Comparison of postoperative cardiopulmonary examinations and chest radiographs to detect pulmonary complications after adult tracheotomy

Effects of nursing intervention on lung infection prevention in patients with tracheotomy

BACKGROUND

This study will evaluate the effects of nursing intervention (NIV) on lung infection prevention (LIP) in patients with tracheotomy.

METHODS

The electronic databases of MEDLINE, Cochrane Library, EMBASE, Web of Science, Chinese Biomedical Literature Database, and China National Knowledge Infrastructure will be retrieved from inception to the June 1, 2019 for randomized controlled trials investigating the effects of NIV on LIP in patients with tracheotomy without any language limitations. In addition, we will also search grey literature to avoid missing any potential studies. Two independent authors will perform study selection, data extraction, and risk of bias evaluation.

RESULTS

This study will investigate the effects of NIV on LIP in patients with tracheotomy. The primary outcome is incidence of lung infection. The secondary outcomes include pulmonary function, quality of life, and complications post-surgery.

CONCLUSION

The results of this study will summarize recent evidence for the effects of NIV on LIP in patients with tracheotomy.No ethic approval is needed in this study, because it will not need any individual data. The results of this study will be published at a peer-reviewed journal.

Is routine chest X-ray after surgical and percutaneous tracheostomy necessary in adults: a systemic review of the current literature

BACKGROUND

For many years, routine post-tracheostomy chest X-ray has been the standard of care for patients in many countries. However, recent evidence suggests that this is unnecessary and cost-ineffective.

OBJECTIVE

To review the current literature and examine the role of routine post-tracheostomy chest X-ray in adult patients.

TYPE OF REVIEW

Systemic review.

SEARCH STRATEGY

Electronic databases (PubMed, EMBASE, Cochrane) were searched using the keywords 'chest X-ray/radiography/radiograph' and 'tracheostomy/tracheotomy' in various permutations. Search period ranged from 1960 to 2012. Inclusion criteria included systematic reviews, meta-analyses, randomised control trials, prospective and retrospective case series. Paediatric and non-English articles were excluded. Abstracts and subsequently full text articles were screened by two of the authors independently. References from obtained articles were also examined.

EVALUATION METHOD

Specific outcome measures were collated to evaluate the usefulness of post-tracheostomy chest X-ray: Chest X-ray detected (tracheostomy-related) complication rates Proportion of cases requiring significant intervention Potential predictors of complications

RESULTS

Routine post-tracheostomy chest X-ray is of a low yield, and its findings had limited impact on patient management. Complication detection rates for surgical and percutaneous tracheostomy are 2.2% and 3.2%, respectively. Only 0.7% and 1.8% of chest X-rays performed in surgical and percutaneous tracheostomy cases, respectively, required intervention. Certain groups of patients, however, are at higher risks of complications, and may benefit from post-tracheostomy chest X-ray. For surgical tracheostomy, these groups include those with post-operative signs and symptoms of complications or had emergent or 'difficult' tracheostomies. For percutaneous tracheostomy, high-risk patients include trauma cases (unspecified), patients with post-procedural signs and symptoms of complications, patients who have high ventilatory requirements, difficult tracheostomy cases or tracheostomy cases performed without bronchoscopic guidance.

CONCLUSION

The practice of routine post-tracheostomy chest X-ray is debatable owing to its low yield and minimal impact on clinical management. However, certain groups of patients appear to be at higher risks of post-tracheostomy complications; currently, there is insufficient evidence to conclude the absolute need for routine chest X-ray in these groups of patients, although it may be prudent to do so based on available evidence in the literature and logical clinical reasoning.

Utility of routine postoperative chest radiography in pediatric tracheostomy

OBJECTIVES

Routine chest radiography following pediatric tracheostomy is commonly performed in order to evaluate for air-tracking complications. Routine chest radiography affords disadvantages of radiation exposure and cost. The primary objective of this study was to determine the utility of routine postoperative chest radiography following tracheostomy in pediatric patients. Secondary objectives were to compare the rates of postoperative complications by various patient and surgeon characteristics.

