1
|
Marc MS, Rosca D, Bratosin F, Fira-Mladinescu O, Oancea C, Pescaru CC, Velescu D, Wellmann N, Motofelea AC, Ciuca IM, Saracin K, Manolescu D. The Effect of Comorbidities and Complications on COVID-19 Mortality: A Detailed Retrospective Study in Western Romania. J Pers Med 2023; 13:1552. [PMID: 38003867 PMCID: PMC10672588 DOI: 10.3390/jpm13111552] [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: 09/25/2023] [Revised: 10/24/2023] [Accepted: 10/27/2023] [Indexed: 11/26/2023] Open
Abstract
COVID-19 continues to impact global health systems even after being declared over, with some patients exhibiting severe complications linked to pre-existing conditions. This study aimed to investigate the association between comorbidities, complications, and survival outcomes among COVID-19 survivors in Western Romania. Our hypothesis posited that comorbidities and complications significantly influence survival rates. We conducted a retrospective analysis of 1948 COVID-19 survivors admitted from January to December 2021, with 192 selected for detailed analysis based on inclusion and exclusion criteria. The severity of COVID-19 was classified according to WHO guidelines, and conditions like hypertension and obesity were defined using criteria from the European Society of Hypertension (ESH), the European Society of Cardiology (ESC), and WHO, respectively. Among the 192 patients, 33 had mild, 62 had moderate, and 97 had severe COVID-19. The median age across the severity groups was 63.2 years. Patients undergoing tracheostomy had a mortality rate of 83.3% versus 22.2% for non-tracheostomy patients (p < 0.001) and presented with significantly higher lung injury, hospitalization duration, and complications. Remarkably, tracheostomized patients were 17.50 times more likely to succumb to the disease (95% CI 4.39-116.91, p < 0.001). Furthermore, pneumothorax increased the mortality risk significantly (OR 22.11, 95% CI 5.72-146.03, p < 0.001). Intriguingly, certain conditions like grade I hypertension and grade II obesity showed a protective effect against mortality, whereas type 2 diabetes mellitus increased mortality risk (univariate OR 2.89, p = 0.001). The presence of certain comorbidities and complications significantly impacts the survival rates of COVID-19 patients in Western Romania. Notably, tracheostomy, pneumothorax, and T2DM were associated with increased mortality. This study underscores the importance of personalized patient care and provides insights for healthcare policymakers in Western Romania to improve clinical management strategies.
Collapse
Affiliation(s)
- Monica Steluta Marc
- Center for Research and Innovation in Precision Medicine of Respiratory Diseases, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (M.S.M.); (O.F.-M.); (C.O.); (C.C.P.); (D.V.); (D.M.)
- Department of Infectious Diseases, Discipline of Pulmonology, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Daniela Rosca
- Doctoral School, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (F.B.); (N.W.)
| | - Felix Bratosin
- Doctoral School, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (F.B.); (N.W.)
- Discipline of Infectious Diseases, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Ovidiu Fira-Mladinescu
- Center for Research and Innovation in Precision Medicine of Respiratory Diseases, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (M.S.M.); (O.F.-M.); (C.O.); (C.C.P.); (D.V.); (D.M.)
- Department of Infectious Diseases, Discipline of Pulmonology, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Cristian Oancea
- Center for Research and Innovation in Precision Medicine of Respiratory Diseases, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (M.S.M.); (O.F.-M.); (C.O.); (C.C.P.); (D.V.); (D.M.)
- Department of Infectious Diseases, Discipline of Pulmonology, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Camelia Corina Pescaru
- Center for Research and Innovation in Precision Medicine of Respiratory Diseases, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (M.S.M.); (O.F.-M.); (C.O.); (C.C.P.); (D.V.); (D.M.)
- Department of Infectious Diseases, Discipline of Pulmonology, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Diana Velescu
- Center for Research and Innovation in Precision Medicine of Respiratory Diseases, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (M.S.M.); (O.F.-M.); (C.O.); (C.C.P.); (D.V.); (D.M.)
- Department of Infectious Diseases, Discipline of Pulmonology, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Norbert Wellmann
- Doctoral School, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (F.B.); (N.W.)
| | - Alexandru Catalin Motofelea
- Department of Internal Medicine, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania;
| | - Ioana Mihaiela Ciuca
- Department of Pediatrics, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania;
- Pediatric Pulmonology Unit, Clinical County Hospital, Evliya Celebi 1-3, 300226 Timisoara, Romania
| | - Karina Saracin
- Emergency County Hospital Craiova, Strada Tabaci 1, 200642 Craiova, Romania;
| | - Diana Manolescu
- Center for Research and Innovation in Precision Medicine of Respiratory Diseases, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (M.S.M.); (O.F.-M.); (C.O.); (C.C.P.); (D.V.); (D.M.)
