP), ICU length of stay, or survival. No complications were observed in the percutaneous or surgical tracheostomy groups. Patients undergoing early tracheostomy benefited in terms of mechanical ventilation days and ICU length of stay but not of discharge status, presence of VAP, or survival.

Supporting Direct Breastfeeding for a Tracheostomy-Dependent Extremely Premature Infant: A Case Study.

The benefits of human milk for preterm infants are well documented. Complex medical conditions can limit the extremely premature infant's ability to breastfeed and to receive human milk directly, yet these vulnerable infants may benefit most from receiving it. Extremely preterm infants are at risk for infections, digestive challenges, and chronic lung disease, and occasionally require a tracheostomy to facilitate weaning from mechanical ventilation. There is a risk of aspiration when orally feeding a child with a tracheostomy. This case study describes a tertiary neonatal team supporting a family's direct breastfeeding goal in an extremely premature infant with a diagnosis of bronchopulmonary dysplasia requiring a tracheostomy. Initially, the infant participant (born at 24 weeks and 3 days of gestation, with a birthweight of 540 g) was gavage fed with human milk. The interdisciplinary team collaborated with the family to guide the infant's feeding goals, providing positive oral stimulation with soothers, oral immune therapy, and frequent skin-to-skin contact to prepare for future oral feeding. Within a month of the tracheotomy procedure, oral feeding was initiated, and direct breastfeeding with the tracheostomy tubing in place was achieved at 50 weeks and 1 day of age as a primary source of nutrition. The open dialogue between the family and healthcare team was the foundation for trialing direct breastfeeding for an extremely premature infant with a tracheostomy. While direct breastfeeding of full-term infants with tracheostomies has been previously described in the literature, this is the first case study of an extremely premature infant with a tracheostomy transitioning to direct breastfeeding.

Cholesteatoma in the pediatric aerodigestive population

ObjectivesTo report the prevalence of cholesteatoma and related comorbidities in pediatric aerodigestive patients requiring tracheostomy or airway reconstruction procedures. To use study findings to inform clinical management of these complex patients. MethodsA repository of clinical data drawn from our institution's electronic medical records was queried to identify airway reconstruction (airway) and complex hospital control (control) patient cohorts. Retrospective chart review was then performed to investigate the occurrence of cholesteatoma and related pathologies in these patients, as well as clinical management. ResultsThe prevalence of cholesteatoma in airway and control patients was 6/374 (1.60 %) and 35/30,565 (0.11 %), respectively. The relative risk of cholesteatoma diagnosis in airway patients was 14.01 (95 % CI 6.06–32.14). Airway patients were more likely than control patients to have pressure equalization tube history (relative risk 3.25, 95 % CI 2.73–3.82). Age at cholesteatoma diagnosis and first surgical intervention was younger in airway compared to control patients (5.43 vs. 8.33, p = 0.0182, and 6.07 vs. 8.82, p = 0.0236). However, time from diagnosis to intervention and extent of surgery were similar between the groups. ConclusionThis is the first study to investigate the prevalence of cholesteatoma in the pediatric aerodigestive population. The relative risk of cholesteatoma diagnosis was found to be 14 times higher in patients with tracheostomy or airway reconstruction history. Underlying eustachian tube and palatal dysfunction are likely contributing factors to the elevated risk. Additionally, cholesteatoma in this population was diagnosed and required surgical intervention at a younger age, which may suggest a more aggressive disease course. Providers should maintain a high degree of suspicion for cholesteatoma in this complex population.

Tracheostomy Timing in Unselected Critically Ill Patients with Prolonged Intubation: A Prospective Cohort Study.