METHODS

All infants and children 18 years of age or less (n=421) who underwent tracheostomy at a single tertiary-care medical center from January 2000 to April 2009 were included in the study. A combination of data obtained from billing and administrative systems and review of electronic medical records were recorded and compiled in a database for statistical analysis.

RESULTS

Three air-tracking complications (2 pneumothoraces and 1 pneumomediastinum) were identified in our population of 421 pediatric patients, for an incidence of 0.71% (95% CI: 0.1-2.0%). No significant relationships were found between the incidence of air-tracking complication and surgical specialty, patient age, or type of procedure (elective, urgent/emergent).

CONCLUSIONS

Our study identified a low rate of pneumothorax and pneumomediastinum following pediatric tracheostomy. In all three cases, the pneumothorax was suspected clinically. This finding suggests that postoperative chest radiography should be reserved for cases where there is suspicion of a complication on the basis of intraoperative findings or clinical parameters.

Routine Chest X-ray after Percutaneous Tracheostomy is Unnecessary

Percutaneous tracheostomy (PT) is an increasingly common procedure in the management of critically ill patients. Current practice for both open and percutaneous tracheostomies is a post-procedure chest X-ray to rule out potentially life-threatening complications such as a pneumothorax or tube malposition. Our study evaluated the utility of chest X-ray after PT. A retrospective chart review was conducted for patients undergoing PT at Kern Medical Center between January 1999 and December 2003. Charts were reviewed for age, sex, and clinical outcome as well as the radiologist's interpretation of the postprocedure chest X-ray. A total of 73 procedures were completed in 47 men and 26 women. The majority of the tracheostomies were in trauma patients who needed prolonged ventilatory support. There were no complications identified on postprocedure chest X-ray. A single patient was converted to an open procedure secondary to bleeding. We conclude that routine chest X-ray after PT is unnecessary.

The Utility of Routine Chest Radiography Following Jet Ventilation in Elective Laryngotracheal Surgery

OBJECTIVES/HYPOTHESIS

Jet ventilation is a useful mode of airway management for laryngotracheal surgery. The objective of this study is to evaluate the utility of routine chest radiography following jet ventilation for these cases.

STUDY DESIGN

Retrospective chart review.

METHODS

Thirty-four elective surgical procedures performed from 1998 to 2002 are reviewed for postoperative airway and pulmonary complications. Data were collected from clinical notes as well as from the results of chest radiographs. This included the need for tracheotomy, reintubation, pneumothorax, pneumomediastinum, and atelectasis.

RESULTS

A retrospective chart examination revealed no major complications. Twenty-nine of the 34 cases had postoperative chest radiography (CXR) performed on a routine basis. Atelectasis was present in 12 of 29 CXR (41%); no intervention was required in these cases.

CONCLUSIONS

Routine postoperative CXR may not be useful following jet ventilation for elective laryngotracheal surgery. The safety of jet ventilation is discussed.

Routine Chest Radiograph is not Indicated after Open Tracheostomy: A Multicenter Perspective

Obtaining a chest radiograph (CXR) after open tracheostomy has been standard practice for many surgeons. We hypothesized that routine CXR after uncomplicated open tracheostomy is unnecessary. A prospective multicenter protocol was carried out on adult surgical patients undergoing uncomplicated tracheostomy. CXR was not routinely ordered in the immediate postoperative period but was obtained only for clinical indications. Preoperative and subsequent postoperative CXRs were reviewed for evidence of complications. Twenty-two surgeons at four institutions performed 151 tracheostomies. Posttracheostomy CXR was not diagnostic in four patients with potential tracheostomy-related complications (i.e., tachypnea, tachycardia, desaturation, and elevated peak airway pressure). In the 147 patients without clinical indications for CXR subsequent CXR revealed no significant new findings. In this era of cost containment the need for CXR after tracheostomy must be questioned. Routine CXR is not indicated or cost effective after uncomplicated open tracheostomy in adults.

Lack of utility of postoperative chest radiograph in pediatric tracheotomy

OBJECTIVE

To assess the incidence of pulmonary complications after nonemergent pediatric tracheotomy and to determine whether obtaining a routine postoperative chest radiograph is warranted.

