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Flagg CA, Stevens JR, Chinn S. Practice Trends and Evidence-Based Practice in Microvascular Reconstruction. Otolaryngol Clin North Am 2023:S0030-6665(23)00071-3. [PMID: 37221115 DOI: 10.1016/j.otc.2023.04.014] [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: 05/25/2023]
Abstract
Microvascular and free flap reconstruction are important to the otolaryngology-head and neck surgery practice. Herein, the reader will find an up-to-date discussion of various evidence-based practice trends related to microvascular surgery, including surgical techniques, anesthetic and airway considerations, free flap monitoring and troubleshooting, surgical efficiency, and both patient-related and surgeon-related risk factors that may affect outcomes.
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Affiliation(s)
- Candace A Flagg
- Department of Otolaryngology-Head and Neck Surgery, San Antonio Uniformed Services Health Education Consortium, JBSA-Fort Sam Houston, TX, USA.
| | - Jayne R Stevens
- Department of Otolaryngology-Head and Neck Surgery, San Antonio Uniformed Services Health Education Consortium, JBSA-Fort Sam Houston, TX, USA
| | - Steven Chinn
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA; Rogel Cancer Center, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
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Airway management following head and neck microvascular reconstruction: is tracheostomy mandatory? Braz J Otorhinolaryngol 2022; 88 Suppl 4:S44-S49. [PMID: 34756557 DOI: 10.1016/j.bjorl.2021.07.007] [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] [Received: 02/23/2021] [Revised: 07/01/2021] [Accepted: 07/09/2021] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Airway management following maxillofacial microvascular reconstruction is a fundamental part of the perioperative management. In oral cavity microvascular reconstruction, the airway is potentially compromised by airway edema, flap edema or bulkiness, hematoma formation, or upper airway sequelae from surgery. Classical teaching advocates elective tracheostomy in patients undergoing maxillofacial free flap reconstruction, while others keep patients intubated overnight (delayed extubation). The optimal method for perioperative airway management is still debated. This study aim was to evaluate the morbidity associated with elective tracheostomy in patients undergoing maxillofacial microvascular reconstruction and to recognize those patients who can avoid elective tracheostomy. METHODS Retrospective review of patients who underwent maxillofacial microvascular free flap reconstruction, between November 1st 2010 and October 31st 2019 in our center. RESULTS One-hundred and nine patients underwent microvascular reconstruction in the maxillofacial region. Sixty-one patients underwent an elective tracheostomy upon the primary surgery. Forty-eight patients were left intubated overnight. Seven patients underwent a late tracheostomy which was performed upon a neck re-exploration for postoperative complications, except for one patient which was due to failed extubation attempt. Patients who didn't receive an elective tracheostomy were younger and had a shorter duration of postoperative hospitalization. Seven patients suffered from tracheostomy- related complications, all of them underwent elective tracheostomy and none were from the late tracheostomy group. CONCLUSIONS Our results suggest, the routine use of elective tracheostomy in maxillofacial microvascular free flap reconstruction is unnecessary. Elective tracheostomy should be considered on case-to-case basis. LEVEL OF EVIDENCE: 4
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Chiang DH, Huang CC, Cheng SC, Cheng JC, Wu CH, Huang SS, Yang YY, Yang LY, Kao SY, Chen CH, Shulruf B, Lee FY. Immersive virtual reality (VR) training increases the self-efficacy of in-hospital healthcare providers and patient families regarding tracheostomy-related knowledge and care skills: A prospective pre-post study. Medicine (Baltimore) 2022; 101:e28570. [PMID: 35029229 PMCID: PMC8757958 DOI: 10.1097/md.0000000000028570] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 12/23/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Virtual reality (VR)-based simulation in hospital settings facilitates the acquisition of skills without compromising patient safety. Despite regular text-based training, a baseline survey of randomly selected healthcare providers revealed deficiencies in their knowledge, confidence, comfort, and care skills regarding tracheostomy. This prospective pre-post study compared the effectiveness of regular text- and VR-based intervention modules in training healthcare providers' self-efficacy in tracheostomy care skills. METHODS Between January 2018 and January 2020, 60 healthcare providers, including physicians, nurses, and respiratory therapists, were enrolled. For the intervention, a newly developed head-mounted display (HMD) and web VR materials were implemented in training and clinical services. Subsequently, in-hospital healthcare providers were trained using either text or head-mounted display virtual reality (HMD-VR) materials in the regular and intervention modules, respectively. For tracheostomy care skills, preceptors directly audited the performance of trainees and provided feedback. RESULTS At baseline, the degree of trainees' agreement with the self-efficacy-related statements, including the aspects of familiarity, confidence, and anxiety