- Department of Radiology, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| |
Collapse
|
2
|
Rahim Akroute A, Støre Brinchmann B, Hovland A, Dreyer Fredriksen ST. Registered nurses' experience of care for adult patients with a temporary tracheostomy at general hospital wards. A phenomenological-hermeneutic explorative study. Intensive Crit Care Nurs 2023; 77:103443. [PMID: 37116436 DOI: 10.1016/j.iccn.2023.103443] [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: 10/24/2022] [Revised: 04/13/2023] [Accepted: 04/17/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND Caring for adult patients with a temporary tracheostomy in general wards can be challenging and complex. Little research has explored registered nurses' experiences with caring for these groups of patients. OBJECTIVES This study sought to interpret and describe registered nurses' lived experiences of caring for adult patients with a tracheostomy in general wards. RESEARCH DESIGN/METHODOLOGY Six registered nurses were interviewed in this study. The interviews were analysed to gain comprehensive knowledge about caring for adult patients with a temporary tracheostomy. The interviews were transcribed, analysed, and interpreted by using Gadameŕs philosophical hermeneutics and Kvale and Brinkmann's three steps of understanding. SETTING Three different wards medical, surgical, and neurological of a teaching hospital in Norway. FINDINGS Three themes emerged from data analysis. These included experiencing clinically challenging patients, a lack of clinical support from the intensive care nurses, and a lack of professional confidence. CONCLUSION This study highlighted the challenges surrounding the care of an adult patient with a tracheostomy in the general wards. Identifying these challenges would lead to further improvement in registered nurses' experiences and, in turn, in the quality of competent care for adult patients with a tracheostomy in the general ward. IMPLICATIONS FOR CLINICAL PRACTICE Understanding the registered nurses' experiences will assist the head nurses in planning and providing relevant information and education to provide safe and holistic patient care. Adequate support from intensive care unit nurses and professional development are required to ensure high-quality care. This study recommends that healthcare managers focus on establishing step-down units to improve patient outcomes, especially for high-risk patients and to increase the competencies of registered nurses in caring for adult patients with a tracheostomy as a whole person.
Collapse
Affiliation(s)
- Abder Rahim Akroute
- Department of Anesthesia and Intensive Care Medicine, Nordland Hospital, N-8049, Norway.
| | - Berit Støre Brinchmann
- The Faculty of Nursing and Health Sciences, Nord University, Bodø 8026, Norway; Nordland Hospital, Bodø 8076, Norway
| | | | - Sven-Tore Dreyer Fredriksen
- Nord University, Norway; Department of Health and Care Sciences, Faculty of Health Sciences, UiT. The Arctic University of Norway, Campus Harstad, Havnegata 5, Harstad 9480, Norway; Professional and Research Nurse at National Resource Center for Chronic Neurological Diseases, Knorrebakken Housing Units, Knorrebakken 2, Harstad 9411, Norway.
| |
Collapse
|
3
|
Tanaka A, Uchiyama A, Kitamura T, Sakaguchi R, Komukai S, Enokidani Y, Koyama Y, Yoshida T, Iguchi N, Sobue T, Fujino Y. Association between tracheostomy and survival in patients with coronavirus disease 2019 who require prolonged mechanical ventilation for more than 14 days: A multicenter cohort study. Auris Nasus Larynx 2023; 50:276-284. [PMID: 35764477 PMCID: PMC9189113 DOI: 10.1016/j.anl.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 05/20/2022] [Accepted: 06/07/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Tracheostomy is a common procedure with potential prognostic advantages for patients who require prolonged mechanical ventilation (PMV). Early recommendations for patients with coronavirus disease 2019 (COVID-19) suggested delayed or limited tracheostomy considering the risk for viral transmission to clinicians. However, updated guidelines for tracheostomy with appropriate personal protective equipment have revised its indications. This study aimed to evaluate the association between tracheostomy and prognosis in patients with COVID-19 requiring PMV. METHODS This was a multicenter, retrospective cohort study using data from the nationwide Japanese Intensive Care PAtient Database. We included adult patients aged ≥16 years who were admitted to the intensive care unit (ICU) due to COVID-19 and who required PMV (for >14 days or until performance of tracheostomy). The primary outcome was hospital mortality, and the association between implementation of tracheostomy and patient prognosis was assessed using weighted Cox proportional hazards regression analysis with inverse probability of treatment weighting (IPTW) using the propensity score to address confounders. RESULTS Between January 2020 and February 2021, 453 patients with COVID-19 were observed. Data from 109 patients who required PMV were analyzed: 66 (60.6%) underwent tracheostomy and 38 (34.9%) died. After adjusting for potential confounders using IPTW, tracheostomy implementation was found to significantly reduce hospital mortality (hazard ratio [HR]: 0.316, 95% confidence interval [CI]: 0.163-0.612). Patients who underwent tracheostomy had a similarly decreased ICU and 28-day mortality (HR: 0.269, 95% CI: 0.124-0.581; HR 0.281, 95% CI: 0.094-0.839, respectively). A sensitivity analysis using different definitions of PMV duration consistently showed reduced mortality in patients who underwent tracheostomy. CONCLUSION The implementation of tracheostomy was associated with favorable patient prognosis among patients with COVID-19 requiring PMV. Our findings support proactive tracheostomy in critically ill patients with COVID-19 requiring mechanical ventilation for >14 days.
