Tracheostomy inner cannula care: a randomized crossover study of two decontamination procedures

Evaluation of the microbiological efficacy of cleaning agents for tracheostomy inner cannulas

PURPOSE

Biofilms are a significant cause of morbidity in patients with indwelling medical devices. Biofilms pose a potential risk with reusable inner cannulas by increasing the risk of infections. Effective decontamination is thus vital in decreasing bioburden. The current guidelines for cleaning inner cannulas are varied, with multiple techniques being recommended, which are not supported by strong evidence. This randomized, controlled, cross-over study attempted to enumerate the bacterial count of inner cannulas used in tracheostomy patients (n = 60) pre-and post-decontamination with detergent (A) or sterile water (B).

MATERIALS AND METHODS

The patients were randomly allocated to sequence A > B or B > A in 1:1 fashion. The saline flushing of the inner cannulas was plated on trypticase soy agar with 5 % sheep blood to enumerate the bacterial count.

RESULTS

The mean ratio [Log (CFU)post/Log (CFU)pre]A/[Log (CFU)post/Log (CFU)pre]B based on 53 samples was 0.918 ± 0.470, two-sided 90 % confidence interval (CI) 0.812, 1.024. The equivalence criterion was met as the mean ratio after cleaning fell within the equivalence region of 0.8 and 1.25.

CONCLUSION

This study demonstrated the microbiological efficacy of both detergent and sterile water in the decontamination of inner cannulas, and that sterile water was not less effective than detergent in reducing the bacterial load for safe re-use of inner cannulas. This has the potential to promote cost savings for patients with tracheostomy, both in the hospital and the community. The study findings may also be relevant in formulating tracheostomy care policies.

LEVEL OF EVIDENCE: 1

Role of chlorhexidine on tracheostomy cannula decontamination in relation to the growth of Biofilm-Forming Bacteria Colony- a randomized controlled trial study

Background

Regular cleaning of the cannula in the trachea is very important for infection prevention. How to wash the tracheal cannula which is good to reduce the possibility of colonies of biofilm-forming bacteria and the growth of bacterial and the pattern of bacterial on the tracheal cannula is still unknown. This study aims to evaluate the efficacy of decontamination of the tracheal cannula using chlorhexidine and NaCl 0.9% in patients using the tracheal cannula to decrease biofilm-forming bacterial colony.

Methods

40 subjects were grouped into 20 subjects in the control group washing the cannula using 0.9% NaCl and the interventional group washing cannula using and with 2.5% chlorhexidine solution and 0.9% NaCl. This study used a parallel randomized controlled trial of 2 groups with a single blinded.

Results

40 subjects studied, 17 subjects (85%) each group produced biofilm-forming bacteria prior to intervention. After intervention in the study group, 15 subjects were biofilm negative and 5 biofilm positive subjects p = 0.001. The most common bacteria found in the control group is Pseudomonas aeruginosa, while in the study group some bacteria such as Acinetobacter sp. and Proteus mirabilis. Amoxicilin-Clavulanate had the highest resistance to biofilm forming bacteria in both groups. Piperacillin, ceftazidime, ciprofloxacin and meropenem have the highest sensitivity to biofilm-forming bacteria.

Conclusion

There was a significant decrease in the number of colonies that produced biofilm in the tracheal cannula in the study group compared to the control group in tracheal cannula washing.

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Biofilm-Forming Bacteria Colony.

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Tracheostomy Cannula.

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Decontamination.

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Chlorhexidine.

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Chlorhexidine with NaCl versus NaCl only.

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Randomized control trial.

Multidisciplinary guidelines for the management of paediatric tracheostomy emergencies

Temporary and permanent tracheostomies are required in children to manage actual or anticipated long-term ventilatory support, to aid secretion management or to manage fixed upper airway obstruction. Tracheostomies may be required from the first few moments of life, with the majority performed in children < 4 years of age. Although similarities with adult tracheostomies are apparent, there are key differences when managing the routine and emergency care of children with tracheostomies. The National Tracheostomy Safety Project identified the need for structured guidelines to aid multidisciplinary clinical decision making during paediatric tracheostomy emergencies. These guidelines describe the development of a bespoke emergency management algorithm and supporting resources. Our aim is to reduce the frequency, nature and severity of paediatric tracheostomy emergencies through preparation and education of staff, parents, carers and patients.

Microbiological evaluation of different reprocessing methods for cuffed and un-cuffed tracheostomy tubes in home-care and hospital setting

Background: Manufacturers’ recommendations on cleaning of tracheostomy tubes focus on general warning information and non-specific manual cleaning procedures. The aim of this experimental study was to evaluate different reprocessing methods and to determine the mechanical integrity and functionality of tracheostomy tubes following reprocessing.

Methods: Sixteen cuffed or un-cuffed tracheostomy tubes obtained from hospital in-patients were reprocessed using one of the following reprocessing methods: a) manual brushing and rinsing with tap water, b) manual brushing followed by disinfection with a glutaraldehyde solution, c) manual brushing followed machine-based cleaning in a dishwasher, and d) manual brushing followed by ultrasound cleaning in a commercially available ultrasound device. Microbial burden of the tubes before and after reprocessing was assessed by measurement of microbial colony-forming units per mL (CFU/mL) of rinsing fluid. After cleaning, tracheostomy tubes were investigated for loss of functionality.

Findings: Manual brushing and rinsing with tap water reduced microbial colonization in average by 10² CFU/mL, but with poor reproducibility and reliability. Complete microbial reduction was achieved only with additional chemical or machine-based thermal disinfection. Ultrasound sonification yielded no further microbial reduction after manual brushing.

