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Kizhner V, Richard B, Robert L. Percutaneous tracheostomy boundaries revisited. Auris Nasus Larynx 2015; 42:39-42. [DOI: 10.1016/j.anl.2014.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 08/11/2014] [Accepted: 08/13/2014] [Indexed: 10/24/2022]
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Cools-Lartigue J, Aboalsaud A, Gill H, Ferri L. Evolution of percutaneous dilatational tracheostomy--a review of current techniques and their pitfalls. World J Surg 2014; 37:1633-46. [PMID: 23571862 DOI: 10.1007/s00268-013-2025-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Tracheostomy is the most commonly performed surgical procedure in critically ill patients with acute respiratory failure. While few absolute indications exist, this procedure is widely used in patients with upper respiratory obstruction and those requiring long-term mechanical ventilation. The traditional approach to tracheostomy has been an open procedure performed in the operating room. This method is associated with an increased rate of complications and costs. Accordingly, percutaneous bedside tracheostomy procedures have largely replaced the traditional operative approach at many institutions. Numerous methods for percutaneous tracheostomy have thus emerged. However, the benefits of one technique versus another have not been well demonstrated. In this article, we review the evidence supporting the use of percutaneous tracheostomy procedures over the traditional operative approach. Furthermore, we review the currently available and emerging methods by which percutaneous tracheostomy can be performed. In addition, we highlight the available evidence concerning the safety and complication rates of each technique.
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Affiliation(s)
- Jonathan Cools-Lartigue
- LD MacLean Surgical Research Laboratories, Department of Surgery, Montreal General Hospital, McGill University, 1650 Cedar Avenue, L9-112, Montreal, QC, H3G 1A4, Canada
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Ikegami Y, Iseki K, Nemoto C, Tsukada Y, Shimada J, Tase C. Patient questionnaire following closure of tracheotomy fistula: percutaneous vs. surgical approaches. J Intensive Care 2014; 2:17. [PMID: 25908982 PMCID: PMC4407319 DOI: 10.1186/2052-0492-2-17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 02/12/2014] [Indexed: 11/21/2022] Open
Abstract
Background Tracheotomy is an indispensable component in intensive care management. Doctors in charge of the intensive care unit (ICU) usually decide whether tracheotomy should be performed. However, long-term follow-up of a closed fistula by these doctors is rarely continued in most cases. Doctors in charge of the ICU should be interested in the long-term prognosis of tracheotomy. The purpose of this study was to evaluate whether different tracheotomy procedures affect the long-term outcome of a closed tracheal fistula. Methods We mailed questionnaires to patients undergoing tracheotomy in Fukushima Medical University Hospital between January 2008 and December 2010. Questions concerned problems related to perception, laryngeal function, and the appearance of a closed fistula. Patients were classified into percutaneous tracheotomy (PT) group and surgical tracheotomy (ST) group. We evaluated the statistical significance of differences in the frequency and degree of each problem between the two groups. A door-to-door objective evaluation using the original scoring system was then performed for patients who replied to the mailed questionnaire. We evaluated the percentage of patients with high scores as well as the mean scores for problems with function and appearance. Results We received completed questionnaires from 28/40 patients in the PT group and 35/55 patients in the ST group. There were no significant differences in age, mean hospital stay, or APACHE II score between the groups. Regarding problems with appearance, the outcomes of PT were significantly better than those of ST with respect to self-evaluation (p = 0.04) and the frequency (p = 0.03) and degree (p = 0.02) of scar unevenness according to door-to-door evaluation. However, there were no significant differences in the frequency or degree of self-evaluation in problems with perception and function between the two groups. There were no significant differences in the frequency or degree of door-to-door evaluation of problems with function. Conclusions This study shows that PT might be superior to ST with respect to problems with long-term appearance. Continuous follow-up of closed tracheal fistulas can help assure that patients recovering from a critical condition experience a better return to their former lives. A systematic follow-up of post-critical-care patients is required.