Collapse
Affiliation(s)
- Aiko Tanaka
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871, Japan.
| | - Akinori Uchiyama
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Ryota Sakaguchi
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Sho Komukai
- Division of Biomedical Statistics, Department of Integrated Medicine, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Yusuke Enokidani
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Yukiko Koyama
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Takeshi Yoshida
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Naoya Iguchi
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Tomotaka Sobue
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Yuji Fujino
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871, Japan
| |
Collapse
|
4
|
Mukai N, Okada M, Konishi S, Okita M, Ogawa S, Nishikawa K, Annen S, Ohshita M, Matsumoto H, Murata S, Harima Y, Kikuchi S, Aibara S, Sei H, Aoishi K, Asayama R, Sato E, Takagi T, Tanaka-Nishikubo K, Teraoka M, Hato N, Takeba J, Sato N. Cricotracheostomy for patients with severe COVID-19: A case control study. Front Surg 2023; 10:1082699. [PMID: 36733889 PMCID: PMC9888534 DOI: 10.3389/fsurg.2023.1082699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 01/03/2023] [Indexed: 01/18/2023] Open
Abstract
Background Tracheostomy is an important procedure for the treatment of severe coronavirus disease-2019 (COVID-19). Older age and obesity have been reported to be associated with the risk of severe COVID-19 and prolonged intubation, and anticoagulants are often administered in patients with severe COVID-19; these factors are also related to a higher risk of tracheostomy. Cricotracheostomy, a modified procedure for opening the airway through intentional partial cricoid cartilage resection, was recently reported to be useful in cases with low-lying larynx, obesity, stiff neck, and bleeding tendency. Here, we investigated the usefulness and safety of cricotracheostomy for severe COVID-19 patients. Materials and methods Fifteen patients with severe COVID-19 who underwent cricotracheostomy between January 2021 and April 2022 with a follow-up period of ≥ 14 days were included in this study. Forty patients with respiratory failure not related to COVID-19 who underwent traditional tracheostomy between January 2015 and April 2022 comprised the control group. Data were collected from medical records and comprised age, sex, body mass index, interval from intubation to tracheostomy, use of anticoagulants, complications of tracheostomy, and decannulation. Results Age, sex, and days from intubation to tracheostomy were not significantly different between the COVID-19/cricotracheostomy and control/traditional tracheostomy groups. Body mass index was significantly higher in the COVID-19 group than that in the control group (P = 0.02). The rate of use of anticoagulants was significantly higher in the COVID-19 group compared with the control group (P < 0.01). Peri-operative bleeding, subcutaneous emphysema, and stomal infection rates were not different between the groups, while stomal granulation was significantly less in the COVID-19 group (P = 0.04). Conclusions These results suggest that cricotracheostomy is a safe procedure in patients with severe COVID-19.
