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Bhatt N, Yang J, DeBaere L, Wang RS, Most A, Zhang Y, Dayanov E, Yang W, Santacatterina M, Kamberi M, Mojica J, Kamen E, Savitski J, Stein J, Jacobson A. Reducing Length of Stay in Reconstructive Head and Neck Surgery Patients: A Quality Improvement Initiative. Otolaryngol Head Neck Surg 2024. [PMID: 39118499 DOI: 10.1002/ohn.933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 06/14/2024] [Accepted: 06/24/2024] [Indexed: 08/10/2024]
Abstract
OBJECTIVE To investigate whether a new preoperative education and discharge planning protocol reduced unexpected discharge delays for patients undergoing reconstructive surgery for head and neck cancer. METHODS A quality improvement (QI) intervention was implemented in January 2021 with several components to address historically prolonged observed lengths of stay (LOS) with head and neck cancer patients. The intervention added a preoperative educational visit with a head and neck cancer advanced practice provider, a standardized preoperative speech and swallow assessment, a personalized patient care plan document, discussion of inpatient hospital stay expectations, and early discharge planning. The intervention group included patients who underwent the preoperative education protocol from February to December 2021. For comparison, an age and sex-matched control group was constructed from inpatients who had been admitted for similar procedures in the 2 years prior to the QI intervention (2019-2020) and received standard of care counseling. RESULTS Our study demonstrated a significant reduction in observed to expected LOS ratio after implementation of the intervention (1.24 ± 0.74 control, 0.95 ± 0.52 intervention; P = .012). DISCUSSION We discuss a preoperative education QI intervention at our institution. Our findings demonstrate that our intervention was associated with decreased LOS for patients undergoing head and neck reconstructive surgeries. IMPLICATIONS FOR PRACTICE This QI study shows the benefit of a new standardized preoperative education and discharge planning protocol for patients undergoing head and neck reconstructive surgeries.
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Affiliation(s)
- Nupur Bhatt
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York City, New York, USA
| | - Jackie Yang
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York City, New York, USA
| | - Lauren DeBaere
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York City, New York, USA
| | - Ronald Shen Wang
- New York University Grossman School of Medicine, New York City, New York, USA
| | - Allison Most
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York City, New York, USA
| | - Yan Zhang
- Department of Population Health, NYU Langone Health, New York City, New York, USA
| | - Elan Dayanov
- Department of Population Health, NYU Langone Health, New York City, New York, USA
| | - Wenqing Yang
- Department of Population Health, NYU Langone Health, New York City, New York, USA
| | | | - Maria Kamberi
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York City, New York, USA
| | - Jacqueline Mojica
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York City, New York, USA
| | - Emily Kamen
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York City, New York, USA
| | - Justin Savitski
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York City, New York, USA
| | - John Stein
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York City, New York, USA
| | - Adam Jacobson
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York City, New York, USA
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De Santis S, Galassi S, Cambi J. The dragonfly technique for trachea closure in temporary tracheostomies. Surgical steps and clinical results. Eur Arch Otorhinolaryngol 2024:10.1007/s00405-024-08821-8. [PMID: 39001918 DOI: 10.1007/s00405-024-08821-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Accepted: 07/01/2024] [Indexed: 07/15/2024]
Abstract
PURPOSE 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. METHODS 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. RESULTS The incidence of tracheal complications and tracheal stenosis was reduced in Group B (6%) compared to Group A (24%). Procedure times (3 min vs. 6 min) durations was significantly shorter. No patients had symptoms of tracheal stenosis at the end of the procedures. CONCLUSION 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.
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Affiliation(s)
| | - Stefania Galassi
- Interventional Radiology, Annunziata Hospital, Cosenza, SS, Italy
| | - Jacopo Cambi
- ENT Department, Misericordia Hospital, Via Senese 161, Grosseto, 58100, Italy.
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Chinta S, Haleem A, Sibala DR, Kumar KD, Pendyala N, Aftab OM, Choudhry HS, Hegazin M, Eloy JA. Association Between Modified Frailty Index and Postoperative Outcomes of Tracheostomies. Otolaryngol Head Neck Surg 2024; 170:1307-1313. [PMID: 38329229 DOI: 10.1002/ohn.667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 12/11/2023] [Accepted: 12/17/2023] [Indexed: 02/09/2024]
Abstract
OBJECTIVE The 5-item modified frailty index (mFI-5) has been used to stratify patients based on the risk of postoperative complications in several surgical procedures but has not yet been done in tracheostomies. This study investigates the association between the mFI-5 score and tracheostomy complications. STUDY DESIGN Retrospective database review. SETTING United States hospitals. METHODS The National Surgical Quality Improvement Program database was queried for tracheostomy patients between 2005 and 2018. The mFI-5 was calculated for each patient by assigning 1 point for each of the following comorbidities: diabetes mellitus, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and functionally dependent health status. Univariate and multivariable analyses were conducted to determine associations between the mFI-5 score and postoperative complications. RESULTS A total of 4438 patients undergoing tracheostomies were queried and stratified into the following groups: mFI = 0 (N = 1741 [39.2%], mFI = 1 (N = 1720 [38.8%]), mFI = 2 (N = 726 [16.4%]), and mFI of 3 or higher (N = 251 [5.7%]). Univariate analysis showed that patients with higher mFI-5 scores had a greater proportion of smoking, dyspnea, obesity, steroid use, emergency cases, complications, reoperations, and mortality (P < .001). Multivariable analyses found associations between mFI-5 score and any complication (odds ratio [OR]: 1.49, 95% confidence interval [CI]: 1.03-2.16, P = .035), mortality (OR: 2.32, 95% CI: 1.15-4.68, P = .019), and any medical complication (OR: 2.75, 95% CI: 1.88-4.02, P < .001). CONCLUSION This study suggests an association between the mFI-5 score and postoperative complications in tracheostomies. mFI-5 score can be used to stratify tracheostomy patients by operative risk.
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Affiliation(s)
- Sree Chinta
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Afash Haleem
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Dhiraj R Sibala
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Keshav D Kumar
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Navya Pendyala
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Owais M Aftab
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Hannaan S Choudhry
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Michael Hegazin
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Jean Anderson Eloy
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
- Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Department of Otolaryngology and Facial Plastic, Surgery, Saint Barnabas Medical Center-RWJBarnabas Health, Livingston, New Jersey, USA
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Sutthipongkiat E, Chumpathong S, Boonmak L, Panyamee S, Vorasanon K, Mangmeesri P. Emergency Tracheostomy: Complications, Anesthetic Techniques, and Outcomes. EAR, NOSE & THROAT JOURNAL 2024:1455613241238620. [PMID: 38462908 DOI: 10.1177/01455613241238620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024] Open
Abstract
Objectives: Acute upper airway obstruction is a critical medical condition that presents considerable challenges to anesthesiologists. This study aims to provide a formal report on the incidence and outcomes of perioperative complications, as well as the factors that influence unstable intraoperative hemodynamics. Methods: This retrospective study reviewed patients aged 18 years and older who underwent emergency tracheostomy between January 2013 and October 2021. Data on perioperative complications and outcomes within the first 24 hours and 7 days after surgery were subjected to analysis. Descriptive and multivariate analyses were used to examine the results. Results: A total of 253 patients were included in the study. The mean age was 61.5 ± 12.9 years. Malignancy was detected in 78.3% of the patients. General anesthesia was administered to 43.9% of the patients. The incidence of intraoperative complications was 51.8%, with hypotension and hypertension occurring in 30.4% and 22.5% of the cases, respectively. Desaturation and cardiac arrest were observed in 4.7% and 0.8% of the patients, respectively. The mortality rate at 7 days after surgery was 1.6%. Multivariate analysis revealed that monitored anesthesia care [adjusted odds ratio (OR) = 1.80; 95% confidence interval (CI): 1.08-3.00] and hypertensive patients (adjusted OR = 1.70, 95% CI: 1.01-2.86) were associated with unstable intraoperative hemodynamics. Conclusions: Cardiovascular instability represented the majority of the complications observed. Monitoring anesthesia care and hypertension were significant prognostic factors for unstable intraoperative hemodynamics. We recommend extensive communication between ear, nose, and throat surgeons and anesthesiologists to determine the appropriate choice of anesthesia.
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Affiliation(s)
- Ekanong Sutthipongkiat
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Saowapark Chumpathong
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Lapatrada Boonmak
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sriwimon Panyamee
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Khanittha Vorasanon
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Peerachatra Mangmeesri
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Erickson EL, Katta J, Sun S, Shan L, Lemeshow S, Schofield ML. Retrospective review of acute post-tracheostomy complications and contributing risk factors. Clin Otolaryngol 2024; 49:277-282. [PMID: 38095241 DOI: 10.1111/coa.14131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/01/2023] [Accepted: 11/18/2023] [Indexed: 02/16/2024]
Abstract
OBJECTIVE Tracheostomy is performed for various indications ranging from prolonged ventilation to airway obstruction. Many factors may play a role in the incidence of complications in the immediate post-operative period including patient-related factors. Chronic obstructive pulmonary disease and asthma are some of the most common pulmonary pathologies in the United States. The relationship between obstructive pulmonary diseases and acute post-tracheostomy complications has been incompletely studied. DESIGN A retrospective chart review was designed in order to answer these objectives. Medical records were reviewed for the technique used, complications, and contributing patient factors. Post-operative complications were defined as any tracheostomy-related adverse event occurring within 14 days. SETTING The study took place at an academic comprehensive cancer. PARTICIPANTS Inclusion criteria included patients from January 2017 through December 2018 who underwent a tracheostomy. Exclusion criteria included presence of stomaplasty, total laryngectomy, and tracheostomies performed at outside hospitals. MAIN OUTCOME MEASURES Patient factors examined included demographics, comorbidities, and body mass index with the primary outcome measured being the rate of tracheostomy complications. RESULTS The most common indication for tracheostomy among the 321 patients that met inclusion criteria was airway obstruction or a head and neck cancer surgical procedure. Obstructive sleep apnea was associated with acute complications in bivariate analysis (29.4% complications, p = .003). Chronic obstructive pulmonary disease and asthma were not associated with acute complications in bivariate analysis (11.6% complications, p = .302). Among the secondary outcomes measured, radiation was associated with early complications occurring in post-operative days 0-6 (1.1%, p = .029). CONCLUSION Patients with obstructive sleep apnea may have a higher risk of acute post-tracheostomy complications that might be due to the patient population at risk for obstructive sleep apnea. Patients with obstructive pulmonary pathologies such as asthma or chronic obstructive pulmonary disorder did not have an elevated risk of complications which is clinically significant when considering the utility of ventilation and tracheostomy in the management of acute respiratory failure secondary to these conditions.