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Affiliation(s)
- Yukihiro Ikegami
- Department of Emergency and Critical Care Medicine, School of Medicine, Fukushima Medical University, 1 Hikarigaoka, Fukushima, 960-1295 Japan
| | - Ken Iseki
- Department of Emergency and Critical Care Medicine, School of Medicine, Fukushima Medical University, 1 Hikarigaoka, Fukushima, 960-1295 Japan
| | - Chiaki Nemoto
- Department of Emergency and Critical Care Medicine, School of Medicine, Fukushima Medical University, 1 Hikarigaoka, Fukushima, 960-1295 Japan
| | - Yasuhiko Tsukada
- Department of Emergency and Critical Care Medicine, School of Medicine, Fukushima Medical University, 1 Hikarigaoka, Fukushima, 960-1295 Japan
| | - Jiro Shimada
- Department of Emergency and Critical Care Medicine, School of Medicine, Fukushima Medical University, 1 Hikarigaoka, Fukushima, 960-1295 Japan
| | - Choichiro Tase
- Department of Emergency and Critical Care Medicine, School of Medicine, Fukushima Medical University, 1 Hikarigaoka, Fukushima, 960-1295 Japan
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Safety, efficiency, and cost-effectiveness of a multidisciplinary percutaneous tracheostomy program. Crit Care Med 2012; 40:1827-34. [PMID: 22610187 DOI: 10.1097/ccm.0b013e31824e16af] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The frequency of bedside percutaneous tracheostomies is increasing in intensive care medicine, and both safety and efficiency of care are critical elements in continuing success of this procedure. Prioritizing patient safety, a tracheostomy team was created at our institution to provide bedside expertise in surgery, anesthesiology, respiratory, and technical support. This study was performed to evaluate the metrics of patient outcome, efficiency of care, and cost-benefit analysis of the multidisciplinary Johns Hopkins Percutaneous Tracheostomy Program. DESIGN A review was performed for patients who received tracheostomies in 2004, the year before the Johns Hopkins Percutaneous Tracheostomy Program was established, and those who received tracheostomies in 2008, the year following the program's establishment. Comparative outcomes were evaluated, including the efficiency of procedure and intensive care unit length of stay, complication rate including bleeding, hypoxia, loss of airway, and a financial cost-benefit analysis. SETTING Single-center, major university hospital. PATIENTS The sample consisted of 363 patients who received a tracheostomy in the years 2004 and 2008. MEASUREMENTS AND MAIN RESULTS The number of percutaneous procedures increased from 59 of 126 tracheostomy patients in 2004, to 183 of 237 in 2008. There were significant decreases in the prevalence of procedural complications, particularly in the realm of airway injuries and physiologic disturbances. Regarding efficiency, the structured program reduced the time to tracheostomy and overall procedural time. The intensive care unit length of stay in nonpulmonary patients and improvement in intensive care unit and operating room back-fill efficiency contributed to an overall institutional financial benefit. CONCLUSIONS An institutionally subsidized, multi-disciplinary percutaneous tracheostomy program can improve the quality of care in a cost-effective manner by decreasing the incidence of tracheostomy complications and improving both the time to tracheostomy, duration of procedure, and postprocedural intensive care unit stay.