Collapse
Affiliation(s)
- Naoki Mukai
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Masahiro Okada
- Department of Otolaryngology, Head and Neck Surgery, Ehime University Graduate School of Medicine, Toon, Japan,Correspondence: Masahiro Okada
| | - Saki Konishi
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Mitsuo Okita
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Siro Ogawa
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Kosuke Nishikawa
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Toon, Japan,Department of Bone and Joint Surgery, Ehime University School of Medicine, Toon, Japan
| | - Suguru Annen
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Muneaki Ohshita
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Hironori Matsumoto
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Satoru Murata
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Yutaka Harima
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Satoshi Kikuchi
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Shiori Aibara
- Department of Otolaryngology, Head and Neck Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Hirofumi Sei
- Department of Otolaryngology, Head and Neck Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Kunihide Aoishi
- Department of Otolaryngology, Head and Neck Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Rie Asayama
- Department of Otolaryngology, Head and Neck Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Eriko Sato
- Department of Otolaryngology, Head and Neck Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Taro Takagi
- Department of Otolaryngology, Head and Neck Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Kaori Tanaka-Nishikubo
- Department of Otolaryngology, Head and Neck Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Masato Teraoka
- Department of Otolaryngology, Head and Neck Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Naohito Hato
- Department of Otolaryngology, Head and Neck Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Jun Takeba
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Norio Sato
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| |
Collapse
|
5
|
Shreckengost CSH, Wan L, Reitz AW, Lin A, Dhamsania RK, Spychalski J, Douglas JM, Lane A, Amin D, Roser S, Berkowitz D, Foianini JE, Moore R, Sreedharan JK, Niroula A, Smith R, Khullar OV. Tracheostomies of Patients With COVID-19: A Survey of Infection Reported by Health Care Professionals. Am J Crit Care 2023; 32:9-20. [PMID: 36065019 DOI: 10.4037/ajcc2022337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Health care professionals (HCPs) performing tracheostomies in patients with COVID-19 may be at increased risk of infection. OBJECTIVE To evaluate factors underlying HCPs' COVID-19 infection and determine whether tracheostomy providers report increased rates of infection. METHODS An anonymous international survey examining factors associated with COVID-19 infection was made available November 2020 through July 2021 to HCPs at a convenience sample of hospitals, universities, and professional organizations. Infections reported were compared between HCPs involved in tracheostomy on patients with COVID-19 and HCPs who were not involved. RESULTS Of the 361 respondents (from 33 countries), 50% (n = 179) had performed tracheostomies on patients with COVID-19. Performing tracheostomies on patients with COVID-19 was not associated with increased infection in either univariable (P = .06) or multivariable analysis (odds ratio, 1.48; 95% CI, 0.90-2.46; P = .13). Working in a low- or middle-income country (LMIC) was associated with increased infection in both univariable (P < .001) and multivariable analysis (odds ratio, 2.88; CI, 1.50-5.53; P = .001). CONCLUSIONS Performing tracheostomy was not associated with COVID-19 infection, suggesting that tracheostomies can be safely performed in infected patients with appropriate precautions. However, HCPs in LMICs may face increased infection risk.
Collapse
Affiliation(s)
| | - Limeng Wan
- Limeng Wan is a student, Rollins School of Public Health, Emory University
| | - Alexandra W Reitz
- Alexandra W. Reitz is a resident physician, Department of Surgery, Emory University
| | - Alice Lin
- Alice Lin is a student, Rollins School of Public Health, Emory University
| | - Rohan K Dhamsania
- Rohan K. Dhamsania is a student, Philadelphia College of Osteopathic Medicine, Suwanee, Georgia
| | - Julia Spychalski
- Julia Spychalski is a student, Rollins School of Public Health, Emory University
| | - J Miller Douglas
- J. Miller Douglas is a student, Department of Surgery and Rollins School of Public Health, Emory University
| | - Andrea Lane
- Andrea Lane is a student, Rollins School of Public Health, Emory University
| | - Dina Amin
- Dina Amin is an assistant professor, Department of Surgery, Emory University and a surgeon, Oral and Maxillofacial Surgery, Grady Memorial Hospital, Atlanta, Georgia
| | - Steven Roser
- Steven Roser is a professor, Department of Surgery, Emory University and a surgeon, Oral and Maxillofacial Surgery, Grady Memorial Hospital, Atlanta, Georgia
| | - David Berkowitz
- David Berkowitz is a physician and professor, Department of Medicine, School of Medicine, Emory University
| | | | - Renée Moore
- Renée Moore is a professor, Rollins School of Public Health, Emory University
| | - Jithin K Sreedharan
- Jithin K. Sreedharan is general secretary, Indian Association of Respiratory Care, Kochi, India
| | - Abesh Niroula
- Abesh Niroula is a physician, Department of Medicine, School of Medicine, Emory University
| | - Randi Smith
- Randi Smith is a surgeon, Department of Surgery, Emory University, a professor, Rollins School of Public Health, Emory University, and a surgeon, Trauma and Surgical Critical Care, Grady Memorial Hospital
| | - Onkar V Khullar
- Onkar V. Khullar is a surgeon, Department of Surgery, Emory University
| | | |
Collapse
|
6
|
Sumiya R, Nagasaka S, Okamoto T, Ikeda T, Hojo M, Omagari N, Kokudo N. Clinical outcomes after tracheostomy in patients with coronavirus disease 2019: a single-center experience in Japan. Surg Today 2023; 53:130-134. [PMID: 35771302 PMCID: PMC9244426 DOI: 10.1007/s00595-022-02541-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/12/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE Many patients with coronavirus disease 2019 require mechanical ventilation and tracheostomy. However, the timing and indications for tracheostomy are controversial. This study assessed 11 patients with coronavirus disease 2019 who underwent tracheostomy with clinical information and retrospective analyses. METHODS A single-center retrospective observational study was performed on patients with coronavirus disease 2019 who underwent tracheostomy between 2020 and 2021. RESULTS Failure to wean was the most common indication for tracheostomy, followed by extracorporeal membrane oxygenation decannulation and the need for secretion management. After tracheostomy, six patients (54.5%) were liberated from the ventilator. The time from intubation to tracheostomy (21.1 ± 9.14 days) was correlated with the duration of ventilator dependency (36.83 ± 20.45 days, r2 = 0.792, p = 0.018). The mean Acute Physiological and Chronic Health Evaluation II score was significantly lower in the ventilator-liberated group (23 ± 2.77) than in the non-ventilator-liberated group (31 ± 6.13, p = 0.0292). Furthermore, patients with Acute Physiological and Chronic Health Evaluation II scores of < 27 points achieved ventilator liberation and a long-term survival (p = 0.0006). CONCLUSIONS This study describes the outcomes of a cohort of patients who underwent tracheostomy after intubation for coronavirus disease 2019. The Acute Physiological and Chronic Health Evaluation II score predicted whether or not the patient could achieve ventilator liberation.