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Affiliation(s)
| | - Juhi Katta
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Shuai Sun
- The Ohio State University Department of Public Health, Columbus, Ohio, USA
| | - Lingpeng Shan
- The Ohio State University Department of Public Health, Columbus, Ohio, USA
| | - Stanley Lemeshow
- The Ohio State University Department of Public Health, Columbus, Ohio, USA
| | - Minka L Schofield
- The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Vargas M, Battaglini D, Antonelli M, Corso R, Frova G, Merli G, Petrini F, Ranieri MV, Sorbello M, Di Giacinto I, Terragni P, Brunetti I, Servillo G, Pelosi P. Follow-up short and long-term mortalities of tracheostomized critically ill patients in an Italian multi-center observational study. Sci Rep 2024; 14:2319. [PMID: 38281994 PMCID: PMC10822864 DOI: 10.1038/s41598-024-52785-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 01/23/2024] [Indexed: 01/30/2024] Open
Abstract
The effects of tracheostomy on outcome as well as on intra or post-operative complications is yet to be defined. Admission of patients with tracheostomy to rehabilitation facility is at higher risk of suboptimal care and increased mortality. The aim of the study was to investigate ICU mortality, clinical outcome and quality of life up to 12 months after ICU discharge in tracheostomized critically ill patients. This is a prospective, multi-center, cohort study endorsed by Italian Society of Anesthesia, Analgesia, Reanimation, and Intensive Care (SIAARTI Prot. n° 643/13) registered in Clinicaltrial.gov (NCT01899352). Patients admitted to intensive care unit (ICU) and requiring elective tracheostomy according to physician in charge decision were included in the study. The primary outcome was ICU mortality. Secondary outcomes included risk factors for ICU mortality, prevalence of mortality at follow-up, rate of discharge from the hospital and rehabilitation, quality of life, performance status, and management of tracheostomy cannula at 3-, 6, 12-months from the day of tracheostomy. 694 critically ill patients who were tracheostomized in the ICU were included. ICU mortality was 15.8%. Age, SOFA score at the day of the tracheostomy, and days of endotracheal intubation before tracheostomy were risk factors for ICU mortality. The regression tree analysis showed that SOFA score at the day of tracheostomy and age had a preeminent role for the choice to perform the tracheostomy. Of the 694 ICU patients with tracheostomy, 469 completed the 12-months follow-up. Mortality was 33.51% at 3-months, 45.30% at 6-months, and 55.86% at 12-months. Patients with tracheostomy were less likely discharged at home but at hospital facilities or rehabilitative structures; and quality of life of patients with tracheostomy was severely compromised at 3-6 and 12 months when compared with patients without tracheostomy. In patients admitted to ICU, tracheostomy is associated with high mortality, difficult rehabilitation, and decreased quality of life. The choice to perform a tracheostomy should be carefully weighed on family burden and health-related quality of life.Clinical trial registration: Clinicaltrial.gov (NCT01899352).
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Affiliation(s)
- Maria Vargas
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Via Pansini, 80100, Naples, Italy.
| | | | - Massimo Antonelli
- Dip Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Ruggero Corso
- Dipartimento delle Terapie Intensive, Anestesiologia e Terapia del Dolore, Ospedale "Guglielmo da Saliceto"-Piacenza, Piacenza, Italy
| | - Giulio Frova
- Università degli Studi di Milano and Dipartimento Anestesia e Rianimazione Spedai Civili si Brescia, Brescia, Italy
| | - Guido Merli
- U.O.C. Anestesia e Rianimazione Ospedale Maggiore di Crema, Asst Crema, Italy
| | - Flavia Petrini
- Coordinamento Strutturale Medicina Perioperatoria, Terapia Dolore, Emergenze Intraospedaliere, Terapia Intensiva - ASL2 Abruzzo, Università di Chieti-Pescara, Pescara, Italy
| | - Marco V Ranieri
- Alma Mater Studiorum-Università di Bologna, IRCCS Policlinico di Sant'Orsola, Anesthesia and Intensive Care Medicine, Bologna, Italy
| | | | - Ida Di Giacinto
- Anesthesia and Intensive Care, Mazzoni Hospital, Ascoli Piceno, Italy
| | - Pierpaolo Terragni
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
| | - Iole Brunetti
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Giuseppe Servillo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Via Pansini, 80100, Naples, Italy
| | - Paolo Pelosi
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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Ibraheem A, Al Khayer A. Tracheal pouch in a child with SMA type 1 after prolonged ventilation via tracheostomy tube. Pediatr Pulmonol 2024; 59:213-214. [PMID: 37787426 DOI: 10.1002/ppul.26711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 09/21/2023] [Accepted: 09/22/2023] [Indexed: 10/04/2023]
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Liu Y, Zhou C, Wu Y, Deng S, Chen Y, Zhou J. Tracheostomy tube changes in patients with tracheostomy: A quality improvement project. Nurs Crit Care 2023. [PMID: 38146628 DOI: 10.1111/nicc.13008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 10/28/2023] [Accepted: 10/31/2023] [Indexed: 12/27/2023]
Abstract
BACKGROUND Tracheostomy tube changes are a considerable part of the management of patients with tracheostomy and are necessary for preventing aspiration pneumonia, especially in patients with long-term tracheostomy. The process of tracheostomy tube changes in many patients may not be timely, safe or efficient. OBJECTIVE The objectives were to implement a quality improvement intervention that reduces the incidence of aspiration pneumonia in patients with tracheostomy, improve staff knowledge about tracheostomy tube changes and improve staff adherence to documentation. METHODS A pre-post intervention design was used in this quality improvement project. We created a change strategy bundle that included identification of the need for and observation determination of the timing of tube changes timing, change assessments, identification of the person and location, preparation, co-operation and maintenance. A tracheostomy tube change workflow was also created. Then, the intervention was implemented in the clinic after staff training. The incidence of aspiration pneumonia, staff knowledge and staff adherence were compared before and after the intervention. RESULTS Two hundred and 20 patients were enrolled (105 in the preintervention group; 115 in the postintervention group) with 88 tracheostomy tube change episodes (23 in the preintervention group; 65 in the postintervention group). Thirty-five staff members completed the training and surveys. The incidence of pneumonia decreased from 43.8% to 27.8% after the intervention (p = .013). The knowledge score of staff increased from 46.57 ± 11.10 to 88.14 ± 6.76, and the implementation rate of the audit increased to 67.32%-100%. CONCLUSIONS This quality improvement project regarding tracheostomy changes reduced the incidence of pneumonia, increased staff knowledge about tracheostomy tube changes and improved staff adherence. RELEVANCE TO CLINICAL PRACTICE A standardized tracheostomy tube change bundle, education, interprofessional collaboration and culture changes were important to ensure the best outcomes in this quality improvement project. These factors improved the timeliness, efficiency and safety of tracheostomy tube changes.
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Affiliation(s)
- Yu Liu
- Rehabilitation Department, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Chunlan Zhou
- Nursing Department, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Yanni Wu
- Nursing Department, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Shuijuan Deng
- Rehabilitation Department, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Ying Chen
- Rehabilitation Department, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Jungui Zhou
- Rehabilitation Department, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
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Ratwani AP, Chen H, Brown L, Schwartz EA, Patel K, Guttentag A, McLaren TA, Sandler KL, Rickman OB, Shojaee S, Lentz RJ, Maldonado F. Inter-rater reliability of a novel objective endpoint for benign central airway stenosis interventions: Segmentation-based volume rendering of computed tomography scans. PLoS One 2023; 18:e0290393. [PMID: 37878622 PMCID: PMC10599541 DOI: 10.1371/journal.pone.0290393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 08/08/2023] [Indexed: 10/27/2023] Open
Abstract
OBJECTIVES To evaluate the reliability of a novel segmentation-based volume rendering approach for quantification of benign central airway obstruction (BCAO). DESIGN A retrospective single-center cohort study. SETTING Data were ascertained using electronic health records at a tertiary academic medical center in the United States. PARTICIPANTS AND INCLUSION Patients with airway stenosis located within the trachea on two-dimensional (2D) computed tomography (CT) imaging and documentation of suspected benign etiology were included. Four readers with varying expertise in quantifying tracheal stenosis severity were selected to manually segment each CT using a volume rendering approach with the available free tools in the medical imaging viewing software OsiriX (Bernex, Switzerland). Three expert thoracic radiologists were recruited to quantify the same CTs using traditional subjective methods on a continuous and categorical scale. OUTCOME MEASURES The interrater reliability for continuous variables was calculated by the intraclass correlation coefficient (ICC) using a two-way mixed model with 95% confidence intervals (CI). RESULTS Thirty-eight patients met the inclusion criteria, and fifty CT scans were selected for measurement. The most common etiology of BCAO was iatrogenic in 22 patients (58%). There was an even distribution of chest and neck CT imaging within our cohort. The average ICC across all four readers for the volume rendering approach was 0.88 (95% CI, 0.84 to 0.93), suggesting good to excellent agreement. The average ICC for thoracic radiologists for subjective methods on the continuous scale was 0.38 (95% CI, 0.20 to 0.55), suggesting poor to fair agreement. The kappa for the categorical approach was 0.26, suggesting a slight to fair agreement amongst the raters. CONCLUSION In this retrospective cohort study, agreement was good to excellent for raters with varying expertise in airway cross-sectional imaging using a novel segmentation-based volume rendering approach to quantify BCAO. This proposed measurement outperformed our expert thoracic radiologists using conventional subjective grading methods.
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Affiliation(s)
- Ankush P. Ratwani
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Heidi Chen
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Leah Brown
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Evan A. Schwartz
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Duke University School of Medicine, Durham, NC, United States of America
| | - Khushbu Patel
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Adam Guttentag
- Department of Radiology and Radiological Science, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Thomas A. McLaren
- Department of Radiology and Radiological Science, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Kim L. Sandler
- Department of Radiology and Radiological Science, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Otis B. Rickman
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Samira Shojaee
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Robert J. Lentz
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Fabien Maldonado
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care, Vanderbilt University Medical Center, Nashville, TN, United States of America
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Weidlich S, Pfeiffer J, Kugler C. Self-management of patients with tracheostomy in the home setting: a scoping review. J Patient Rep Outcomes 2023; 7:101. [PMID: 37823948 PMCID: PMC10570259 DOI: 10.1186/s41687-023-00643-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 10/05/2023] [Indexed: 10/13/2023] Open
Abstract
PURPOSE The aim of this study was to create a model of patient-centered outcomes with respect to self-management tasks and skills of patients with a tracheostomy in their home setting. METHODS A scoping review using four search engines was undertaken (Medline, CINAHL, PsycINFO, Cochrane Library) to identify studies relevant to this issue and published since 2000. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statements for Scoping Reviews (PRISMA-ScR), the Joanna Briggs Institute (JBI) approach of conducting and reporting a scoping review, and the Participants, Concept, Context (PCC) scheme were employed. The following elements of the framework synthesis study data were screened, and presented based on the self-management model of Lorig and Holman. RESULTS 34 publications from 17 countries met the criteria for study inclusion: 24 quantitative, 8 qualitative and 2 mixed methods designs. Regarding the dimensions of self-management, 28 articles reported on "managing the therapeutic regimen", 27 articles discussed "managing role and behavior changes", and 16 articles explored "managing emotions". A model of self-management of patients with tracheostomy was developed, which placed the patient in the center, since it is this individual who is completing the tasks and carrying out his or her skill sets. CONCLUSION This scoping review represents the first comprehensive overview and modeling of the complex self-management tasks and skills required of patients with tracheostomy in their home setting. The theoretical model can serve as a cornerstone for empirical intervention studies to better support this patient-centered outcome for this population in the future.