about tracheostomy-related knowledge and care skills, were not different between the control and intervention groups. At follow-up stage, compared with the regular group, a higher percentage of intervention group' trainees reported that they are "strongly agree" or "somewhat agree" that the HMD-VR simulation increases their self-efficacy, including the aspects of familiarity and confidence, and reduced their anxiety about tracheostomy-related knowledge and care skills. After implementation, a higher degree of trainees' average satisfaction with VR-based training and VR materials was observed in the intervention group than in the regular group. Most reported that VR materials enabled accurate messaging and decreased anxiety. The increasing trend of the average written test and hands-on tracheostomy care skills scores among the intervention group trainees was significant compared to those in the regular group. The benefits of HMD-VR simulations and web-VR material-based clinical services for in-hospital healthcare providers and patient families persisted until 3 to 4 weeks later. CONCLUSION The current study suggests that VR materials significantly enhance trainees' self-efficacy (increased familiarity, increased confidence, and reduced anxiety) and their satisfaction with the training, while motivating them to use acquired knowledge and skills in clinical practice.
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Affiliation(s)
- Dung-Hung Chiang
- Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, Taipei, Taiwan
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
| | - Chia-Chang Huang
- Faculty of Medicine, Taipei, Taiwan
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
- Medical Innovation Research Office, Clinical Innovation Center, Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shu-Chuan Cheng
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Division of Respiratory Therapy, Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jui-Chun Cheng
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Division of Respiratory Therapy, Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Cheng-Hsien Wu
- Faculty of Medicine, Taipei, Taiwan
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shiau-Shian Huang
- Faculty of Medicine, Taipei, Taiwan
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
- Medical Innovation Research Office, Clinical Innovation Center, Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ying-Ying Yang
- Faculty of Medicine, Taipei, Taiwan
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
- Medical Innovation Research Office, Clinical Innovation Center, Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ling-Yu Yang
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shou-Yen Kao
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Division of Family Dentistry, Department of Stomatology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chen-Huan Chen
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | | | - Fa-Yauh Lee
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
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Variation in UK Deanery publication rates in the British Journal of Oral and Maxillofacial Surgery: where are the current 'hot spots'? Br J Oral Maxillofac Surg 2021; 59:e48-e64. [DOI: 10.1016/j.bjoms.2020.08.090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 08/06/2020] [Indexed: 02/07/2023]
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Littlewood CG, Jebril A, Lowe D, Konig R, Groom P, Rogers SN. Factors contributing to delayed decannulation of temporary tracheostomies following free tissue reconstructive surgery for head and neck cancer. Br J Oral Maxillofac Surg 2020; 59:472-477. [PMID: 33485712 DOI: 10.1016/j.bjoms.2020.09.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 09/15/2020] [Indexed: 11/20/2022]
Abstract
Temporary tracheostomies (TT) are performed to secure the airway perioperatively and postoperatively in head and neck cancer patients undergoing tumour resection and free tissue reconstructive surgery. Patients report that having a TT is unpleasant and they appreciate its removal at the earliest opportunity. Early removal not only improves patient satisfaction but should allow for a more rapid recovery. The aim of this prospective study was to assess factors that contribute to delays in decannulation following TT and hence to provide an insight into the factors that will support earlier decannulation when it is safe to do so. Consecutive patients who had TT over a six-month period were included. Delayed decannulation was defined as that after day seven postoperatively. There were 42 patients with a median (IQR) age of 70 (60-74) years, 26 of whom were men. The tracheostomy was surgical in 29 and percutaneous in 13. The median (IQR) time to decannulation was 4 (3-5) days (range 1-11 days). Seven patients had delayed removal (7-11 days), the reasons being hospital-acquired pneumonia (HAP) (n=4), prolonged stay in the high dependency unit (HDU) following postoperative myocardial infarction and cardiac arrest (n=1), failure to tolerate TT occlusion (n=1), and not stated (n=1). There were early postoperative complications in 14 patients but despite this seven decannulations were still performed within two and six days. Additional multiprofessional assessment over weekends is likely to facilitate earlier decannulation. As some TTs are removed after a few days there is a need for better selection to avoid their use in certain patients.