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Pandian V, Miller CR, Mirski MA, Schiavi AJ, Morad AH, Vaswani RS, Kalmar CL, Feller-Kopman DJ, Haut ER, Yarmus LB, Bhatti NI. Multidisciplinary Team Approach in the Management of Tracheostomy Patients. Otolaryngol Head Neck Surg 2012; 147:684-91. [DOI: 10.1177/0194599812449995] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective To examine whether the implementation of a multidisciplinary percutaneous tracheostomy team decreases complications, improves efficiency in patient care, and reduces length of stay and cost in patients undergoing percutaneous tracheostomy. Study Design Case series with planned data collection. Setting Urban, academic, tertiary care medical center. Subjects and Methods Patients who underwent a percutaneous tracheostomy in 2004 and 2008, before and after the formation of a multidisciplinary percutaneous tracheostomy team, were included in the study. Data for the study were retrieved from a tracheostomy database. Measured outcomes include complications, efficiency, length of stay, and cost. Results Complications such as airway bleeding and physiological disturbances decreased significantly in 2008 as compared with 2004. The percentage of patients who received a tracheostomy within 2 days increased from 42.3% to 92% (2004 vs 2008), showing improvement in efficiency of care. There was no significant difference between the groups in terms of infection rate, length of stay, or mortality. However, in a subanalysis, the length of stay was found to be decreased in patients whose primary diagnosis was a neurological disorder. Finally, despite the necessity of a hospital-based subsidy, the team approach yielded substantial financial benefit to the medical center. Conclusions Airway bleeding, physiological disturbances, and efficiency of care improved after the institution of a multidisciplinary percutaneous tracheostomy team approach and may have a favorable impact on health care costs.
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Affiliation(s)
- Vinciya Pandian
- Percutaneous Tracheostomy Service, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Christina R. Miller
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Marek A. Mirski
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Adam J. Schiavi
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Athir H. Morad
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Ravi S. Vaswani
- Percutaneous Tracheostomy Service, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Christopher L. Kalmar
- Percutaneous Tracheostomy Service, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - David J. Feller-Kopman
- Department of Pulmonary and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Elliott R. Haut
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
- Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Lonny B. Yarmus
- Department of Pulmonary and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Nasir I. Bhatti
- Department of Otolaryngology Head and Neck Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Kornblith LZ, Burlew CC, Moore EE, Haenel JB, Kashuk JL, Biffl WL, Barnett CC, Johnson JL. One thousand bedside percutaneous tracheostomies in the surgical intensive care unit: time to change the gold standard. J Am Coll Surg 2010; 212:163-70. [PMID: 21193331 DOI: 10.1016/j.jamcollsurg.2010.09.024] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Revised: 09/22/2010] [Accepted: 09/22/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Bedside percutaneous tracheostomy (BPT) is a cost-effective alternative to open tracheostomy. Small series have consistently documented minimal morbidity, but BPT has yet to be embraced as the standard of care. Because this has been our preferred technique in the surgical ICU for more than 20 years, we reviewed our experience to ascertain its safety. We hypothesize that BPT has acceptably minimal morbidity, even in high-risk patients. STUDY DESIGN Patients undergoing BPT from January 1998 to June 2008 were reviewed. High-risk patients were defined as those with cervical collar or halo, cervical spine injuries, systemic heparinization, positive end-expiratory pressure >10 cm H(2)O or fraction of inspired oxygen > 50%. RESULTS During the study period, 1,000 patients underwent BPT (74% men; mean ± SEM age 46 ± 0.6 years; 70% trauma). BPT was performed 8.9 ± 0.2 days (mean ± SEM) after admission. Patients remained ventilator dependent for an additional 9.7 ± 0.4 days (mean ± SEM). There were 482 (48%) patients undergoing BPT who were considered high-risk: 1 risk category, 273 patients; 2 risk categories, 139 patients; 3 risk categories, 56 patients; 4 risk categories, 12 patients; 5 risk categories, 2 patients. Complications occurred in 14 (1.4%) patients. Early complications included tracheostomy tube misplacement requiring revision (n = 4), bleeding requiring intervention (n = 2), infection (n = 1), and procedure failure requiring cricothyroidotomy (n = 1). Late complications included persistent stoma requiring operative closure (n = 4) and subglottic stenosis (n = 2). There were 6 complications (1.2%) in normal risk and 8 complications (1.7%) in high-risk patients. There were no deaths related to BPT. CONCLUSIONS BPT in the surgical intensive care unit is a safe procedure, even in high-risk patients. We believe BPT is the new gold standard for patients requiring tracheostomy for mechanical ventilation.