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Affiliation(s)
- Sandra Weidlich
- Faculty of Medicine, Department of Oto-Rhino-Laryngology, Medical Center - University of Freiburg, Freiburg, Germany
| | - Jens Pfeiffer
- Center for Oto-Rhino-Laryngology (HNO Center am Theater), Freiburg, Germany
| | - Christiane Kugler
- Faculty of Medicine, Institute of Nursing Science, University of Freiburg, Breisacher Str. 153, Freiburg, 79110, Germany.
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11
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Zaga CJ, Berney S, Hepworth G, Cameron TS, Baker S, Giddings C, Howard ME, Bellomo R, Vogel AP. Tracheostomy clinical practices and patient outcomes in three tertiary metropolitan hospitals in Australia. Aust Crit Care 2023; 36:327-335. [PMID: 35490111 DOI: 10.1016/j.aucc.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 02/24/2022] [Accepted: 03/06/2022] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND There is a paucity of literature in Australia on patient-focused tracheostomy outcomes and process outcomes. Exploration of processes of care enables teams to identify and address existing barriers that may prevent earlier therapeutic interventions that could improve patient outcomes following critical care survival. OBJECTIVES The objectives of this study were to examine and provide baseline data and associations between tracheostomy clinical practices and patient outcomes across three large metropolitan hospitals. METHODS We performed a retrospective multisite observational study in three tertiary metropolitan Australian health services who are members of the Global Tracheostomy Collaborative. Deidentified data were entered into the Global Tracheostomy Collaborative database from Jan 2016 to Dec 2019. Descriptive statistics were used for the reported outcomes of length of stay, mortality, tracheostomy-related adverse events and complications, tracheostomy insertion, airway, mechanical ventilation, communication, swallowing, nutrition, length of cannulation, and decannulation. Pearson's correlation coefficient and one-way analyses of variance were performed to examine associations between variables. RESULTS The total cohort was 380 patients. The in-hospital mortality of the study cohort was 13%. Overall median hospital length of stay was 46 days (interquartile range: 31-74). Length of cannulation was shorter in patients who did not experience any tracheostomy-related adverse events (p= 0.036) and who utilised nonverbal communication methods (p = 0.041). Few patients (8%) utilised verbal communication methods while mechanically ventilated, compared with 80% who utilised a one-way speaking valve while off the ventilator. Oral intake was commenced in 20% of patients prior to decannulation. Patient nutritional intake varied prior to and at the time of decannulation. Decannulation occurred in 83% of patients. CONCLUSIONS This study provides baseline data for tracheostomy outcomes across three large metropolitan Australian hospitals. Most outcomes were comparable with previous international and local studies. Future research is warranted to explore the impact of earlier nonverbal communication and interventions targeting the reduction in tracheostomy-related adverse events.
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Affiliation(s)
- Charissa J Zaga
- Department of Speech Pathology, Division of Allied Health, Austin Health Melbourne, Australia; Tracheostomy Review and Management Service, Austin Hospital, Melbourne, Australia; Institute of Breathing and Sleep, Austin Health, Melbourne, Australia; Centre for Neuroscience of Speech, The University of Melbourne, Melbourne, Australia.
| | - Sue Berney
- Institute of Breathing and Sleep, Austin Health, Melbourne, Australia; Department of Physiotherapy, Division of Allied Health, Austin Health, Melbourne, Australia; Department of Physiotherapy, School of Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Graham Hepworth
- Statistical Consulting Centre, The University of Melbourne, Melbourne, Australia
| | - Tanis S Cameron
- Tracheostomy Review and Management Service, Austin Hospital, Melbourne, Australia
| | - Sonia Baker
- Department of Speech Pathology, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Charles Giddings
- Department of Ear, Nose and Throat Surgery, Monash Health, Melbourne, Australia
| | - Mark E Howard
- Institute of Breathing and Sleep, Austin Health, Melbourne, Australia; Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia; Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia
| | - Adam P Vogel
- Centre for Neuroscience of Speech, The University of Melbourne, Melbourne, Australia; Department of Neurodegeneration, Hertie Institute for Clinical Brian Research, Tübingen, Germany; Redenlab, Mebourne, Australia
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12
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Brauer PR, Bryson PC, Tierney WS, Wu SS, Jia X, Lamarre ED. Readmission Rates Following Major Head and Neck Surgery With Concurrent Tracheostomy. Ann Otol Rhinol Laryngol 2023; 132:182-189. [PMID: 35301871 DOI: 10.1177/00034894221083778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To determine the influence of major head and neck procedures on readmission and complication rates following tracheostomy. METHODS A retrospective cohort study using the 2005 to 2017 National Surgical Quality Improvement Program (NSQIP) database. Current Procedural Terminology codes were used to identify tracheostomy patients and to define the underlying head and neck procedure. Patients under the age of 18 and with unknown pre-operative variables were excluded. Univariate and multivariable analyses were performed. RESULTS A total of 3240 tracheostomy patients undergoing major head and neck surgery were identified in NSQIP. The 30-day mortality rate was 104 (3.2%) and 258 (9.0%) patients were readmitted. 637 (19.7%) patients had an unplanned return to the operating room. There were 1606 (49.6%) non-tracheostomy specific complications, which included 850 (26.2%) medical and 1142 (35.2%) surgical complications. On multivariable analysis, we found that the underlying procedures did not impact the risk of readmission (P > .05 for all). The underlying procedure was also not associated with unplanned return to the operating room except for thyroidectomies, which had a lower risk than free tissue graft reconstruction (OR = 0.53 (95%CI 0.31, 0.88), P = .018). CONCLUSION While almost 1 in every 2 patients had a complication following major head and neck surgery that included creation of a tracheostomy, the rate of readmission is comparatively low and is not associated with the underlying procedure. These findings should reassure head and neck surgeons that properly managed tracheostomies do not constitute a disproportionate risk of readmission.
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Affiliation(s)
- Philip R Brauer
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA.,Head and Neck Institute, The Cleveland Clinic, Cleveland, OH, USA
| | - Paul C Bryson
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA.,Head and Neck Institute, The Cleveland Clinic, Cleveland, OH, USA.,Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | | | - Shannon S Wu
- Head and Neck Institute, The Cleveland Clinic, Cleveland, OH, USA.,Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Xuefei Jia
- Taussig Cancer Institute, The Cleveland Clinic, Cleveland, OH, USA
| | - Eric D Lamarre
- Head and Neck Institute, The Cleveland Clinic, Cleveland, OH, USA
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13
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Etiology and Management of Bilateral Vocal Fold Paralysis: a Retrospective Cohort Study. J Voice 2022. [DOI: 10.1016/j.jvoice.2022.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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14
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Tucker J, Hollenbeak CS, Goyal N. Discharge destination and readmissions among patients with head and neck cancer. Laryngoscope Investig Otolaryngol 2022; 7:1407-1429. [PMID: 36262465 PMCID: PMC9575139 DOI: 10.1002/lio2.890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/26/2022] [Accepted: 07/26/2022] [Indexed: 11/10/2022] Open
Abstract
Objective Lowering hospital readmission rates is a national goal, and presents an opportunity to lower health care costs, improve quality, and increase patient satisfaction. We aim to assess whether discharge disposition is associated with readmission. Methods A retrospective cohort study using logistic regression to quantify risk factors of hospital readmission in patients with confirmed head and neck cancer (HNC) who underwent surgery from 2010 to 2018 contained in the Pennsylvania Health Care Cost Containment Council database, which includes patients treated in Pennsylvania hospitals. Results The readmission rate in this study was 18.1%. Cancers of the hypopharynx had the highest rates of readmission (29.2%). Male sex (odds ratio [OR]: 0.87, 95% CI: 0.75-1.00), emergent admission (vs. elective admission: OR = 1.33, 95% CI: 1.02-1.74), discharge to home health (vs. home: OR = 1.85, 95% CI: 1.59-2.16), discharge to skilled nursing facility (SNF) (vs. home: OR = 2.21, 95% CI: 1.80-2.72), and having 4+ comorbidities (vs. 0-1: OR = 1.39, 95% CI: 1.09-1.76) were significant risk factors for hospital readmission. Conclusion It is necessary to consider the readmission risk associated with HNC patients. Reasons for readmission are multifactorial and can be related to demographics, hospital course, comorbidities, or discharge disposition-this requires further assessment. There is importance in increasing HNC awareness and staff education about the unique needs of this population. Level of Evidence 4.
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Affiliation(s)
- Jacqueline Tucker
- College of MedicineThe Pennsylvania State UniversityHersheyPennsylvaniaUSA
| | - Christopher S. Hollenbeak
- Department of Health Policy and Administration, College of Health and Human DevelopmentThe Pennsylvania State UniversityUniversity ParkPennsylvaniaUSA
| | - Neerav Goyal
- College of MedicineThe Pennsylvania State UniversityHersheyPennsylvaniaUSA
- Department of Otolaryngology–Head and Neck SurgeryPenn State College of MedicineHersheyPennsylvaniaUSA
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15
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Mulima G, Lie SA, Charles A, Hanif AB, Varela CG, Banza LN, Young S. Tracheostomy without mechanical ventilation in patients with traumatic brain injury at a tertiary referral hospital in Malawi: a cross sectional study. Malawi Med J 2022; 34:152-156. [PMID: 36406102 PMCID: PMC9641605 DOI: 10.4314/mmj.v34i3.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background Tracheostomy alone, without mechanical ventilation, has been advocated to maintain a free airway in patients with traumatic brain injury in low-income settings with minimal critical care capacity. However, no reports exist on the outcomes of this strategy. We examine the results of this practice at a central hospital in Malawi. Methods This is a retrospective review of medical records and prospectively gathered trauma surveillance data of patients admitted to Kamuzu Central Hospital, with traumatic brain injury from January 2010 to December 2015. In-hospital mortality rates were examined according to registered traumatic brain injury severity and airway management. Results In our analysis, 1875 of 2051 registered traumatic brain injury patients were included; 83.3% were male, mean age 32.6 (SD 12.9) years. 14.2% (n=267) of the patients had invasive airway management (endotracheal tube or tracheostomy) with or without mechanical ventilation. Mortality in severe traumatic brain injury treated with tracheostomy without mechanical ventilation was 42% (10/24) compared to 21% (14/68) in patients treated without intubation or tracheostomy (p= 0.043). Tracheostomies had an overall complication rate of 11%. Conclusion Tracheostomy without mechanical ventilation in severe traumatic brain injury did not improve survival outcomes in our setting. Tracheostomy for severe traumatic brain injury cannot be recommended when mechanical ventilation is not available unless there are sufficient specialized human resources for follow up in the ward. Efforts to improve critical care facilities and human resource capacity to allow proper use of mechanical ventilation in severe traumatic brain injury should be a high priority in low-income countries where the burden of trauma is high.