Conclusion: Manual brushing alone will not result in complete eradication of microorganism colonising cuffed or un-cuffed tracheostomy tubes. However, manual cleaning followed by chemical or thermal disinfection may be regarded as safe and reproducible reprocessing method. If a machine-based reprocessing method is used for cuffed tubes, the cuffs’ ventilation hose must be secured in a safe position prior to thermal disinfection.

Tolerability and performance of BIP endotracheal tubes with noble metal alloy coating--a randomized clinical evaluation study

Background

Hospital acquired infections worsen the outcome of patients treated in intensive care units and are costly. Coatings with silver or metal alloys may reduce or alter the formation of biofilm on invasive medical devices. An endotracheal tube (ETT) is used to connect the patient to a ventilator and coated tubes have been tested in relation to bacterial colonization and respiratory infection. In the present study, we aimed to evaluate and compare a coated and uncoated ETT for patient symptoms and local tracheal tolerability during short term clinical use. Degree of bacterial colonization was also described.

Methods

A silver-palladium-gold alloy coating (‘Bactiguard®’Infection Protection, BIP) has been extensively used on urinary tract catheters and lately also on central venous catheters. We performed a randomised, single-blinded, controlled, first in man, post Conformité Européenne (EC) certification and CE marking study, focused on Bactiguard® coated ETTs (BIP ETT). Thirty patients at a tertiary university hospital scheduled for upper abdominal elective surgery with an expected duration of anaesthesia of at least 3 h were randomised; BIP ETT (n = 20) or standard ETT (n = 10). The tolerability was assessed with a modified version of Quality of Life Head and Neck Module, QLQ-H&N35 and by inspection of the tracheal mucosa with a fibre-optic bronchoscope before intubation and at extubation. Adverse Events (AE) and bacterial adherence were also studied. Statistical evaluations were carried out with the Fisher’s Exact Test, the Clopper-Pearson method, as well as a Proportional Odds Model.

Results

Differences between groups were identified in 2 of 8 patient related symptoms with regard to tolerability by QLQ-H&N35 (cough, p = 0.022 and dry mouth, p = 0.014 in the treatment group.). No mucosal damage was identified with bronchoscopy. A low level of bacterial colonization with normal flora, equal between groups, was seen after short-term of intubation (median 5 h). No serious Adverse Events related to the use of an ETT were observed. The results should be treated with caution due to statistical confounders, a small study size and large inter-individual variability in bacterial adhesion.

Conclusions

The new device BIP ETT is well tolerated and has good clinical performance during short-term intubation. Studies with larger sample sizes and longer intubation periods (>24 h) in the ICU-setting are needed and can now be planned in order to identify possible differences in clinical outcomes.

Trial registration

Registered in ClinicalTrials.gov, Registration number: NCT01682486, Date of Registration: August, 30, 2012

Tracheostomy care and management in general wards and community settings: literature review

AIMS AND OBJECTIVES

To identify current perspectives and areas for research regarding care and management of tracheostomized adult patients discharged to general wards and the community.

BACKGROUND

The increased number of tracheostomies being performed has led to more tracheostomized patients being discharged to non-specialized areas. Staff within these diverse areas may care for this patient group on an infrequent basis, and may lack the skills, knowledge and confidence to provide safe tracheostomy care. Although several guidelines and quality improvement initiatives have been developed to guide and improve tracheostomy care, concerns continue to be raised regarding this aspect of care. These factors inadvertently create significant risks for example, tube displacement in addition to the risks associated with procedures such as tracheal suctioning.

SEARCH STRATEGY

Database searches of MEDLINE, BRITISH NURSING INDEX and CINAHL (1998-2009). Inclusion criteria was literature regarding tracheostomized adult patients discharged to non-specialized areas. Exclusion criteria was paediatric literature.

CONCLUSIONS

Although best practice is applied to the care of tracheostomized adult patients in some areas, including support for ward staff from specialist nurses or teams, this is not always formalized or consistent. Furthermore studies indicate a lack of medical follow-up once the patient is discharged from specialized areas with a tracheostomy. Research is very limited in relation to the care and management of tracheostomized adult patients outside specialized areas, yet there is morbidity and mortality associated with this patient group. Staff education is widely recommended, but further development is needed to determine the best methods of delivering education, especially for health care professionals who care for tracheostomized patients on an infrequent basis.

RELEVANCE TO CLINICAL PRACTICE

More tracheostomized patients are being discharged to non-specialized areas, and issues have been raised regarding risks to patients. Research is required to determine the best methods of promoting best practice to improve tracheostomy care.

Material wear of polymeric tracheostomy tubes: a six-month study

OBJECTIVES

The objectives were to study long-term material wear of tracheostomy tubes made of silicone (Si), polyvinyl chloride (PVC), and polyurethane (PU) after 3 and 6 months of clinical use.

STUDY DESIGN

The study has a prospective and comparative design.

METHODS

Nineteen patients with long-term tracheostomy, attending the National Respiratory Center in Sweden, were included, n = 6 with Si tubes, n = 8 with PVC tubes, and n = 5 with PU tubes. The tubes were exposed to the local environment in the trachea for 3 and 6 months and analyzed by scanning electron microscopy, attenuated total reflectance Fourier transform infrared spectroscopy, and differential scanning calorimetry.

RESULTS

All tubes revealed severe surface changes. No significant differences were established after 3 or 6 months of exposure between the various materials. The changes had progressed significantly after this period, compared to previously reported changes after 30 days of exposure. The results from all analyzing techniques correlated well.

CONCLUSIONS

All tubes, exposed in the trachea for 3-6 months, revealed major degradation and changes in the surface of the material. Polymeric tracheostomy tubes should be changed before the end of 3 months of clinical use.