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Affiliation(s)
- C G Littlewood
- Department of Medical Education, University Hospital Aintree, Liverpool, L9 1AE, UK.
| | - A Jebril
- Regional Maxillofacial Unit, University Hospital Aintree, Liverpool, L9 1AE, UK.
| | - D Lowe
- Evidence-Based Practice Research Centre (EPRC), Faculty of Health, Edge Hill University, St Helens Road, Ormskirk, L39 4QP.
| | - R Konig
- Anaesthesia and Theatres Department, Aintree University Hospital NHS Foundation Trust, Liverpool, UK.
| | - P Groom
- Anaesthesia and Theatres Department, Aintree University Hospital NHS Foundation Trust, Liverpool, UK.
| | - S N Rogers
- Faculty of Health and Social Care, Edge Hill University, Ormskirk, L39 4QP; Liverpool Head and Neck Centre, Liverpool University Hospital Aintree, Liverpool, UK.
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Pilot of the Patient Concerns Inventory - Ward Discharge in Patients following major reconstructive surgery for head and neck cancer. Br J Oral Maxillofac Surg 2020; 59:425-432. [PMID: 33789810 PMCID: PMC7441974 DOI: 10.1016/j.bjoms.2020.08.080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 08/12/2020] [Indexed: 11/25/2022]
Abstract
Planning discharge from hospital following microvascular free-tissue surgery can be complex and challenging. Planning involves the patient, carers and multiple health professionals. Poor communication and expectations can delay discharge or give a suboptimal discharge process. It was hypothesised that prompt-list modelled along the principals of the Patient Concerns Inventory (PCI) could be help in discharge planning. The aim of this study was to define the items and format of a PCI-Ward Discharge (PCI-WD) and undertake a small pilot. Items appropriate for the PCI-WD were formulated through discussion with patients, carers, ward staff, Head and Neck Clinical Nurse Specialists, and clinicians. The pilot took place over 3 months from December 2019 through February 2020. Audit approval was given by the hospital Audit Department. The PCI-WD comprises 43 items. Items from existing PCIs for use at diagnosis and follow-up consultations were reduced in number and 38 new or modified items added; 6 treatment related, 5 social care and social well-being, 4 psychological, emotional and spiritual well-being, 7 physical and functional well-being and 16 discharge related. The pilot involved 14 free-tissue transfer patients, 7 male, 7 female, with age range 57 to 87 and average age 72. Eight PCI-WD were returned. PCI-WD items identified most frequently were ‘surgery site other than head/neck’, ‘when do I come back to hospital’, ‘dental check-up/oral health care’ and ‘diet/eating’. Early findings suggest that PCI-WD could be a useful tool in aiding the discharge process. Further evaluation is required.