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Affiliation(s)
- Gift Mulima
- Department of Surgery, Kamuzu Central Hospital, P.O. Box 149, Lilongwe, Malawi
| | - Stein Atle Lie
- The Norwegian Arthroplasty Registry, Haukeland University Hospital, Bergen, Norway
| | - Anthony Charles
- Department of Surgery, University of North Carolina, 4008 Burnett Womack Bldg, CB 7050, Chapel Hill, NC, 27599 USA
| | - Asma Bilal Hanif
- Department of Surgery, Kamuzu Central Hospital, P.O. Box 149, Lilongwe, Malawi
| | - Carlos G Varela
- Department of Surgery, Kamuzu Central Hospital, P.O. Box 149, Lilongwe, Malawi
| | - Leonard N Banza
- Department of Surgery, Kamuzu Central Hospital, P.O. Box 149, Lilongwe, Malawi
| | - Sven Young
- Department of Surgery, Kamuzu Central Hospital, P.O. Box 149, Lilongwe, Malawi, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
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16
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Murray M, Shen C, Massey B, Stadler M, Zenga J. Retrospective analysis of post-tracheostomy complications. Am J Otolaryngol 2022; 43:103350. [PMID: 34974381 DOI: 10.1016/j.amjoto.2021.103350] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 12/13/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To elucidate patient, disease, and surgical factors that are significantly associated with 90-day tracheostomy complications, readmissions, and mortality. STUDY DESIGN Retrospective case series with chart review. SETTING A single academic tertiary care center between 2011 and 2018. METHODS Patients who underwent tracheostomy by any technique for any indication were included. Demographic, disease, and operative details were examined. Multivariable analysis was performed to determine factors associated with 90-day complications, 90-day readmissions, and overall mortality. RESULTS 697 patients were included. 75% of patients had severe comorbidity (ACE-27 score of 3).1 Patients were intubated for 12 days prior to tracheostomy placement on average. The primary indication was ventilator dependence due to critical illness (85%). 74% were performed open and 26% percutaneous. 10% of patients had a tracheostomy-related complication within 90 days. Complications occurred at a median of post-operative day 11, and hemorrhage was most common (n = 35). 14 patients required immediate return to the operating room, and 3 patients died of their complication, all within 3 days of tracheostomy placement. 40% of patients undergoing tracheostomy died within 30 days. In multivariable analysis, only a documented difficult tracheostomy placement was significantly associated with a 90-day complication. CONCLUSIONS While complications after tracheostomy are infrequent, they are often severe. A heightened level of preparedness to immediately manage accidental tracheostomy decannulation or hemorrhage is required for patients with a difficult tracheostomy placement. 30-day mortality is high, which reinforces the need for multi-disciplinary evaluation, including palliative care, to determine appropriate candidacy for tracheostomy.
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Affiliation(s)
- Molly Murray
- Medical College of Wisconsin, 8701 W Watertown Plank Rd, Wauwatosa, WI 53226, United States of America.
| | - Christine Shen
- Medical College of Wisconsin, 8701 W Watertown Plank Rd, Wauwatosa, WI 53226, United States of America
| | - Becky Massey
- Medical College of Wisconsin, 8701 W Watertown Plank Rd, Wauwatosa, WI 53226, United States of America
| | - Michael Stadler
- Medical College of Wisconsin, 8701 W Watertown Plank Rd, Wauwatosa, WI 53226, United States of America
| | - Joseph Zenga
- Medical College of Wisconsin, 8701 W Watertown Plank Rd, Wauwatosa, WI 53226, United States of America
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17
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Quinton BA, Tierney WS, Bryson PC, Bribriesco A, Gillespie CT, Hopkins BD. An institution-wide tracheostomy rounding team: Initial caregiver perceptions. Am J Otolaryngol 2022; 43:103367. [PMID: 34991021 DOI: 10.1016/j.amjoto.2021.103367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 12/13/2021] [Accepted: 12/18/2021] [Indexed: 11/01/2022]
Abstract
PURPOSE To analyze and present the initial findings of provider perceptions regarding the impact of the implementation of a hospital-wide Tracheostomy Rounding Team (TRT) on the delivery of tracheostomy care at the Cleveland Clinic. MATERIALS AND METHODS Based on prior literature, a novel multidisciplinary TRT was designed and implemented at the Cleveland Clinic in December of 2018. After the TRT began clinical care, a previously validated RedCap survey was administered anonymously to 358 caregivers to assess provider experience, comfort, and prior education regarding tracheostomy management. Survey results were collected, and descriptive statistics were applied. Answers were compared between providers who interacted with the TRT clinically and those who did not. RESULTS 42.9% of providers who interacted with the TRT clinically reported that the TRT improved hands-on assistance with tracheostomy care, and 36.7% reported that the TRT improved the identification of safety concerns. Similarly, 34.7% reported that the TRT improved the overall quality of tracheostomy care at the Cleveland Clinic. Providers with active exposure to the TRT additionally reported statistically higher comfort with multiple topics surrounding tracheostomy care. CONCLUSIONS The implementation of this team improved provider comfort in managing patients with tracheostomies both qualitatively and quantifiably. This intervention offered a perceived benefit to patient care at our institution. Further study of the impact of this team on quantitative patient outcomes is forthcoming.
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Affiliation(s)
- Brooke A Quinton
- Case Western Reserve University School of Medicine, 10900 Euclid Ave, Cleveland, OH 44106, USA
| | - William S Tierney
- Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Paul C Bryson
- Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | | | - Colin T Gillespie
- Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Brandon D Hopkins
- Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, USA..
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18
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Karna ST, Trivedi S, Singh P, Khurana A, Gouroumourty R, Dodda B, Saigal S, Sharma JP, Karna A, Shrivastava P, Hussain A, Gupta V, Behera G, Waindeskar V. Weaning Outcomes and 28-day Mortality after Tracheostomy in COVID-19 Patients in Central India: A Retrospective Observational Cohort Study. Indian J Crit Care Med 2022; 26:85-93. [PMID: 35110850 PMCID: PMC8783235 DOI: 10.5005/jp-journals-10071-24080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background Tracheostomy is integral in long-term intensive care of coronavirus disease-2019 (COVID-19) patients. There is a paucity of studies on weaning outcomes and mortality after tracheostomy in COVID-19 in Indian scenario. Materials and methods We conducted a retrospective, single-center, observational study of severe COVID-19 patients who underwent elective tracheostomy (n = 65) during critical care in a tertiary care institute in Central India from May 1, 2020, to April 30, 2021. Data were collected from Medical records, ICU charts, and follow-up visits by patient. A primary objective was to study the clinical characteristics, tracheostomy complications, weaning outcomes, and mortality at 28 and 60 days of ICU admission. We categorized the cohort into two groups (deceased and survivor) and studied association of clinical parameters with 28-day mortality. Cox Proportional regression analysis was applied to calculate the hazard ratio among the predictors of mortality with p value <0.05 as significant. Results Elective tracheostomy was done in 69 of 436 (15.8%) patients on invasive mechanical ventilation, of which 65 were included. Tracheostomy was percutaneous in 45/65 (69%) and surgical in 20/65 (31%) with timing from intubation as early in 41/65 and late in 24/65 with most common indication as weaning failure followed by anticipated prolonged ventilation. Tracheostomy complications were present in 29/65 (45%) patients with no difference in complication rates between timing and type of tracheostomy. Downsizing, decannulation, and weaning were successful in 22%, 32 (49%), and 35/65 (54%) patients after tracheostomy. The 28-day mortality was 30/65 (46%). The fractional inspired oxygen concentration (FiO2) requirement in survivors was lower (0.4–0.6, p = 0.015) with a higher PaO2/FiO2 ratio (118–200, p = 0.033). Early tracheostomy within 7 days of intubation was not associated with weaning or survival benefit. Conclusions We suggest that tracheostomy should be delayed to after 7 days of intubation, especially till FiO2 reduces to 0.5 with improvement in PaO2/FiO2 for better outcomes and avoiding a wasted procedure (CTRI/2021/07/034768). Study Highlights Tracheostomy is integral in care of COVID-19 patients needing prolonged ventilation. There is no difference in complications in early/late or percutaneous dilatational/surgical technique. We observed successful weaning post-tracheostomy in 54% patients. Mortality at 28 days was 46%. Early tracheostomy within 7 days of intubation did not improve weaning or survival. How to cite this article Karna ST, Trivedi S, Singh P, Khurana A, Gouroumourty R, Dodda B, et al. Weaning Outcomes and 28-day Mortality after Tracheostomy in COVID-19 Patients in Central India: A Retrospective Observational Cohort Study. Indian J Crit Care Med 2022;26(1):85–93.
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Affiliation(s)
- Sunaina Tejpal Karna
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Saurabh Trivedi
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Pooja Singh
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
- Pooja Singh, Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India, Phone: +91 9340969292, e-mail:
| | - Alkesh Khurana
- Department of Pulmonary Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Revadi Gouroumourty
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Brahmam Dodda
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Saurabh Saigal
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Jai Prakash Sharma
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Amit Karna
- Department of Anesthesiology and Critical Care, Chirayu Medical College and Hospital, Bhopal, Madhya Pradesh, India
| | - Pranav Shrivastava
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Aqeel Hussain
- Department of Pulmonary Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Vikas Gupta
- Department of Otorhinolaryngology, Head and Neck Surgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Gankalyan Behera
- Department of Otorhinolaryngology, Head and Neck Surgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Vaishali Waindeskar
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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19
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Stewart JM, Snowden V, Charles CE, Farmer EA, Flanagan CE. Barriers to Discharge Patients With a Tracheostomy: A Qualitative Analysis. J Nurse Pract 2022. [DOI: 10.1016/j.nurpra.2021.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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20
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Smith JD, Correll JA, Stucken CL, Stucken EZ. Ear, Nose, and Throat Surgery: Postoperative Complications After Selected Head and Neck Operations. Surg Clin North Am 2021; 101:831-844. [PMID: 34537146 DOI: 10.1016/j.suc.2021.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Unanticipated complications of ENT surgeries may have profound functional and esthetic consequences for patients. Herein, we provide a broad overview of postoperative complications after ENT surgery, illustrating their unique nature, impact, and principles of management. The discussion is organized by subspecialty to highlight the great anatomic complexity of the head and neck and the importance of critical neurovascular and sensory structures that make ENT an impactful, yet challenging surgical specialty.