Background: Tracheostomy procedures are performed in the intensive care unit (ICU) for prolonged intubation, unsuccessful weaning and infection prevention through either percutaneous or surgical techniques. This study aimed to outline the impact of tracheostomy timing in the ICU on mortality, need for mechanical ventilation, and complications. Methods: Patients were included in the study on the day of tracheostomy. Demographic information, tracheostomy timing, technique, complications, sedation requirement and need for mechanical ventilation at discharge were recorded by an anesthesiologist, including the pre-tracheostomy period. Results: Tracheostomy was performed on 33 patients during the first 14 days of intubation and on 54 patients on the 15th day and beyond. There was no significant difference between the tracheostomy timing and mortality, sedation requirement, or weaning from the ventilator. We observed that patients who underwent tracheostomy with the surgical technique experienced more complications, but there was no significant difference. Tracheostomy performed after the 14th day was shown to be associated with prolonged hospital stay. Conclusions: Early tracheostomy does not have any influence on the need for mechanical ventilation, sedation and mortality. The optimal timing for tracheostomy is still controversial. We are of the opinion that randomized controlled trials involving patient groups with similar survival expectations are needed.

Pediatric neurosurgical medulloblastoma outcomes in La Paz, Bolivia: How a Lower Middle-Income Country (LMIC) institution in South America compares to the United States.

How pediatric medulloblastoma patients fare in Lower Middle-Income Country (LMICs) in South America is not well understood. Correspondingly, the aim of this study was to summarize the pediatric neurosurgical experience of an institution in La Paz, and compare outcomes to that of a generalized High Income Country (HIC) United States (US) experience. A retrospective review of all pediatric neurosurgical medulloblastoma patients at the Children's Hospital of La Paz, Bolivia (Hospital del Niño "Dr. Ovidio Aliaga Uria") between 2014 and 2023 was conducted and compared to a generalized US experience abstracted from the US National Cancer Database (NCDB) and National Inpatient Sample (NIS) databases. Categorical, continuous and survival data were statistically summarized and compared. A total of 24 pediatric medulloblastoma patients underwent neurosurgical treatment at the Hospital del Niño. In this La Paz cohort, there were 15 (63%) males and 9 (38%) females, with a mean age of 5.6 years old at diagnosis. The majority of patients underwent subtotal resection (STR, 79%), while the remaining patients underwent biopsy only. Ten (42%) patients expired during their hospitalization, and mean length of stay overall was 39 days. Only 8 (33%) patients received adjuvant treatment after surgery. Median overall survival from diagnosis in the La Paz cohort was 1.9 months. Compared to the US databases, the La Paz cohort experienced significantly more emergency room admissions for surgery, less gross total resection, more STR, more return to operating room for ventriculoperitoneal shunting, more bacteremia, more tracheostomy procedures, more percutaneous gastrostomy placements, longer lengths of stay, less adjuvant chemotherapy, less radiation therapy, shorter follow-up, and ultimately, significantly shorter overall survival (all P < 0.050). Pediatric neurosurgical medulloblastoma outcomes at the Children's Hospital of La Paz, Bolivia are significantly inferior to that of a generalized US experience. Future research is required to identify institution- and country-specific initiatives to improve discrepancies between institutions in LMICs in South America compared to HICs.

Time to death and its predictors among adult patients on mechanical ventilation admitted to intensive care units in West Amhara comprehensive specialized hospitals, Ethiopia: a retrospective follow-up study

IntroductionMechanical ventilation is the most common intervention for patients with respiratory failure in the intensive care unit. There is limited data from African countries, including Ethiopia on time to death and its predictors among patients on mechanical ventilators. Therefore, this study aimed to assess time to death and its predictors among adult patients on mechanical ventilation admitted in comprehensive specialized hospitals in West Amhara, Ethiopia.MethodsAn institutional-based retrospective follow-up study was conducted from January 1, 2020, to December 31, 2022. A simple random sampling was used to select a total of 391 patients’ charts. Data were collected using data the extraction tool, entered into Epi-data version 4.6.0, and exported to STATA version 14 for analysis. Kaplan–Meier failure curve and the log-rank test were fitted to explore the survival difference among groups. The Cox regression model was fitted, and variables with a p-value < 0.25 in the bivariable Cox regression were candidates for the multivariable analysis. In the multivariable Cox proportional hazard regression, an adjusted hazard ratio with 95% confidence intervals were reported to declare the strength of association between mortality and predictors when a p value is < 0.05.ResultsA total of 391 mechanically ventilated patients were followed for 4098 days at risk. The overall mortality of patients on mechanical ventilation admitted to the intensive care units was 62.2%, with a median time to death of 16 days (95% CI: 11, 22). Those patients who underwent tracheostomy procedure (AHR = 0.40, 95% CI: 0.20, 0.80), received cardio-pulmonary resuscitation (AHR = 8.78, 95% CI: 5.38, 14.35), being hypotensive (AHR = 2.96, 95% CI: 1.11, 7.87), and had a respiratory rate less than 12 (AHR = 2.74, 95% CI: 1.48, 5.07) were statistically significant predictors of time to death among mechanically ventilated patients.ConclusionThe mortality rate of patients on mechanical ventilation was found to be high and the time to death was short. Being cardiopulmonary resuscitated, hypotensive, and had lower respiratory rate were significant predictors of time to death, whereas patients who underwent tracheostomy was negatively associated with time to death. Tracheostomy is needed for patients who received longer mechanical ventilation, and healthcare providers should give a special attention for patients who are cardiopulmonary resuscitated, hypotensive, and have lower respiratory rate.