Collapse
Affiliation(s)
- Ryusuke Sumiya
- Department of General Thoracic Surgery, National Center for Global Health and Medicine, 1-21-1, Toyama, Shinjuku, Tokyo, 162-8655, Japan.
| | - Satoshi Nagasaka
- Department of General Thoracic Surgery, National Center for Global Health and Medicine, 1-21-1, Toyama, Shinjuku, Tokyo, 162-8655, Japan
| | - Tatsuya Okamoto
- Department of Intensive Care Medicine, National Center for Global Health and Medicine, Tokyo, Japan
| | - Takeshi Ikeda
- Department of General Thoracic Surgery, National Center for Global Health and Medicine, 1-21-1, Toyama, Shinjuku, Tokyo, 162-8655, Japan
| | - Masaaki Hojo
- Department of Respiratory Medicine, National Center for Global Health and Medicine, Tokyo, Japan
| | - Norio Omagari
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Norihiro Kokudo
- Department of Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| |
Collapse
|
7
|
Battaglini D, Premraj L, White N, Sutt AL, Robba C, Cho SM, Di Giacinto I, Bressan F, Sorbello M, Cuthbertson BH, Bassi GL, Suen J, Fraser JF, Pelosi P. Tracheostomy outcomes in critically ill patients with COVID-19: a systematic review, meta-analysis, and meta-regression. Br J Anaesth 2022; 129:679-692. [PMID: 36182551 PMCID: PMC9345907 DOI: 10.1016/j.bja.2022.07.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/12/2022] [Accepted: 07/12/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND We performed a systematic review of mechanically ventilated patients with COVID-19, which analysed the effect of tracheostomy timing and technique (surgical vs percutaneous) on mortality. Secondary outcomes included intensive care unit (ICU) and hospital length of stay (LOS), decannulation from tracheostomy, duration of mechanical ventilation, and complications. METHODS Four databases were screened between January 1, 2020 and January 10, 2022 (PubMed, Embase, Scopus, and Cochrane). Papers were selected according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Population or Problem, Intervention or exposure, Comparison, and Outcome (PICO) guidelines. Meta-analysis and meta-regression for main outcomes were performed. RESULTS The search yielded 9024 potentially relevant studies, of which 47 (n=5268 patients) were included. High levels of between-study heterogeneity were observed across study outcomes. The pooled mean tracheostomy timing was 16.5 days (95% confidence interval [CI]: 14.7-18.4; I2=99.6%). Pooled mortality was 22.1% (95% CI: 18.7-25.5; I2=89.0%). Meta-regression did not show significant associations between mortality and tracheostomy timing, mechanical ventilation duration, time to decannulation, and tracheostomy technique. Pooled mean estimates for ICU and hospital LOS were 29.6 (95% CI: 24.0-35.2; I2=98.6%) and 38.8 (95% CI: 32.1-45.6; I2=95.7%) days, both associated with mechanical ventilation duration (coefficient 0.8 [95% CI: 0.2-1.4], P=0.02 and 0.9 [95% CI: 0.4-1.4], P=0.01, respectively) but not tracheostomy timing. Data were insufficient to assess tracheostomy technique on LOS. Duration of mechanical ventilation was 23.4 days (95% CI: 19.2-27.7; I2=99.3%), not associated with tracheostomy timing. Data were insufficient to assess the effect of tracheostomy technique on mechanical ventilation duration. Time to decannulation was 23.8 days (95% CI: 19.7-27.8; I2=98.7%), not influenced by tracheostomy timing or technique. The most common complications were stoma infection, ulcers or necrosis, and bleeding. CONCLUSIONS In patients with COVID-19 requiring tracheostomy, the timing and technique of tracheostomy did not clearly impact on patient outcomes. SYSTEMATIC REVIEW PROTOCOL PROSPERO CRD42021272220.