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Affiliation(s)
- Joshua D Smith
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Jason A Correll
- University of Michigan Medical School, 1301 Catherine Street, Ann Arbor, MI 48109, USA
| | - Chaz L Stucken
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Emily Z Stucken
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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21
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Newton M, Johnson RF, Wynings E, Jaffal H, Chorney SR. Pediatric Tracheostomy-Related Complications: A Cross-sectional Analysis. Otolaryngol Head Neck Surg 2021; 167:359-365. [PMID: 34520273 DOI: 10.1177/01945998211046527] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To determine the rate of tracheostomy-related complications in pediatric patients from nationally representative databases. STUDY DESIGN Cross-sectional analysis. SETTING 2016 Kids' Inpatient Database and 2016 Nationwide Readmission Database. METHODS All pediatric tracheostomy procedures were included. Complication type, admission outcomes, and readmission rates were recorded with a logistic regression analysis to determine patient characteristics associated with complications. RESULTS An estimated 5309 tracheostomies were performed among pediatric patients in 2016, 8% (n = 432) of whom developed tracheostomy-related complications. This group was younger (4.7 vs 8.7 years, P < .001) and required longer hospital admissions (68.7 vs 33.2 days, P < .001) than children without tracheostomy-related complications. Mean costs ($459,324 vs $397,937, P < .001) and mean total charges ($1,573,964 vs $1,099,347, P < .001) were increased if a tracheostomy-related complication occurred. These events occurred more often in those with bronchopulmonary dysplasia (24% vs 12%, P < .001), heart disease (24% vs 12%, P = .001), gastroesophageal reflux disease (31% vs 19%, P < .001), short gestational age (24% vs 14%, P < .001), and subglottic stenosis (9.9% vs 5.4%, P = .001). The estimated 30-day readmission rate was 24% (SE, 1.7%) but did not increase after tracheostomy complications (27% vs 15%, P = .04). Tracheostomy-related complications were predicted by gastroesophageal reflux disease (odds ratio [OR], 1.50; 95% CI, 1.14-1.97; P = .004), younger age (OR, 1.12; 95% CI, 1.04-1.22; P = .002), and lengthier hospitalization (OR, 1.00; 95% CI, 1.00-1.01; P < .001) on multiple logistic regression analysis. CONCLUSION Tracheostomy-related complications occur in approximately 8% of pediatric patients and are higher in younger children or those with longer admission lengths. These data have implications for benchmarking standards of posttracheostomy complications across institutions.
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Affiliation(s)
- Micah Newton
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Romaine F Johnson
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Children's Health Airway Management Program, Children's Medical Center Dallas, Dallas, Texas, USA
| | - Erin Wynings
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Hussein Jaffal
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Stephen R Chorney
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Children's Health Airway Management Program, Children's Medical Center Dallas, Dallas, Texas, USA
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22
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Haribhakti N, Agarwal P, Vida J, Panahon P, Rizwan F, Orfanos S, Stoll J, Baig S, Cabrera J, Kostis JB, Ananth CV, Kostis WJ, Scardella AT. A Simple Scoring Tool to Predict Medical Intensive Care Unit Readmissions Based on Both Patient and Process Factors. J Gen Intern Med 2021; 36:901-907. [PMID: 33483824 PMCID: PMC8041987 DOI: 10.1007/s11606-020-06572-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 12/29/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Although many predictive models have been developed to risk assess medical intensive care unit (MICU) readmissions, they tend to be cumbersome with complex calculations that are not efficient for a clinician planning a MICU discharge. OBJECTIVE To develop a simple scoring tool that comprehensively takes into account not only patient factors but also system and process factors in a single model to predict MICU readmissions. DESIGN Retrospective chart review. PARTICIPANTS We included all patients admitted to the MICU of Robert Wood Johnson University Hospital, a tertiary care center, between June 2016 and May 2017 except those who were < 18 years of age, pregnant, or planned for hospice care at discharge. MAIN MEASURES Logistic regression models and a scoring tool for MICU readmissions were developed on a training set of 409 patients, and validated in an independent set of 474 patients. KEY RESULTS Readmission rate in the training and validation sets were 8.8% and 9.1% respectively. The scoring tool derived from the training dataset included the following variables: MICU admission diagnosis of sepsis, intubation during MICU stay, duration of mechanical ventilation, tracheostomy during MICU stay, non-emergency department admission source to MICU, weekend MICU discharge, and length of stay in the MICU. The area under the curve of the scoring tool on the validation dataset was 0.76 (95% CI, 0.68-0.84), and the model fit the data well (Hosmer-Lemeshow p = 0.644). Readmission rate was 3.95% among cases in the lowest scoring range and 50% in the highest scoring range. CONCLUSION We developed a simple seven-variable scoring tool that can be used by clinicians at MICU discharge to efficiently assess a patient's risk of MICU readmission. Additionally, this is one of the first studies to show an association between MICU admission diagnosis of sepsis and MICU readmissions.
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Affiliation(s)
- Nirav Haribhakti
- Division of Pulmonary and Critical Care Medicine, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite 5200B, New Brunswick, NJ, 08901, USA.
| | - Pallak Agarwal
- Division of Pulmonary and Critical Care Medicine, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite 5200B, New Brunswick, NJ, 08901, USA
| | - Julia Vida
- Department of Computer Science, Rutgers, The State University of New Jersey, New Brunswick, NJ, USA
| | - Pamela Panahon
- Division of Pulmonary and Critical Care Medicine, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite 5200B, New Brunswick, NJ, 08901, USA
| | - Farsha Rizwan
- Division of Pulmonary and Critical Care Medicine, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite 5200B, New Brunswick, NJ, 08901, USA
| | - Sarah Orfanos
- Division of Pulmonary and Critical Care Medicine, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite 5200B, New Brunswick, NJ, 08901, USA
| | - Jonathan Stoll
- Division of Pulmonary and Critical Care Medicine, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite 5200B, New Brunswick, NJ, 08901, USA
| | - Saqib Baig
- Division of Pulmonary, Allergy, and Critical Care, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Javier Cabrera
- Department of Statistics and Biostatistics, Rutgers, The State University of New Jersey, New Brunswick, NJ, USA.,Cardiovascular Institute, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - John B Kostis
- Cardiovascular Institute, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Cande V Ananth
- Cardiovascular Institute, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.,Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers, The State University of New Jersey, New Brunswick, NJ, USA.,Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ, USA
| | - William J Kostis
- Cardiovascular Institute, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Anthony T Scardella
- Division of Pulmonary and Critical Care Medicine, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite 5200B, New Brunswick, NJ, 08901, USA
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Masoudi MS, Taheri R, Zoghi S. Predictive Factors for Postoperative Tracheostomy Requirement in Children Undergoing Surgical Resection of Medulloblastoma. World Neurosurg 2021; 150:e746-e749. [PMID: 33812068 DOI: 10.1016/j.wneu.2021.03.129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 01/07/2023]
Abstract
OBJECTIVE This study is aimed at identifying factors predicting tracheostomy requirement in children diagnosed with a posterior fossa medulloblastoma postoperatively. METHODS A retrospective chart review of all patients younger than 18 undergoing medulloblastoma resection from 2012 to 2020 at Namazi Hospital was conducted. RESULTS Forty-five patients (26%) needed tracheostomy after the operation. The most common correlates were brainstem compression and absence of gag reflex before operation. Patients who had brainstem compression and infiltration by medulloblastoma, bilateral absence of gag reflex before operation, subtotal resection of the tumor, and postoperative brainstem contusion were more likely to require tracheostomy. No statistically significant difference was observed between males and females and different ages. CONCLUSIONS Medulloblastoma is the most common pediatric malignancy. Postoperative ventilator dependency is an important complication in postoperative recovery of patients undergoing medulloblastoma resection. Considering the mutism syndrome with all its question marks by means of predisposing factors, we dealt with a 2-week policy whether there would be any clinical resolution regarding patients' gag reflex. The results show that if we aim for total tumor resection, tracheostomy that is a highly costly and stressful postoperative morbidity can be prevented.
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Affiliation(s)
| | - Reza Taheri
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Sina Zoghi
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran; Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
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Ruohoalho J, Xin G, Bäck L, Aro K, Tapiovaara L. Tracheostomy complications in otorhinolaryngology are rare despite the critical airway. Eur Arch Otorhinolaryngol 2021; 278:4519-4523. [PMID: 33656585 PMCID: PMC8486710 DOI: 10.1007/s00405-021-06707-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/17/2021] [Indexed: 11/28/2022]
Abstract
Purpose To identify complications of surgical tracheostomies in otorhinolaryngologic patients and adjust our processes to be properly prepared in the future. Methods We reviewed retrospectively all surgical tracheostomies (n = 255) performed by otolaryngologist-head and neck surgeons at Helsinki University Hospital between Jan 2014 and Feb 2017. Patient demographics, surgical details, surgical and medical complications, and tracheostomy-related mortality were recorded from the hospital charts. Risk factors for complications were assessed. Results Altogether, 55 (22%) complications were identified in 39 (15%) patients, with pneumonia, accidental decannulation, and bleeding being the most common. No patient or surgery-related factor reached significance in overall complication risk factor analysis. Medical complications were more common after elective tracheostomies compared to emergency procedures (10.6% vs. 3.5%, p < 0.05). Majority of complications (78%) were classified as mild or moderate according to Clavien–Dindo. Only 2 (0.8%) tracheostomy-related deaths were recorded. Conclusion In otorhinolaryngologists service, severe complications and tracheostomy-related deaths are very rare. Reducing their prevalence even further with careful planning is possible.
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Affiliation(s)
- Johanna Ruohoalho
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, PO Box 263, 00029 HUS, Helsinki, Finland.
| | - Guanyu Xin
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, PO Box 263, 00029 HUS, Helsinki, Finland
| | - Leif Bäck
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, PO Box 263, 00029 HUS, Helsinki, Finland
| | - Katri Aro
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, PO Box 263, 00029 HUS, Helsinki, Finland
| | - Laura Tapiovaara
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, PO Box 263, 00029 HUS, Helsinki, Finland
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25
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Ahmed Y, Cao A, Thal A, Shah S, Kinkhabwala C, Liao D, Li D, Parides M, Mehta V, Ow T, Smith R, Schiff BA. Tracheotomy Outcomes in 64 Ventilated COVID-19 Patients at a High-Volume Center in Bronx, NY. Laryngoscope 2021; 131:E1797-E1804. [PMID: 33410517 DOI: 10.1002/lary.29391] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/23/2020] [Accepted: 12/30/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVES/HYPOTHESIS The COVID-19 pandemic has resulted in a dramatic increase in the number of patients requiring prolonged mechanical ventilation. Few studies have reported COVID-19 specific tracheotomy outcomes, and the optimal timing and patient selection criteria for tracheotomy remains undetermined. We delineate our outcomes for tracheotomies performed on COVID-19 patients during the peak of the pandemic at a major epicenter in the United States. METHODS This is a retrospective observational cohort study. Mortality, ventilation liberation rate, complication rate, and decannulation rate were analyzed. RESULTS Sixty-four patients with COVID-19 underwent tracheotomy between April 1, 2020 and May 19, 2020 at two tertiary care hospitals in Bronx, New York. The average duration of intubation prior to tracheotomy was 20 days ((interquartile range [IQR] 16.5-26.0). The mortality rate was 33% (n = 21), the ventilation liberation rate was 47% (n = 30), the decannulation rate was 28% (n = 18), and the complication rate was 19% (n = 12). Tracheotomies performed by Otolaryngology were associated with significantly improved survival (P < .05) with 60% of patients alive at the conclusion of the study compared to 9%, 12%, and 19% of patients undergoing tracheotomy performed by Critical Care, General Surgery, and Pulmonology, respectively. CONCLUSIONS So far, this is the second largest study describing tracheotomy outcomes in COVID-19 patients in the United States. Our early outcomes demonstrate successful ventilation liberation and decannulation in COVID-19 patients. Further inquiry is necessary to determine the optimal timing and identification of patient risk factors predictive of improved survival in COVID-19 patients undergoing tracheotomy. LEVEL OF EVIDENCE 4-retrospective cohort study Laryngoscope, 131:E1797-E1804, 2021.