Healthcare service use and medical outcomes of tracheostomy-dependent children: a nationwide study

BackgroundDespite the rising trend of tracheostomies in children, there is a lack of comprehensive resources for families to navigate the challenges of living with a tracheostomy, emphasising the need for...

Impact of Vertical and Horizontal Skin Incisions on Outcome Measures in Tracheostomies.

Tracheostomy is a life-saving procedure in which an opening is created in the anterior wall of the trachea. Different skin incision types are administered in tracheostomy procedures, predominantly vertical and horizontal. Various literature on the skin incision types in tracheostomy had contradictory findings, with different studies observing that one skin incision type had better outcomes than its counterpart.Hence the objective of this study was to compare the outcomes associated with vertical and horizontal skin incisions in patients undergoing tracheostomy. Method The present study assessed the outcome measures between the two incision types (vertical and horizontal) in tracheostomy. A prospective longitudinal study was done based on an academic tertiary hospital in Bhopal, Madhya Pradesh. Participants above 18 years who underwent tracheostomy were enrolled in the study and followed up over six months during intraoperative, immediate, within seven days, and long-term periods. Result In intraoperative complications, bleeding was most common (n = 15, 16.7%), followed by passage of tube into false tract (n = 6, 6.7%) and saturation drop (n = 2, 2.2%). Immediate complications comprised T-tube blockage (n = 4, 4.4%) and bleeding (n = 1, 1.1%). Complications within seven days occurred only in the horizontal group in which stomal site ulceration (n = 4, 6.7%) and delayed bleeding (n = 2, 3.3%) was seen, and one participant had unintended decannulation. In the long term, complications observed were stomal granulation (n = 9, 19.1%), dysphagia (n = 7, 14.9%), and unintended decannulation (n = 4, 8.5%). Conclusion In the current study, the most common intraoperative complication was bleeding, the immediate complication was tube dislodgement, and tracheostomy site ulcer was the most common complication within seven days, similar to the literature findings.

Bronchoscopy guided percutaneous dilatational tracheostomy; performed by anaesthesiology residents

Aims: Percutaneous dilatational tracheostomy can be performed safely at the bedside in critical patients today. Clinical studies on tracheostomy were mostly carried out by experienced healthcare professionals. This study was designed to investigate the differences of percutaneous dilatational tracheostomy performed by anaesthesiology residents using two different methods. Methods: Patients hospitalized in anaesthesia intensive care unit who underwent percutaneous tracheostomy were examined. All tracheostomy procedures were performed by anaesthesiology residents using the “Griggs” or “Ciaglia” method. The procedure time, difficulty and complications of both methods were recorded. Results: 38 patients were included in the study. It was observed that 22 of the patients had tracheostomy with the Griggs technique, and 16 with the Ciaglia technique. Tracheostomy application time was measured as 6.05 minutes with the Griggs technique and 6.35 minutes with the Ciaglia technique (p=0.939). There was no difference in complications and technical difficulties between the two methods. Conclusion: In this study, where bedside bronchoscopy guided percutaneous dilatational tracheostomies were applied by two different methods by anaesthesiology residents, no difference was found between the two methods in terms of complications and technical difficulties. We believe that "Griggs" and "Ciaglia Blue Rhino", two of the percutaneous dilatational tracheostomy methods, are not superior to each other in terms of ease of use and complications in anaesthesiology education.