Collapse
Affiliation(s)
- Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy; Department of Medicine, University of Barcelona, Barcelona, Spain.
| | - Lavienraj Premraj
- Griffith University School of Medicine, Gold Coast, QLD, Australia; Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Nicole White
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology (QUT), Brisbane, QLD, Australia
| | - Anna-Liisa Sutt
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia; Faculty of Medical and Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Sung-Min Cho
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anaesthesiology and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ida Di Giacinto
- Unit of Anesthesia and Intensive Care, Mazzoni Hospital, Ascoli Piceno, Italy
| | - Filippo Bressan
- Anesthesia and Intensive Care, Anestesia e Rianimazione Ospedale Santo Stefano di Prato, Prato, Italy
| | - Massimiliano Sorbello
- Anesthesia and Intensive Care, Policlinico San Marco University Hospital, Catania, Italy
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; University Department of Anaesthesiology in Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia; Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology (QUT), Brisbane, QLD, Australia; Queensland University of Technology, Brisbane, QLD, Australia; Critical Care Medicine, UnitingCare Health, Brisbane, QLD, Australia
| | - Jacky Suen
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia; Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology (QUT), Brisbane, QLD, Australia; Queensland University of Technology, Brisbane, QLD, Australia; Critical Care Medicine, UnitingCare Health, Brisbane, QLD, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia; Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology (QUT), Brisbane, QLD, Australia; Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anaesthesiology and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Queensland University of Technology, Brisbane, QLD, Australia; Critical Care Medicine, UnitingCare Health, Brisbane, QLD, Australia
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| |
Collapse
|
8
|
Chong WH, Tan CK. Clinical Outcomes of Early Versus Late Tracheostomy in Coronavirus Disease 2019 Patients: A Systematic Review and Meta-Analysis. J Intensive Care Med 2022; 37:1121-1132. [PMID: 35506907 DOI: 10.1177/08850666221098930] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND A significant proportion of Coronavirus Disease 2019 (COVID-19) patients require admission to the intensive care unit (ICU) and invasive mechanical ventilation (IMV). Tracheostomy is increasingly performed when a prolonged course of IMV is anticipated. OBJECTIVES To determine clinical and resource utilization benefits of early versus late tracheostomy among COVID-19 patients. METHODS Pubmed, Cochrane Library, Scopus, and Embase were used to identify relevant studies comparing outcomes of COVID-19 patients undergoing early and late tracheostomy from January 1, 2020, to December 1, 2021. RESULTS Twelve studies were selected, and 2222 critically ill COVID-19 patients hospitalized between January to December 2020 were included. Among the included patients, 34.5% and 65.5% underwent early and late tracheostomy, respectively. Among the included studies, 58.3% and 41.7% defined early tracheostomy using cutoffs of 14 and 10 days, respectively. All-cause in-hospital mortality was not different between the early and late tracheostomy groups (32.9% vs. 33.1%; OR = 1.00; P = 0.98). Sensitivity analysis demonstrated a similar mortality rate in studies using a cutoff of 10 days (34.6% vs. 35.5%; OR = 0.97; P = 0.89) or 14 days (31.2% vs. 27.7%; OR = 1.05; P = 0.78). The early tracheostomy group had shorter ICU length of stay (LOS) (mean: 23.18 vs. 30.51 days; P < 0.001) and IMV duration (mean: 20.49 vs. 28.94 days; P < 0.001) than the late tracheostomy group. The time from tracheostomy to decannulation was longer (mean: 23.36 vs. 16.24 days; P = 0.02) in the early tracheostomy group than in the late tracheostomy group, but the time from tracheostomy to IMV weaning was similar in both groups. Other clinical characteristics, including age, were similar in both groups. CONCLUSIONS Early tracheostomy reduced the ICU LOS and IMV duration among COVID-19 patients compared with late tracheostomy, but the mortality rate was similar in both groups. The findings have important implications for the treatment of COVID-19 patients, especially in a resource-limited setting.