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Affiliation(s)
- Yasmina Ahmed
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, U.S.A
| | - Angela Cao
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, U.S.A
| | - Arielle Thal
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, U.S.A
| | - Sharan Shah
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, U.S.A
| | - Corin Kinkhabwala
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, U.S.A
| | - David Liao
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, U.S.A
| | - Daniel Li
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, U.S.A
| | - Michael Parides
- Department of Epidemiology and Population Health, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, U.S.A
| | - Vikas Mehta
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, U.S.A
| | - Thomas Ow
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, U.S.A
| | - Richard Smith
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, U.S.A
| | - Bradley A Schiff
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, U.S.A
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Mamidi IS, Benito DA, Lee R, Thakkar PG, Goodman JF, Joshi AS. Obesity is a predictor of increased morbidity after tracheostomy. Am J Otolaryngol 2021; 42:102651. [PMID: 33068956 DOI: 10.1016/j.amjoto.2020.102651] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 07/04/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The purpose of this study was to analyze the relationship between body mass index (BMI) and 30-day morbidity and mortality risk in patients undergoing tracheostomy using the American College of Surgeons National Quality Improvement Program (ACS-NSQIP). STUDY DESIGN This is a retrospective, cross-sectional, cohort study. SETTING Patients were identified with Current Procedural Terminology codes in the ACS-NSQIP database. SUBJECTS AND METHODS Patients who underwent tracheostomy from 2005 to 2018 were queried. They were stratified into four BMI classes and matched to normal BMI cohorts. Multivariate logistic regression was used to identify independent predictors for complications, readmissions, and unplanned reoperations within 30 days. RESULTS Among 3784 patients meeting inclusion and exclusion criteria, obesity was shown to be a significant independent risk factor for overall complications (OR 1.439, 95% CI 1.226-1.689, p < 0.001), postoperative acute renal failure (OR 10.715, 95% CI 1.213-94.646, p = 0.033), and unplanned readmissions (OR 1.702, 95% CI 1.095-2.647, p = 0.018). A significantly lower rate of postoperative transfusions was observed for obese patients (OR 0.581, 95% CI 0.432-0.781, p < 0.001). CONCLUSIONS Obesity was found to be independently associated with an increased risk of overall complication, developing acute renal failure, and having an unplanned 30-day readmission following tracheostomy. The risk of postoperative transfusion appears to be lower in obese patients. LEVEL OF EVIDENCE 4.
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27
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Zein Eddine SB, Carver TW, Karam BS, Pooni I, Ericksen F, Milia DJ. Neither Skin Sutures nor Foam Dressing Use Affect Tracheostomy Complication Rates. J Surg Res 2020; 260:116-121. [PMID: 33338887 DOI: 10.1016/j.jss.2020.11.066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 11/12/2020] [Accepted: 11/17/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Tracheostomy is commonly used for managing the airway of trauma patients. Complications are common and result in increased length of stays and treatment cost. The aim of this study is to evaluate whether the utilization of skin sutures or foam barrier dressings affect tracheostomy complication rates. MATERIALS AND METHODS This is a single-center retrospective review of patients who underwent a tracheostomy by the trauma service between January 2014 and December 2017. Collected variables included demographics, patient history, treatment variables, complications, and outcomes. Univariate and multivariate analyses were constructed to identify significant predictors for the development of complications. RESULTS A total of 268 patients were included. The median age was 43.5 y, 221 (82.5%) patients were men, and the median BMI was 28 (IQR 24.6, 32.2). Most (87.3%) of the procedures were performed in the operating room and 82.5% were open. Skin sutures were used in 46.3% and 53.4% had a foam barrier dressing placed. Current smoking [OR 8.1 (95% CI 1.5, 43.6)] and BMI [OR 1.1 (95% CI 1.03, 1.2)] significantly increased the risk of developing pressure necrosis. Use of sutures or foam dressings was not associated with pressure necrosis, bleeding, or surgical site infection. There were no unexpected tracheostomy decannulations regardless of the use of skin sutures. CONCLUSIONS Suturing the tracheostomy or applying a foam barrier dressing was not associated with overall complications or decannulation rates. Based on our data, we suggest that skin sutures may be safely abandoned.
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Affiliation(s)
- Savo Bou Zein Eddine
- Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Thomas W Carver
- Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Basil S Karam
- Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Inderjit Pooni
- Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Forrest Ericksen
- Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David J Milia
- Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
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Goethe EA, LoPresti MA, Gadgil N, Lam S. Predicting postoperative tracheostomy requirement in children undergoing surgery for posterior fossa tumors. Childs Nerv Syst 2020; 36:3013-3019. [PMID: 32270273 DOI: 10.1007/s00381-020-04605-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 03/30/2020] [Indexed: 01/19/2023]
Abstract
PURPOSE Posterior fossa tumor (PFT) resection can be associated with postoperative respiratory failure. We aimed to identify risk factors predicting tracheostomy dependence in children after PFT resection. METHODS Retrospective chart review of all children undergoing PFT resection from April 2007 to May 2017 at our institution was performed. RESULTS A total of 197 patients were included; 12 (6.1%) required tracheostomy placement at a mean 69.1 days postoperatively (SD 112.7, range 7-388). Patients requiring tracheostomy were younger (3.4 vs. 6.8 years, p < 0.01), more likely to have postoperative dysphagia (91.7% vs. 17.3%, p < 0.01), and more likely to have an ependymoma (41.7% vs. 15.1%, p < 0.01) or astrocytoma (25.0% vs. 8.1%, p < 0.01). Patients with eventual tracheostomy were less likely extubated immediately postoperatively (45.5% vs. 79.6%, p < 0.01), had longer intubation duration postoperatively (5.7 vs. 0.5 days, p < 0.01), and had higher rates of reintubation within 48 h (63.6% vs. 1.3%, p < 0.01). Patients requiring tracheostomy had longer hospital length of stay (45.8 vs. 15.3 days, p < 0.01) and ICU stay postoperatively (13.5 vs. 2.1 days, p < 0.01). Of those requiring tracheostomy, three (25.0%) were decannulated by 1 year postoperatively. Decannulation rates did not vary by age (p < 0.47), extubation failure (p < 0.24), duration of intubation (p < 0.10), tumor histology (p < 0.23), or tumor grade (p < 0.13). CONCLUSION Lower cranial neuropathy following PFT resection is common. Identifying risk factors correlated with need for tracheostomy can help identify patients who may benefit from early tracheostomy, reducing prolonged intubation trauma, time on mechanical ventilation, and length of stay.
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Affiliation(s)
- Eric A Goethe
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin St, Houston, TX, 77030, USA
| | - Melissa A LoPresti
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin St, Houston, TX, 77030, USA
| | - Nisha Gadgil
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin St, Houston, TX, 77030, USA
| | - Sandi Lam
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin St, Houston, TX, 77030, USA.
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Northwestern University Feinberg School of Medicine, Lurie Children's Hospital, 225 E Chicago Ave, Chicago, IL, 60611, USA.
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Jin YJ, Han SY, Park B, Park IS, Kim JH, Choi HG. Mortality and cause of death in patients with tracheostomy: Longitudinal follow-up study using a national sample cohort. Head Neck 2020; 43:145-152. [PMID: 32954559 DOI: 10.1002/hed.26471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 08/22/2020] [Accepted: 09/04/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The purpose of this study was to evaluate the long-term mortality and cause of death in patients with tracheostomy. METHODS Data from the Korean National Health Insurance Service-Health Screening Cohort were collected from 2002 to 2013. A total of 2394 tracheostomy participants and 9536 control participants were included in this study. The crude and adjusted hazard ratios (HRs) for tracheostomy-associated mortality were analyzed. Subgroup analysis according to age and cause of death was analyzed. RESULTS The tracheostomy group showed a significantly higher rate of death (69.1%) than the nontracheostomy group (13.3%). The adjusted HR for mortality was 13.5 in the tracheostomy group. The most common cause of death after tracheostomy was a circulatory disease, followed by neoplasm, respiratory disease, and trauma. CONCLUSIONS Patients with tracheostomy had a significantly increased long-term mortality rate compared with patients with nontracheostomy. The circulatory disease was the most common cause of death following tracheostomy.
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Affiliation(s)
- Young Ju Jin
- Department of Otorhinolaryngology-Head & Neck Surgery, Wonkwang University Hospital, Wonkwang University College of Medicine, Iksan, South Korea
| | - Seung Yoon Han
- Department of Otorhinolaryngology-Head & Neck Surgery, Wonkwang University Hospital, Wonkwang University College of Medicine, Iksan, South Korea
| | - Bumjung Park
- Department of Otorhinolaryngology-Head & Neck Surgery, Hallym University College of Medicine, Anyang, South Korea
| | - Il-Seok Park
- Department of Otorhinolaryngology-Head & Neck Surgery, Hallym University College of Medicine, Seoul, South Korea
| | - Jin-Hwan Kim
- Department of Otorhinolaryngology-Head & Neck Surgery, Hallym University College of Medicine, Dongtan, South Korea
| | - Hyo Geun Choi
- Department of Otorhinolaryngology-Head & Neck Surgery, Hallym University College of Medicine, Anyang, South Korea.,Hallym Data Science Laboratory, Hallym University College of Medicine, Anyang, South Korea
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30
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Oh TK, Kim K, Kim JH, Han SH, Hwang JW. Perioperative fluid balance and 30-day unplanned readmission after lung cancer surgery: a retrospective study. J Thorac Dis 2020; 12:3949-3958. [PMID: 32944306 PMCID: PMC7475599 DOI: 10.21037/jtd-20-1474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Perioperative positive fluid balance (FB) is associated with increased complications after lung resection surgery. However, its impact on the 30-day unplanned readmission rate is unclear. This study aimed to determine whether perioperative FB status during and up to 24 hours after lung resection surgery is associated with the 30-day unplanned readmission rate. Methods This retrospective cohort study examined adult patients aged 19 years or older who underwent lung cancer surgery at a single tertiary academic hospital between January 2005 and February 2018. Weight-based cumulative FB (%) was calculated during and up to 24 hours after surgery and was categorized as positive (≥5%), normal (0-5%), or negative (<0%). Univariable and multivariable logistic regression analyses were performed. Results The final analysis included 2,412 patients; 164 patients had unplanned readmission during the first 30 postoperative days (6.9%; 164/2,412). According to the multivariable logistic regression model, the positive FB group had a 2.42-time higher risk of 30-day unplanned readmission compared to the normal FB group [odds ratio (OR): 2.42; 95% confidence interval (CI): 1.20 to 4.89; P=0.014]. However, the risk of the negative FB group did not significantly differ from that of the normal FB group (OR: 1.20; 95% CI: 0.46 to 3.12; P=0.711). Conclusions Perioperative positive FB (>5%) during and up to 24 hours after surgery was associated with an increased 30-day unplanned readmission rate after lung cancer surgery. Future prospective studies are needed to confirm these findings.