STUDY DESIGN

Retrospective review of the records of 107 consecutive patients (age 1 month to 18 years) who underwent tracheotomy from October 1994 to June 2000. Main outcome measures included frequency of pulmonary complications and use of information obtained from postoperative chest radiograph for intervention.

SETTING

Tertiary care university children's hospital.

RESULTS

No pneumothoraces or significant pulmonary complications were detected in the immediate postoperative period. No management changes were undertaken as a result of information obtained from any chest radiograph in this period.

CONCLUSIONS

The incidence of significant pulmonary complications after pediatric tracheotomy is low. Little information is obtained from chest radiograph after tracheotomy, and this information does not change management.

SIGNIFICANCE

Routine postoperative chest radiograph after pediatric tracheotomy is not indicated in all patients.

The role of postoperative chest radiography in pediatric tracheotomy

A postoperative chest radiograph has traditionally been obtained after tracheotomies to evaluate for the presence of a pneumothorax and to assess tube position. Several recent studies in adults have questioned the usefulness of routine postoperative chest radiography in uncomplicated cases, but the role of post-operative chest radiography in pediatric patients has not been previously reviewed. We performed this study to examine the clinical utility of post-tracheotomy chest radiography in pediatric patients and determine if this routine practice impacts patient management enough to merit continued usage. A retrospective review was performed of 200 consecutive pediatric patients who underwent tracheotomies by the otolaryngology service in a tertiary care pediatric hospital from January 1994 to June 1999. All patients received postoperative chest radiographs. Five of 200 patients had a new postoperative radiographic finding, with three requiring interventions. Two patients required chest tube placement for pneumothorax, and one patient required tracheostomy tube change for repositioning. Fifty-one patients, including both pneumothoraces, exhibited clinical signs of pneumothorax (decreased breath sounds or oxygen saturation) in the immediate postoperative period. Chest X-ray ruled out a pneumothorax in the remaining 49 patients. The majority of these 51 patients were less than 2 years old (94%, P=0.002) or weighed less than 17 kg (89%, P=0.004). Postoperative chest X-rays yielded clinically relevant information in 168 patients that fell into one or more of four high risk categories: age less than 2, weight less than 17 kg, emergent procedures, or concomitant central line placement. Avoiding chest X-rays in the remaining 32 patients would have resulted in potential savings of $5000, which does not reflect the actuarial cost of a missed complication. Since the majority of our patients (84%) fell into a high-risk category, we feel it would be prudent to continue obtaining postoperative chest radiographs following all pediatric tracheotomies.

Chest radiographs after dilatational percutaneous tracheotomy: are they necessary?

BACKGROUND

The efficacy of routinely obtaining chest radiographs after standard open tracheotomy has been questioned. Recent literature would suggest that after a routine, uncomplicated tracheotomy, chest radiography is a low-yield procedure that incurs unnecessary expense. Percutaneous dilatational tracheotomy (PDT) is rapidly replacing open tracheotomy as the intensive care unit procedure of choice for airway management. Complication rates are equivalent between the two procedures.

OBJECTIVE

We examined the value and cost-effectiveness of routine postoperative chest radiographs in patients undergoing PDT.

STUDY DESIGN AND SETTING

The study was a prospective analysis of 54 consecutive PDTs performed at a tertiary care academic institution.

RESULTS

Eighteen (33%) patients had chest radiographs obtained within 1 hour of PDT (6 at the request of the otolaryngology service); 35 (66%) underwent radiography more than 2 hours later at the request of the intensive care unit for reasons other than PDT. There were no incidents of pneumothorax, pneumomediastinum, or tracheotomy tube malposition in any patient. Patients undergoing chest radiography within 1 hour of the PDT also had chest radiographs within 12 hours at the request of ICU staff for their underlying disease.

CONCLUSIONS

Routine chest radiography after PDT is of low yield. Because most of these patients require chest radiographs for their underlying disease within 12 hours, a cost savings of approximately $13,500 would be realized in this patient population.

SIGNIFICANCE

Routine chest radiography after PDT is unwarranted in most cases.