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Affiliation(s)
- Lucy Z Kornblith
- Department of Surgery, Denver Health Medical Center and theUniversity of Colorado, Denver, CO, USA
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Who is performing percutaneous tracheotomies? Practice patterns of surgeons in the USA. Eur Arch Otorhinolaryngol 2010; 268:415-8. [DOI: 10.1007/s00405-010-1406-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Accepted: 10/07/2010] [Indexed: 11/25/2022]
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Cianchi G, Zagli G, Bonizzoli M, Batacchi S, Cammelli R, Biondi S, Spina R, Peris A. Comparison between single-step and balloon dilatational tracheostomy in intensive care unit: a single-centre, randomized controlled study. Br J Anaesth 2010; 104:728-32. [PMID: 20413380 DOI: 10.1093/bja/aeq087] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Balloon dilatational tracheostomy using the Ciaglia Blue Dolphin device has recently been introduced as a modification of the Ciaglia technique. The aim of this study was to compare the new Dolphin system with the single-step dilatational tracheostomy (Ciaglia Blue Rhino) in intensive care unit (ICU) patients. METHODS Consecutive patients admitted to the ICU of the Emergency Department (Careggi Teaching Hospital, Florence, Italy) from January 2009 to October 2009, aged >18 years and with an indication for percutaneous dilatational tracheostomy (PDT), were enrolled. Exclusion criteria were infection/injury/malignancy of the neck, thyroid gland hypertrophy, severe head injury with uncontrolled intracranial hypertension, and coagulopathy. Patients were randomly assigned to undergo PDT using either the Ciaglia Blue Rhino (n=35) or the Ciaglia Blue Dolphin technique (n=35). Groups were compared according to tracheal puncture, tracheal tube placement time, procedure-related complications, and bleeding. RESULTS Baseline clinical data were comparable between the two groups. Median procedure time was significantly shorter in the Rhino group compared with the Dolphin group (1.5 vs 4 min, P = 0.035). The presence of limited intra-tracheal bleeding at bronchoscopy examination after 6 h from PDT was more frequent in the Dolphin group than in the Rhino group patients (68.6% vs 34.3%, respectively, P = 0.008). No major bleeding occurred in either group. CONCLUSIONS PDT using the Ciaglia Blue Dolphin technique is a feasible and viable option in ICU patients, but the Rhino technique had a shorter execution time and seemed to be associated with fewer tracheal injuries.
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Affiliation(s)
- G Cianchi
- Anesthesia and Intensive Care Unit of Emergency Department, Careggi Teaching Hospital, Florence, Italy
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Early tracheostomy in intensive care unit: a retrospective study of 506 cases of video-guided Ciaglia Blue Rhino tracheostomies. ACTA ACUST UNITED AC 2010; 68:367-72. [PMID: 20154550 DOI: 10.1097/ta.0b013e3181a601b3] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Percutaneous dilatational tracheostomy (PDT) is a common procedure in critically ill patients, but the correct timing is still controversial. This study was designed to establish whether an early timing in video-guided Ciaglia Blue Rhino PDT affects the duration of mechanical ventilation (MV) and the length of stay (LOS) in intensive care unit (ICU). Secondary clinical outcomes were the overall hospitalization duration and the mortality rate. METHODS A retrospective, single-center study of 2,210 patients admitted to the ICU of the Emergency Department of the Careggi Teaching Hospital (Florence, Italy) between 2002 and 2007. Among the 506 patients who underwent PDT, 256 and 250 patients were retrospectively assigned to the early tracheostomy (ET) or late tracheostomy (LT) group according to whether the procedure was performed before (ET) or after (LT) 3 days of MV (median time of procedure execution). RESULTS The two groups of patients showed comparable demographic and clinical characteristics. The video-guided PDT procedures were performed without major complications in all cases. The average timing of tracheostomy in the ET group was 1.9 +/- 0.9 days, whereas in LT group resulted 6.8 +/- 3.8 days (mean +/- SD). Total hospital LOS and mortality rate were not different between the two groups. However, the duration of MV days and of ICU LOS group were significantly shorter in the ET group (13.3 +/- 9.6 and 16.9 +/- 13.0 days, respectively; p = 0.0001) than in the LT group (16.7 +/- 8.3 days and 20.8 +/- 9.2 days, respectively; p < 0.0001). Stratified analysis by the three major ICU admission diagnosis confirmed that both traumatized and nontraumatized (medical and postsurgical) ET patients had a shorter MV duration and ICU LOS as compared with LT patients. CONCLUSIONS Video-guided Ciaglia Blue Rhino PDT is safe and easy to perform in ICU. No difference in overall hospital LOS, incidence of pneumonia, and mortality rate between the ET and LT groups was found. However, in both traumatized and nontraumatized patients, shortened duration of ICU LOS and MV in the ET group (<or=3 days) indicates this procedure as a useful approach for patients and healthcare system.