Collapse
Affiliation(s)
- Woon Hean Chong
- Department of Intensive Care Medicine, 242949Ng Teng Fong General Hospital, National University Health System, Singapore, Singapore
| | - Chee Keat Tan
- Department of Intensive Care Medicine, 242949Ng Teng Fong General Hospital, National University Health System, Singapore, Singapore
| |
Collapse
|
9
|
Favier V, Lescroart M, Pequignot B, Grimmer L, Florentin A, Gallet P. Measurement of airborne particle emission during surgical and percutaneous dilatational tracheostomy COVID-19 adapted procedures in a swine model: Experimental report and review of literature. PLoS One 2022; 17:e0278089. [PMID: 36417482 PMCID: PMC9683587 DOI: 10.1371/journal.pone.0278089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 11/09/2022] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Surgical tracheostomy (ST) and Percutaneous dilatational tracheostomy (PDT) are classified as high-risk aerosol-generating procedures and might lead to healthcare workers (HCW) infection. Albeit the COVID-19 strain slightly released since the vaccination era, preventing HCW from infection remains a major economical and medical concern. To date, there is no study monitoring particle emissions during ST and PDT in a clinical setting. The aim of this study was to monitor particle emissions during ST and PDT in a swine model. METHODS A randomized animal study on swine model with induced acute respiratory distress syndrome (ARDS) was conducted. A dedicated room with controlled airflow was used to standardize the measurements obtained using an airborne optical particle counter. 6 ST and 6 PDT were performed in 12 pigs. Airborne particles (diameter of 0.5 to 3 μm) were continuously measured; video and audio data were recorded. The emission of particles was considered as significant if the number of particles increased beyond the normal variations of baseline particle contamination determinations in the room. These significant emissions were interpreted in the light of video and audio recordings. Duration of procedures, number of expiratory pauses, technical errors and adverse events were also analyzed. RESULTS 10 procedures (5 ST and 5 PDT) were fully analyzable. There was no systematic aerosolization during procedures. However, in 1/5 ST and 4/5 PDT, minor leaks and some adverse events (cuff perforation in 1 ST and 1 PDT) occurred. Human factors were responsible for 1 aerosolization during 1 PDT procedure. ST duration was significantly shorter than PDT (8.6 ± 1.3 vs 15.6 ± 1.9 minutes) and required less expiratory pauses (1 vs 6.8 ± 1.2). CONCLUSIONS COVID-19 adaptations allow preventing for major aerosol leaks for both ST and PDT, contributing to preserving healthcare workers during COVID-19 outbreak, but failed to achieve a perfectly airtight procedure. However, with COVID-19 adaptations, PDT required more expiratory pauses and more time than ST. Human factors and adverse events may lead to aerosolization and might be more frequent in PDT.
Collapse
Affiliation(s)
- Valentin Favier
- Department of Otolaryngology-Head and Neck Surgery, Gui de Chauliac Hospital, University Hospital of Montpellier, Montpellier, France
- Montpellier Laboratory of Informatics, Robotics and Microelectonics (LIRMM), ICAR Team, French National Centre for Scientific Research (CNRS), Montpellier University, Montpellier, France
- * E-mail:
| | - Mickael Lescroart
- Intensive Care Unit Brabois, University Regional Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Benjamin Pequignot
- Intensive Care Unit Brabois, University Regional Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Léonie Grimmer
- Department of Hygiene, Environmental Risks and Healthcare Associated Risks, University of Lorraine, Vandoeuvre-lès-Nancy, France
| | - Arnaud Florentin
- Department of Hygiene, Environmental Risks and Healthcare Associated Risks, University of Lorraine, Vandoeuvre-lès-Nancy, France
- Infection Prevention and Control Team, Regional University Hospital of Nancy, Vandœuvre-lès-Nancy, France
| | - Patrice Gallet
- ENT Department, Regional University Hospital of Nancy, University of Lorraine, Vandœuvre-lès-Nancy, France
- Virtual Hospital of Lorraine, University of Lorraine, Vandoeuvre-lès-Nancy, France
- NGERE, INSERM U1256 Lab, University of Lorraine, Vandoeuvre-lès-Nancy, France
| |
Collapse
|
10
|
Mehta Y, Kochar G. Tracheostomy in COVID Times. JOURNAL OF CARDIAC CRITICAL CARE TSS 2021. [DOI: 10.1055/s-0041-1732837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Yatin Mehta
- Department of Anesthesiology and Critical Care, Medanta – The Medicity, Gurugram, India
| | - Gaurav Kochar
- Department of Anesthesiology and Critical Care, Medanta – The Medicity, Gurugram, India
| |
Collapse
|
11
|
Staibano P, Levin M, McHugh T, Gupta M, Sommer DD. Association of Tracheostomy With Outcomes in Patients With COVID-19 and SARS-CoV-2 Transmission Among Health Care Professionals: A Systematic Review and Meta-analysis. JAMA Otolaryngol Head Neck Surg 2021; 147:646-655. [PMID: 34042963 PMCID: PMC8160928 DOI: 10.1001/jamaoto.2021.0930] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 04/08/2021] [Indexed: 12/16/2022]
Abstract