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Affiliation(s)
- Tak Kyu Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Gyeonggi, Republic of Korea
| | - Kwanmien Kim
- Department of Cardiovascular and Thoracic Surgery, Seoul National University Bundang Hospital, Gyeonggi, Republic of Korea
| | - Jin-Hee Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Gyeonggi, Republic of Korea.,Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Sung-Hee Han
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Gyeonggi, Republic of Korea.,Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Jung-Won Hwang
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Gyeonggi, Republic of Korea.,Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, Republic of Korea
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Factors associated with a 30-day unplanned readmission after elective spine surgery: a retrospective cohort study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 30:191-199. [DOI: 10.1007/s00586-020-06541-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 06/23/2020] [Accepted: 07/14/2020] [Indexed: 12/11/2022]
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32
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Jenkins R, Badjatia N, Haac B, Van Besien R, Biedlingmaier JF, Stein DM, Chang WT, Schwartzbauer G, Parikh G, Morris NA. Factors associated with tracheostomy decannulation in patients with severe traumatic brain injury. Brain Inj 2020; 34:1106-1111. [DOI: 10.1080/02699052.2020.1786601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Ryne Jenkins
- R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Neeraj Badjatia
- R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA
- Section of Neurocritical Care and Emergency Neurology, Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bryce Haac
- R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Richard Van Besien
- R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA
| | - John F. Biedlingmaier
- Department of Otolaryngology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Deborah M. Stein
- R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA
- Zuckerberg San Francisco General Hospital and Trauma Center, Program in Trauma, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Wan-Tsu Chang
- Section of Neurocritical Care and Emergency Neurology, Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gary Schwartzbauer
- Section of Neurocritical Care and Emergency Neurology, Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gunjan Parikh
- Section of Neurocritical Care and Emergency Neurology, Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nicholas A. Morris
- Section of Neurocritical Care and Emergency Neurology, Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
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Barrera SC, Sanford EJ, Ammerman SB, Ferrell JK, Simpson CB, Dominguez LM. Postoperative Complications in Obese Patients After Tracheostomy. OTO Open 2020; 4:2473974X20953090. [PMID: 32923919 PMCID: PMC7453467 DOI: 10.1177/2473974x20953090] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 07/07/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the prevalence of varying classes of obesity in patients undergoing tracheostomy and the associated complication rates as compared with nonobese patients. STUDY DESIGN A retrospective chart review was performed from 2012 to 2018 on all patients who underwent open tracheostomy by the Department of Otolaryngology-Head and Neck Surgery. SETTING All tracheostomies were performed at a single tertiary care center. METHODS Patients were classified by body mass index (BMI) according to the World Health Organization classification system: underweight (<18.5), normal-overweight (18.5-29.9), class I (30-34.9), class II (35-39.9), and class III (>40). Charts were reviewed for patient demographic information, Charlson Comorbidity Index score, surgical indication, operative time, tracheostomy tube type, and postoperative complications. RESULTS A total of 387 patients (mean ± SD BMI, 31.3 ± 14.2) were identified per the inclusion/exclusion criteria. Of patients with BMI >30 (n=153), 34.6% were categorized as obesity class I, 29.4% as class II, and 35.9% as class III. The most common indication for tracheostomy was malignancy in nonobese patients (41.5%) and respiratory failure for obese patients (58.2%). Operative time was significantly longer in obese patients, and most of these patients required an extended-length tracheostomy tube. Patients with a BMI >40 had higher rates of multiple postoperative complications or death (P = .009). Underweight patients also had a higher rate of complication than normal-overweight patients (P = .016). CONCLUSION Class III and underweight patients had higher rates of postoperative complications, which should be taken into consideration during perioperative counseling.
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Affiliation(s)
- Shelby C. Barrera
- Department of Otolaryngology–Head and Neck Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Evan J. Sanford
- Department of Otolaryngology–Head and Neck Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Sarah B. Ammerman
- Department of Deaf Education and Hearing Science, UT Health San Antonio, San Antonio, Texas, USA
| | - Jay K. Ferrell
- Department of Otolaryngology–Head and Neck Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - C. Blake Simpson
- Department of Otolaryngology–Head and Neck Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Laura M. Dominguez
- Department of Otolaryngology–Head and Neck Surgery, UT Health San Antonio, San Antonio, Texas, USA
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Marinone Lares SG, Clark S, Mathy JA, Chaplin J, McIvor N. Evaluation of a novel database for quality assurance at a head and neck service in New Zealand: an audit of free flap head and neck reconstruction. ANZ J Surg 2020; 90:1386-1390. [PMID: 32436238 DOI: 10.1111/ans.15974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 04/17/2020] [Accepted: 04/25/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Clinical audit is a critical quality improvement exercise, yet efficient audit tools are lacking. The main objective of this study was to evaluate a recently deployed database in facilitating the process of clinical audit, and the secondary objective was to evaluate the outcomes of free flap reconstruction of the head and neck at our centre. METHODS A head and neck cancer-specific database was customized to suit the needs of our head and neck multidisciplinary team. Data has been entered prospectively into this database since March of 2018. An audit of free flap reconstruction of the head and neck over a 12-month period was performed using the database and analysed as a case study to examine its efficacy as a clinical audit tool. Additionally, the outcomes of free flap reconstruction at our centre were compared to those reported in the international literature. RESULTS The database allows flexible and specific queries, analysis and export of data, and can provide immediate results. However, issues with data quality and completeness were identified. In this audit, the overall 30-day complication rate and 30-day mortality in patients undergoing free flap reconstruction of the head and neck were 58% and 3%, respectively. CONCLUSION The database is fit for its intended purpose as an audit tool. Outcomes of free flap reconstruction of the head and neck at our centre are comparable to those of institutions overseas.
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Affiliation(s)
| | - Sita Clark
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Jon A Mathy
- Department of Surgery, The University of Auckland, Auckland, New Zealand.,Department of Otolaryngology-Head and Neck Surgery, Auckland City Hospital, Auckland, New Zealand.,Auckland Regional Plastic Surgery Unit, Auckland, New Zealand
| | - John Chaplin
- Department of Otolaryngology-Head and Neck Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Nick McIvor
- Department of Otolaryngology-Head and Neck Surgery, Auckland City Hospital, Auckland, New Zealand
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Ledderhof NJ, Carlson ER, Heidel RE, Winstead ML, Fahmy MD, Johnston DT. Are Tracheotomies Required for Patients Undergoing Composite Mandibular Resections for Oral Cancer? J Oral Maxillofac Surg 2020; 78:1427-1435. [PMID: 32353259 DOI: 10.1016/j.joms.2020.03.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 02/16/2020] [Accepted: 03/20/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Prophylactic tracheotomy has traditionally been performed during composite mandibular resection of oral cavity cancer to avoid postoperative airway compromise. The purpose of the present study was to measure the frequency and identify the factors associated with an increased or a decreased risk of an adverse airway event (AAE) within 30 days postoperatively. PATIENTS AND METHODS A retrospective cohort study of patients who had undergone composite mandibular resection for oral cancer from 2006 to 2018 was conducted at the University of Tennessee Medical Center. The primary predictor variable was composite resection with or without immediate flap reconstruction. The primary outcome variable was realization of a 30-day AAE, defined as the requirement for tracheotomy for any reason, emergent endotracheal reintubation at any time during the postoperative admission, or prolonged (>48 hours) postoperative endotracheal intubation. The secondary outcome variable was the inpatient length of stay. Descriptive and bivariate statistics were used to compare the patients with and without an AAE for demographic, confounding, and clinical characteristics. RESULTS A total of 114 patients were identified through retrospective medical record review. The prevalence of AAEs in the sample was 8.8% (10 of 114). None of the 49 patients without immediate flap reconstruction developed an AAE. Of the 65 patients who had undergone flap reconstruction, 10 (15.4%) developed an AAE. The χ2 analysis revealed a significantly greater rate of AAEs when flap reconstruction was implemented (P < .05). Also, a significantly greater rate of AAEs was found in the group requiring resection of the floor of the mouth with bilateral neck dissections and immediate flap reconstruction compared with all other flap reconstruction groups (P < .05). CONCLUSIONS A composite resection involving the floor of the mouth with bilateral neck dissection and flap reconstruction should receive strong consideration for prophylactic tracheotomy to avoid an AAE.
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Affiliation(s)
- Nicholas J Ledderhof
- Former Fellow, Oral/Head and Neck Oncologic Surgery, Department of Oral and Maxillofacial Surgery, University of Tennessee Medical Center, Knoxville, TN
| | - Eric R Carlson
- Professor and Kelly L. Krahwinkel Chairman, Department of Oral and Maxillofacial Surgery, University of Tennessee Medical Center, Knoxville, TN.
| | - R Eric Heidel
- Associate Professor of Biostatistics, Department of Surgery, University of Tennessee Medical Center, Knoxville, TN
| | - Michael L Winstead
- Resident, Department of Oral and Maxillofacial Surgery, University of Tennessee Medical Center, Knoxville, TN
| | - Mina D Fahmy
- Resident, Department of Oral and Maxillofacial Surgery
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Rubin SJ, Saunders SS, Kuperstock J, Gadaleta D, Burke PA, Grillone G, Moses JM, Murphy JP, Rodriguez G, Salama A, Platt MP. Quality improvement in tracheostomy care: A multidisciplinary approach to standardizing tracheostomy care to reduce complications. Am J Otolaryngol 2020; 41:102376. [PMID: 31924414 DOI: 10.1016/j.amjoto.2019.102376] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 12/10/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE Develop a model for quality improvement in tracheostomy care and decrease tracheostomy-related complications. METHODS This study was a prospective quality improvement project at an academic tertiary care hospital. A multidisciplinary team was assembled to create institutional guidelines for clinical care during the pre-operative, intra-operative, and post-operative periods. Baseline data was compiled by retrospective chart review of 160 patients, and prospective tracking of select points over 8 months in 73 patients allowed for analysis of complications and clinical parameters. RESULTS Implementation of a quality improvement team was successful in creating guidelines, setting baseline parameters, and tracking data with run charts. Comparison of pre- and post-guideline data showed a trend toward decreased rate of major complications from 4.38% to 2.74% (p = 0.096). Variables including time to tracheotomy for prolonged intubation, surgical technique, day of first tracheostomy tube change, and specialty performing surgery did not show increased risk of complications. There were increased tracheostomy-related complications in cold months (p = 0.04). CONCLUSIONS An interdisciplinary quality improvement team can improve tracheostomy care by identifying system factors, standardizing care among specialties, and providing continuous monitoring of select data points.