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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: 3] [Impact Index Per Article: 0.8] [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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Gigliotti J, Cheung G, Suhaym O, Agnihotram RV, El-Hakim M, Makhoul N. Nasotracheal Intubation: The Preferred Airway in Oral Cavity Microvascular Reconstructive Surgery? J Oral Maxillofac Surg 2018; 76:2231-2240. [DOI: 10.1016/j.joms.2018.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 03/31/2018] [Accepted: 04/02/2018] [Indexed: 11/28/2022]
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Nazir H, Lowe D, Rogers S. Patients’ experience of the monitoring of free flaps after reconstruction for oral cancer. Br J Oral Maxillofac Surg 2017; 55:1008-1012. [DOI: 10.1016/j.bjoms.2017.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 10/09/2017] [Indexed: 11/27/2022]
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Rogers SN, Barber B. Using PROMs to guide patients and practitioners through the head and neck cancer journey. PATIENT-RELATED OUTCOME MEASURES 2017; 8:133-142. [PMID: 29184455 PMCID: PMC5687779 DOI: 10.2147/prom.s129012] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The measurement of patient-reported outcome measures (PROMs) following head and neck cancer (HNC) has the capacity to substantially enhance the care of patients and their care-givers following the diagnosis and treatment of HNC. Literature concerning PROMs has increased exponentially in the past 2 decades, producing a vast array of data upon which the multidisciplinary team can reflect. For this review, “Handle On QOL” has been used as a source of references to illustrate the points raised. PROMs are contextualized by considering the clinically-distinct key stages that cancer patients endure: diagnosis, treatment, acute toxicity, early recovery, late effects, recurrence, and palliation. The PROMs are considered in six main categories: 1) those addressing cornucopia of issues not specific to cancer; 2) those addressing issues common to all cancers; 3) questionnaires with items specific to HNC; 4) questionnaires that focus on a particular aspect of head and neck function; 5) those measuring psychological concerns, such as depression, anxiety, or self-esteem; and 6) item prompt lists. Potential benefits of PROMs in clinical practice are discussed, as are barriers to use. The way forward in integrating PROMs into routine HNC care is discussed with an emphasis on information technology.
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Affiliation(s)
- Simon N Rogers
- Evidence-Based Practice Research Centre (EPRC), Faculty of Health and Social Care, Edge Hill University, Ormskirk, UK.,Regional Maxillofacial Unit, University Hospital Aintree, Liverpool, UK
| | - Brittany Barber
- Head and Neck Department, Icahn School of Medicine at Mount Sinai (MSSM), New York, NY, USA
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Rogers S. Re: Re: Patients experience of temporary tracheostomy after microvascular reconstruction for cancer of the head and neck. Br J Oral Maxillofac Surg 2017; 55:569. [DOI: 10.1016/j.bjoms.2016.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 12/22/2016] [Indexed: 11/29/2022]
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Garcia-Rodriguez L, Miah T, Lindholm J, Chang S, Ghanem T. EKG Electrode as a Tactile Locator of Stoma after Decannulation: A Pilot Study. OTO Open 2017; 1:2473974X17691223. [PMID: 30480174 PMCID: PMC6239050 DOI: 10.1177/2473974x17691223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 12/08/2016] [Accepted: 01/10/2017] [Indexed: 11/23/2022] Open
Abstract
Objective We aimed to evaluate the use of an electrocardiogram (EKG) electrode over
decannulation dressings covering the stoma to improve speech intelligibility
and volume and reduce air escape by facilitating identification of the
“sweet spot” of the dressing. No objective data exist for patient outcomes
with use of the EKG electrode dressing. Methods This prospective study included head and neck oncology patients at a tertiary
hospital who received a tracheostomy. A standard tracheostomy decannulation
dressing was placed followed by an EKG electrode. A speech pathologist
evaluated speech volume via sound-level meter and captured speech
intelligibility for random sentence-level speech. A blinded reviewer scored
speech samples for intelligibility. Patients completed a 4-question
satisfaction survey. Results Four patients completed the study. Based on the survey, the patients favored
the button, with the lowest scores being 8.5 out of 10. Speech understanding
was 48.5% without the button and 83% with the button. Normal speech volume
was 73.75 dB without the button and 77.75 dB with the button. Loud speech
volume was 80.75 dB without the button and 87 dB with the button. Discussion This pilot study shows objective benefits of the EKG button as well as
improved patient satisfaction. Inexpensive and low maintenance, the EKG
electrode provides better occlusion of stoma dressing with easier
localization. Implications for Practice Dissemination of our results will aim to improve quality and patient outcomes
following decannulation.
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Affiliation(s)
- Laura Garcia-Rodriguez
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Tayaba Miah
- Wayne State University, School of Medicine, Detroit, Michigan, USA
| | - Jamie Lindholm
- Department of Neurology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Steven Chang
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Tamer Ghanem
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Hospital, Detroit, Michigan, USA
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