Importance Approximately 5% to 15% of patients with COVID-19 require invasive mechanical ventilation (IMV) and, at times, tracheostomy. Details regarding the safety and use of tracheostomy in treating COVID-19 continue to evolve. Objective To evaluate the association of tracheostomy with COVID-19 patient outcomes and the risk of SARS-CoV-2 transmission among health care professionals (HCPs). Data Sources EMBASE (Ovid), Medline (Ovid), and Web of Science from January 1, 2020, to March 4, 2021. Study Selection English-language studies investigating patients with COVID-19 who were receiving IMV and undergoing tracheostomy. Observational and randomized clinical trials were eligible (no randomized clinical trials were found in the search). All screening was performed by 2 reviewers (P.S. and M.L.). Overall, 156 studies underwent full-text review. Data Extraction and Synthesis We performed data extraction in accordance with Meta-analysis of Observational Studies in Epidemiology guidelines. We used a random-effects model, and ROBINS-I was used for the risk-of-bias analysis. Main Outcomes and Measures SARS-CoV-2 transmission between HCPs and levels of personal protective equipment, in addition to complications, time to decannulation, ventilation weaning, and intensive care unit (ICU) discharge in patients with COVID-19 who underwent tracheostomy. Results Of the 156 studies that underwent full-text review, only 69 were included in the qualitative synthesis, and 14 of these 69 studies (20.3%) were included in the meta-analysis. A total of 4669 patients were included in the 69 studies, and the mean (range) patient age across studies was 60.7 (49.1-68.8) years (43 studies [62.3%] with 1856 patients). We found that in all studies, 1854 patients (73.8%) were men and 658 (26.2%) were women. We found that 28 studies (40.6%) investigated either surgical tracheostomy or percutaneous dilatational tracheostomy. Overall, 3 of 58 studies (5.17%) identified a small subset of HCPs who developed COVID-19 that was associated with tracheostomy. Studies did not consistently report the number of HCPs involved in tracheostomy. Among the patients, early tracheostomy was associated with faster ICU discharge (mean difference, 6.17 days; 95% CI, -11.30 to -1.30), but no change in IMV weaning (mean difference, -2.99 days; 95% CI, -8.32 to 2.33) or decannulation (mean difference, -3.12 days; 95% CI, -7.35 to 1.12). There was no association between mortality or perioperative complications and type of tracheostomy. A risk-of-bias evaluation that used ROBINS-I demonstrated notable bias in the confounder and patient selection domains because of a lack of randomization and cohort matching. There was notable heterogeneity in study reporting. Conclusions and Relevance The findings of this systematic review and meta-analysis indicate that enhanced personal protective equipment is associated with low rates of SARS-CoV-2 transmission during tracheostomy. Early tracheostomy in patients with COVID-19 may reduce ICU stay, but this finding is limited by the observational nature of the included studies.
Collapse
Affiliation(s)
- Phillip Staibano
- Department of Surgery, Otolaryngology–Head and Neck Division, McMaster University, Hamilton, Ontario, Canada
| | - Marc Levin
- Department of Otolaryngology–Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Tobial McHugh
- Department of Surgery, Otolaryngology–Head and Neck Division, McMaster University, Hamilton, Ontario, Canada
| | - Michael Gupta
- Department of Surgery, Otolaryngology–Head and Neck Division, McMaster University, Hamilton, Ontario, Canada
| | - Doron D. Sommer
- Department of Surgery, Otolaryngology–Head and Neck Division, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
12
|
Yokokawa T, Homma A. Authors' reply to: Comment on the article by Dr. Dmitry Tretiakow: Management of tracheostomy in COVID-19 patients: The Japanese experience. Auris Nasus Larynx 2021; 48:802. [PMID: 33691936 PMCID: PMC7931736 DOI: 10.1016/j.anl.2021.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Taizo Yokokawa
- Department of Otolaryngology-Head and Neck Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North 15 West 7, Sapporo 060-8638, Japan
| | - Akihiro Homma
- Department of Otolaryngology-Head and Neck Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North 15 West 7, Sapporo 060-8638, Japan.
| |
Collapse
|
13
|
Tretiakow D, Skorek A, Narozny W, Przewozny T. Management of tracheostomy in COVID-19 patients: The Japanese experience. Auris Nasus Larynx 2021; 48:800-801. [PMID: 33653636 PMCID: PMC7904516 DOI: 10.1016/j.anl.2021.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 02/18/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Dmitry Tretiakow
- Department of Otolaryngology, Medical University of Gdansk, Smoluchowskiego str. 17, 80-214, Gdansk, Poland.
| | - Andrzej Skorek
- Department of Otolaryngology, Medical University of Gdansk, Smoluchowskiego str. 17, 80-214, Gdansk, Poland
| | - Waldemar Narozny
- Department of Otolaryngology, Medical University of Gdansk, Smoluchowskiego str. 17, 80-214, Gdansk, Poland
| | - Tomasz Przewozny
- Department of Otolaryngology, Medical University of Gdansk, Smoluchowskiego str. 17, 80-214, Gdansk, Poland
| |
Collapse
|