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Luna Azoulay B, Béquignon A, Babin E, Moreau S. [Preliminary results of percutaneous tracheotomies]. ACTA ACUST UNITED AC 2009; 126:125-32. [PMID: 19464672 DOI: 10.1016/j.aorl.2009.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2008] [Accepted: 04/14/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Percutaneous tracheotomy (PT) is an alternative to surgical tracheotomy (ST). We describe our procedure and discuss the current status of PT through a retrospective study of our first 30 cases. MATERIAL AND METHODS Thirty patients had a PT between October 2006 and March 2008 in the intensive care units of Caen University Hospital (France). Twenty-eight were done with the Ciaglia Blue Rhino (CBR) and two with the Percutwist. Each PT was endoscopically guided. We retrospectively collected preoperative data and most of the intraoperative as well as early postoperative complications. RESULTS No death was reported with the PT application. Twenty-two (73.3%) PTs had neither preoperative nor early postoperative complications. Eight complications were observed, half preoperative and half early postoperative. The most frequent complication was minor bleeding in three cases (10%), the most important one was the intraoperative appearance of a tracheoesophageal fistula with the CBR. DISCUSSION The principal advantages of PT are safety attributable to simultaneous endoscopic guidance as well as shorter operative time and lower cost in comparison with the ST technique. CONCLUSION PT is a safe and valid alternative procedure to ST. Initially performed by intensivists, it should be part of the ENT/head and neck surgeon's repertory as the upper airway specialist.
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Affiliation(s)
- B Luna Azoulay
- Service d'ORL et de chirurgie cervicofaciale, CHU de Caen, avenue de la Côte-de-Nacre, 14000 Caen, France.
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Goldenberg D, Park SS, Carr M. Percutaneous tracheotomy in otolaryngology-head and neck surgery residency training programs. Laryngoscope 2009; 119:289-92. [DOI: 10.1002/lary.20080] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Pandian V, Nguyen TT, Mirski M, Bhatti NI. Percutaneous Tracheostomy: A Multidisciplinary Approach. ACTA ACUST UNITED AC 2008. [DOI: 10.1044/vvd18.2.87] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
The techniques of performing a tracheostomy has transformed over time. Percutaneous tracheostomy is gaining popularity over open tracheostomy given its advantages and as a result the number of bedside tracheostomies has increased necessitating the need for a Percutaneous Tracheostomy Program. The Percutaneous Tracheostomy Program at the Johns Hopkins Hospital is a comprehensive service that provides care to patients before, during, and after a tracheostomy with a multidisciplinary approach aimed at decreasing complications. Education is provided to patients, families, and health-care professionals who are involved in the management of a tracheostomy. Ongoing prospective data collection serves as a tool for Quality Assurance.
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Affiliation(s)
- Vinciya Pandian
- Percutaneous Tracheostomy Service, Johns Hopkins Medical Institutions Baltimore, MD
| | - Thai Tran Nguyen
- Anesthesia and Critical Care Medicine, Johns Hopkins Medical Institutions Baltimore, MD
| | - Marek Mirski
- Percutaneous Tracheostomy Service, Johns Hopkins Medical Institutions Baltimore, MD
| | - Nasir Islam Bhatti
- Otolaryngology, Head and Neck Surgery, Johns Hopkins Medical Institutions Baltimore, MD
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