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Bibas BJ, Cardoso PFG, Hoetzenecker K. The burden of tracheal stenosis and tracheal diseases health-care costs in the 21 st century. Transl Cancer Res 2020; 9:2095-2096. [PMID: 35117562 PMCID: PMC8798798 DOI: 10.21037/tcr.2020.02.59] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 02/21/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Benoit Jacques Bibas
- Division of Thoracic Surgery, Heart Institute (InCor), Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo. São Paulo, Brazil
| | - Paulo Francisco Guerreiro Cardoso
- Division of Thoracic Surgery, Heart Institute (InCor), Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo. São Paulo, Brazil
| | - Konrad Hoetzenecker
- Division of Thoracic Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
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Masood MM, Farquhar DR, Biancaniello C, Hackman TG. Association of Standardized Tracheostomy Care Protocol Implementation and Reinforcement With the Prevention of Life-Threatening Respiratory Events. JAMA Otolaryngol Head Neck Surg 2019; 144:527-532. [PMID: 29799998 DOI: 10.1001/jamaoto.2018.0484] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Importance Mucus plugging after tracheostomy is a preventable cause of respiratory distress. Implementation of standardized tracheostomy care guidelines may reduce the occurrence of fatal respiratory compromise. Objective To determine the effect of implementing and reinforcing a standardized tracheostomy care protocol on the occurrence of acute life-threatening respiratory events. Design, Setting, and Participants Retrospective cohort study of adult patients who received a tracheostomy between May 2014 and August 2016 at a tertiary care center. Main Outcomes and Measures Patient demographics, tracheostomy indication, rapid response for mucus plugging and other acute events, duration of hospital stay, and levels of care that the patients received were recorded through examination of clinical logs. Statistical analysis was conducted between patients before protocol implementation and patients after protocol implementation in terms of rapid-response use, and intragroup comparison of the mean length of stay in various hospital units was also analyzed. Results A total of 247 patients (89 women [36%]; mean [SD] age, 58.5 [12.3] years), 117 preprotocol and 130 postprotocol, met inclusion criteria. Of the 130 patients in the postprotocol cohort, 123 (93%) were on the new tracheostomy care protocol. Preprotocol rapid-response rate was 21 of 117 patients (17.9%) and postprotocol response rate was 12 of 130 patients (9.2%) for a difference of 8.7% (95% CI, 0.2%-18.0%). In terms of mucus plugging, preprotocol rate was 8 of 117 patients (6.8%) and the postprotocol rate was 1 of 130 patients (0.8%) for a difference of 6.0% (95% CI, 1.3%-12.2%). Intragroup difference of the mean time spent (days) in various care units between patients in the no rapid-response group vs rapid-response group demonstrated clinically meaningful longer stay for rapid responses in both preprotocol and postprotocol groups for the intensive care unit (preprotocol, 2.03; 95% CI, 1.03-3.03 vs postprotocol, 3.02; 95% CI, 1.49-4.45) and step down units (preprotocol, 1.40; 95% CI, 0.77-2.02 vs postprotocol, 2.11; 95% CI, 0.78 to 3.44). Conclusions and Relevance Implementation and reinforcement of a standardized tracheostomy care protocol was associated with a reduction in the occurrences of rapid-response calls for life-threatening mucus plugging and is recommended for clinical practice. In addition, length of stay in the intensive care unit and intermediate surgical care unit was increased in a clinically meaningful way for patients who experienced a rapid-response event.
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Affiliation(s)
- Maheer M Masood
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina School of Medicine, Chapel Hill
| | - Douglas R Farquhar
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina School of Medicine, Chapel Hill
| | | | - Trevor G Hackman
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina School of Medicine, Chapel Hill
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Liao DZ, Mehta V, Kinkhabwala CM, Li D, Palsen S, Schiff BA. The safety and efficacy of open bedside tracheotomy: A retrospective analysis of 1000 patients. Laryngoscope 2019; 130:1263-1269. [DOI: 10.1002/lary.28234] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 07/20/2019] [Accepted: 07/23/2019] [Indexed: 12/14/2022]
Affiliation(s)
- David Z. Liao
- Albert Einstein College of Medicine Bronx New York U.S.A
| | - Vikas Mehta
- Department of Otorhinolaryngology–Head and Neck SurgeryMontefiore Medical Center Bronx New York U.S.A
| | | | - Daniel Li
- Albert Einstein College of Medicine Bronx New York U.S.A
| | - Sarah Palsen
- Albert Einstein College of Medicine Bronx New York U.S.A
| | - Bradley A. Schiff
- Department of Otorhinolaryngology–Head and Neck SurgeryMontefiore Medical Center Bronx New York U.S.A
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Kaufman MR, Alfonso KP, Burke K, Aouad RK. Awake vs Sedated Tracheostomies: A Review and Comparison at a Single Institution. Otolaryngol Head Neck Surg 2018; 159:830-834. [DOI: 10.1177/0194599818789079] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective The literature surrounding awake tracheostomies is sparse, particularly comparing awake tracheostomy patients to that of the sedated tracheostomy population. This study sought to compare tracheostomy patient demographics, indications, and outcomes of the 2 populations. Study Design Case series with chart review. Setting Tertiary care center. Materials and Methods All tracheostomies performed at our tertiary academic medical institution between January 2013 through November 2015 were reviewed. The data collected included demographics, comorbidity, anticoagulation, and outcomes. Results A total of 978 tracheostomies performed during this period met inclusion criteria, with 78 (8.0%) on awake patients. Most awake procedures were performed by otolaryngology (97.4%). Male sex predominated (73.1% awake vs 57.8% sedated). Forty-four patients (56.4%) were smokers in the awake group vs 326 of 900 (36.2%) in the sedated group. Malignancy was the primary indication for awake tracheostomy (68/78, 87.1%). One patient (1.3%) had significant postoperative bleeding compared to 26 of 900 (2.9%) of the sedated tracheostomy patients ( P = .406). Only 9 (11.4%) were ever decannulated. Thirty-one (39.2%) patients ultimately underwent total laryngectomy, 3 could not be decannulated secondary to anatomical causes (stenosis or vocal fold paralysis), and 19 were lost to follow-up after discharge. There were 12 of 78 (15.4%) overall deaths in the awake cohort, with 215 of 900 (23.9%) in the sedated cohort ( P = .088). Conclusion Despite all the differences between the 2 patient populations, the urgent awake tracheostomy appears to be safe and its complications do not appear significantly different from the sedated population.
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Affiliation(s)
- Michael R. Kaufman
- Department of Otolaryngology, University of Kentucky Medical Center, Lexington, Kentucky, USA
| | - Kristan P. Alfonso
- Department of Otolaryngology, University of Kentucky Medical Center, Lexington, Kentucky, USA
| | - Kristen Burke
- Department of Otolaryngology, University of Kentucky Medical Center, Lexington, Kentucky, USA
| | - Rony K. Aouad
- Department of Otolaryngology, University of Kentucky Medical Center, Lexington, Kentucky, USA
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Schmutz A, Dieterich R, Kalbhenn J, Voss P, Loop T, Heinrich S. Protocol based evaluation for feasibility of extubation compared to clinical scoring systems after major oral cancer surgery safely reduces the need for tracheostomy: a retrospective cohort study. BMC Anesthesiol 2018; 18:43. [PMID: 29678147 PMCID: PMC5910593 DOI: 10.1186/s12871-018-0506-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 04/13/2018] [Indexed: 12/18/2022] Open
Abstract
Background Despite risks, complications and negative impact to quality of life, tracheostomy is widely used to bypass upper airway obstruction after major oral cancer surgery (MOCS). Decision to tracheostomy is frequently based on clinical scoring systems which mainly have not been validated by different cohorts. Delayed extubation in the Intensive Care Unit (ICU) may be a suitable alternative in selected cases. We hypothesize that delayed routine ICU extubation after MOCS instead of scoring system based tracheostomy is safe, feasible and leads to lower tracheostomy rates. Methods We retrospectively analyzed our clinical protocol which provides routine extubation of patients after MOCS in the ICU. The primary outcome measure was a composite of early reintubation within 24 h or secondary tracheostomy. Secondary outcome measures included airway obstruction related morbidity and mortality. Predictor variables included tumor localisation, surgical procedure and reconstruction method, length of operation and pre-existing morbidity. Furthermore we assessed the ability of four clinical scoring systems to identify patients requiring secondary tracheostomy. Statistical processing includes basic descriptive statistics, Chi-squared test and multivariate logistic regression analysis. Results Two hundred thirty four cases were enclosed to this retrospective study. Fourteen patients (6%) required secondary tracheostomy, Ten patients (4%) required reintubation within 24 h after extubation. No airway obstruction associated mortality, morbidity and cannot intubate cannot ventilate situation was observed. Seventy five percent of the patients were extubated within 17 h after ICU admission. All evaluated scores showed a poor positive predictive value (0.08 to 0.18) with a sensitivity ranged from 0.13 to 0.63 and specificity ranged from 0.5 to 0.93. Conclusions Our data demonstrate that common clinical scoring systems fail to prevent tracheostomy in patients after MOCS. Application of scoring systems may lead to a higher number of unnecessary tracheostomies. Delayed routine extubation in the ICU after MOCS seems an appropriate and safe approach to avoid tracheostomy and the related morbidity. Electronic supplementary material The online version of this article (10.1186/s12871-018-0506-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Axel Schmutz
- Department of Anaesthesiology and Critical Care Medicine, Medical Center, University of Freiburg, Faculty of Medicine, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Rolf Dieterich
- Department of Anaesthesiology and Critical Care Medicine, Medical Center, University of Freiburg, Faculty of Medicine, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Johannes Kalbhenn
- Department of Anaesthesiology and Critical Care Medicine, Medical Center, University of Freiburg, Faculty of Medicine, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Pit Voss
- Department of Oral and Maxillofacial Surgery & Regional Plastic Surgery, Medical Center, University of Freiburg, Faculty of Medicine, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Torsten Loop
- Department of Anaesthesiology and Critical Care Medicine, Medical Center, University of Freiburg, Faculty of Medicine, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Sebastian Heinrich
- Department of Anaesthesiology and Critical Care Medicine, Medical Center, University of Freiburg, Faculty of Medicine, Hugstetter Strasse 55, 79106, Freiburg, Germany.
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McCall AL, Salemi J, Bhanap P, Strickland LM, Elmallah MK. The impact of Pompe disease on smooth muscle: a review. J Smooth Muscle Res 2018; 54:100-118. [PMID: 30787211 PMCID: PMC6380904 DOI: 10.1540/jsmr.54.100] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 12/26/2018] [Indexed: 12/24/2022] Open
Abstract
Pompe disease (OMIM 232300) is an autosomal recessive disorder caused by mutations in the gene encoding acid α-glucosidase (GAA) (EC 3.2.1.20), the enzyme responsible for hydrolyzing lysosomal glycogen. The primary cellular pathology is lysosomal glycogen accumulation in cardiac muscle, skeletal muscle, and motor neurons, which ultimately results in cardiorespiratory failure. However, the severity of pathology and its impact on clinical outcomes are poorly described in smooth muscle. The advent of enzyme replacement therapy (ERT) in 2006 has improved clinical outcomes in infantile-onset Pompe disease patients. Although ERT increases patient life expectancy and ventilator free survival, it is not entirely curative. Persistent motor neuron pathology and weakness of respiratory muscles, including airway smooth muscles, contribute to the need for mechanical ventilation by some patients on ERT. Some patients on ERT continue to experience life-threatening pathology to vascular smooth muscle, such as aneurysms or dissections within the aorta and cerebral arteries. Better characterization of the disease impact on smooth muscle will inform treatment development and help anticipate later complications. This review summarizes the published knowledge of smooth muscle pathology associated with Pompe disease in animal models and in patients.
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Affiliation(s)
- Angela L McCall
- Department of Pediatrics, School of Medicine, Duke University, Durham, NC, USA
| | - Jeffrey Salemi
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Preeti Bhanap
- Department of Pediatrics, School of Medicine, Duke University, Durham, NC, USA
| | - Laura M Strickland
- Department of Pediatrics, School of Medicine, Duke University, Durham, NC, USA
| | - Mai K Elmallah
- Department of Pediatrics, School of Medicine, Duke University, Durham, NC, USA
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