Recognition and Prevention of Hospitalised Malnutrition: A Case Report

Rationale: Poly-trauma post road traffic accident often induces a state of malnutrition due to the pathological changes and the insufficient protein and caloric intake for long time. If left unmanaged, malnutrition will have negative consequences on rehabilitation. Nutritional intervention provides caloric requirements and the nutritional support necessary to cover the daily nutritional needs and help contrast hospitalised infections. Our hypothesis is that integration of organised and continuous nutritional assessment and management can enhance prevent the state of malnutrition and increase rehabilitation outcomes.&#x0D; Patient Concerns: We present the case of an adult man with Poly-trauma post caused by road traffic. The patient underwent tracheostomy and percutaneous endoscopic gastrostomy (PEG) procedures, had severe consciousness disorder.&#x0D; Diagnosis: He has severe consciousness disorder that necessitated the tracheostomy and the PEG.&#x0D; Interventions: Our approach included regular nutritional assessment and caloric calculation and implementation of as well as the gradual introduction of diet from NPO to clear liquid, as well as using of supplements and enteral formulas.&#x0D; Outcomes: The patient was followed for seven months during which the metabolic/nutritional pattern and the blood tests improved, normal weight restored, and consciousness regained.&#x0D; Conclusion: Nutritional intervention integrated has prevented drastic loss in weight, a better recovery, and the stabilization of the metabolic-nutritional framework. Nutritional approach used has contributed to the reduction of recovery times, making the therapeutic path more effective and applicable.

Percutaneous Dilatational Tracheostomy; Diagnosis and Mortality Rate in Intensive Care Saiful Anwar Hospital

Introduction: Tracheostomy is a common surgical procedure performed on critically ill intensive care patients. Reports have documented considerable associated morbidity, with complication rates varying from 6 to 66%. The reports on mortality associated with tracheostomy range from 0 to 5%. Since its introduction, percutaneous dilatational tracheostomies (PDT) have gained increasing popularity. The most commonly cited advantages are the ease of the familiar technique and the ability to perform the procedure at the bedside.7 This paper aims to study the mortality rate and diagnosis of patients who performed the percutaneous dilatational tracheostomy procedure in the ICU of Saiful Anwar Malang Hospital.&#x0D; Methods: Observational analytical research is carried out cross-sectionally. Data was collected from the medical records of patients undergoing PDT for the period July 2022 – October 2022. Statistical analysis using the Chi-square test.&#x0D; Results: From 39 subjects, 34 (87.2%) subjects experienced respiratory failure. The most common cause was HAP pneumonia (61.5%), followed by CVA (17.9%) and CAP pneumonia (12.8%); the rest were EDH, SAH, and ASD secundum, as much as 2.6%. The outcome was that 13 (33.3%) subjects died, and the rest survived and were transported to a care ward. Correlation between patient outcomes with respiratory failure p=0.735, with diagnosis p=0.309.&#x0D; Conclusion: The most common diagnosis of PDT is HAP pneumonia. There was no significant correlation between diagnosis and mortality of patients performed by PDT.

Unusual Presentation of Double-seronegative Myasthenia Gravis with Positive Anti-LRP4 Antibody: Diagnostic Utility of a Videofluoroscopic Swallowing Study.

An 86-year-old woman was admitted to our hospital with cryptogenic progressive dyspnea and dysphagia following a tracheostomy procedure 4 months prior to presentation. She exhibited fluctuating diplopia, bilateral vocal fold paralysis, normal nerve test results, negative findings for serum anti-acetylcholine receptor and anti-muscle-specific kinase antibodies, and positive findings for anti-LDL-receptor related protein 4 (LRP4). A videofluoroscopic swallowing study (VFSS) with edrophonium revealed an improvement in bulbar paralysis. Consequently, the patient was diagnosed with double-seronegative myasthenia gravis (DSN-MG) and began immunomodulatory therapy. This case emphasizes the diagnostic challenges of bulbar-type DSN-MG and underscores the value of a VFSS with edrophonium for diagnosing this condition.