Percutaneous dilatational tracheostomy: results and long-term outcome of critically ill patients following cardiac surgery

Long-term laryngotracheal complications following cardiac surgery

BACKGROUND AND AIM OF THE STUDY

Long-term laryngotracheal complications have not been described in adult patients undergoing cardiac surgery. The purpose of this study was to determine the incidence of and risk factors for laryngotracheal complications following cardiac surgery.

METHODS

A retrospective chart review of patients at high risk for laryngotracheal complications following cardiac surgery between 2006 and 2016 was performed. High-risk patients were reviewed to determine the presence of laryngotracheal complications including laryngotracheal stenosis, keyhole deformity, or vocal cord immobility. Logistic regression was used to identify predictors of long-term laryngotracheal complications.

RESULTS

Of 11,417 patients who underwent cardiac surgery, 1099 were identified as at high risk. Of these, 24 (2.2%) developed laryngotracheal complications following their surgery and intensive care unit (ICU) stay. Laryngotracheal stenosis and keyhole deformity were present in 13 (1.2%) and 6 (0.5%) patients, respectively. Logistic regression demonstrated older age (age ≥ 70 odds ratio [OR] 0.31, 95% confidence interval [CI] 0.12-0.83) was protective, while readmission to ICU for ventilation (OR 3.11, 95% CI 1.17-8.25) and receiving a tracheostomy (OR 7.83, 95% CI 2.22-27.6) were associated with laryngotracheal complications.

CONCLUSIONS

The incidence of long-term laryngotracheal complications following cardiac surgery was 2.2%. Readmission to ICU for ventilation and having a tracheostomy performed were associated with laryngotracheal complications.

Comparison of the efficacy of surgical tracheostomy and percutaneous dilatational tracheostomy with flexible lightwand and ultrasonography in geriatric intensive care patients

AIM

To compare the applicability, technical difficulties and postoperative complications of surgical tracheostomy and percutaneous dilatational tracheostomy with the flexible lightwand + ultrasonography method applied because of prolonged intubation to geriatric patients in the intensive care unit.

METHODS

A retrospective evaluation was made of 76 patients who received surgical tracheostomy (group 1) and 78 patients who received percutaneous dilatational tracheostomy (group 2). The patients were evaluated in respect of demographic data, duration of intubation, length of stay in the intensive care unit and discharge status, and after the intervention, the development of tube-related complications, early stage local complications and late-stage complications.

RESULTS

The time from intubation to tracheostomy was determined as 22.73 ± 15.23 days in group 1 and 12.65 ± 7.64 days in group 2. The mortality rate of patients in group 1 was determined to be statistically significantly higher than that of group 2 (P = 0.048). When evaluated in respect to early and late complications, nine early- and seven late-stage complications developed in group 1, and three early- and three late-stage complications developed in group 2 (P = 0.05). In the evaluation of factors related to mortality, the time from intubation to tracheostomy (r = 0.249, P = 0.01) and the presence of a comorbidity (r = 0.325, P = 0.004) were determined to have a positive correlation with the development of mortality.

CONCLUSION

Percutaneous dilatational tracheostomy with the flexible lightwand + ultrasonography technique is a safe, rapid and effective method with the advantage of management in respect to early complications, such as bleeding, and can be used safely in the geriatric patient population in intensive care conditions. Geriatr Gerontol Int 2020; ••: ••-••.

The Effect of Flexible Lightwand and Ultrasonography Combination on Complications of the Percutaneous Dilatational Tracheostomy Procedure

The aim of this study was to evaluate the effect of the flexible lightwand and ultrasonography (USG) combination on reducing the complications in percutaneous dilatational tracheostomy (PDT) opened with the forceps dilatation method. A retrospective examination was made of 138 patients between January 2014 and December 2018. Before starting to process, the anatomic structures of the patients were visualized with USG and the tracheostomy area was marked. Sedation and local anesthesia were applied to patients before the procedure, then the percutaneous tracheostomy was performed using the Griggs technique after confirmation of the tracheostomy localization defined with USG using the transillumination method with a flexible lightwand within an endotracheal tube. Complications that developed associated with the procedure were recorded. The mean age of the patients was 59.1±22.0 years and the mean length of stay in the intensive care unit was 42.3±35.5 days (range, 11-207 days). Overall, complications developed in 22 (15.6%) patients, of which 10.7% were early complications (1.4% related to the tube, 5.8% minor and 3.5% major complications). Tube- related complications were seen to develop in two patients. In the evaluation of the early minor complications, the most frequently seen complication was minor bleeding in 5.8% of the patients. No major vessel bleeding was determined in any patient in the early or late period. Of the late complications, the infection was seen to develop in four (2.8%) patients and stenosis in three (2.1%). The combination of flexible lightwand and USG in the PDT procedure minimized tube-related complications and contributed to the prevention of bleeding complications.

Perioperative management in myasthenia gravis: republication of a systematic review and a proposal by the guideline committee of the Japanese Association for Chest Surgery 2014

Thymectomy is regarded as a useful therapeutic option for myasthenia gravis (MG), though perioperative management in MG patients is largely empirical. While evidence-based medicine is limited in the perioperative management of MG patients, treatment guidelines are required as a benchmark. We selected issues faced by physicians in clinical practice in the perioperative management of extended thymectomy for MG, and examined them with a review of the literature. The present guidelines have reached the stage of consensus within the Japanese Association for Chest Surgery.

[Ballon dilatational tracheostomy. Technique and first clinical experience with the Ciaglia Blue Dolphin method]

BACKGROUND

Percutaneous dilatational tracheostomy (PDT) has become an established therapy for patients with prolonged intubation. It is of utmost importance for respiratory weaning of long-term ventilated patients in modern intensive care medicine. One attempt to bring PDT to perfection is a balloon dilatation technique that exerts mainly radial force to widen the tracheostoma.

PATIENTS AND METHODS

Twenty patients from a cardiosurgical intensive care unit underwent PDT with the new system. We analyzed the results based on the practical feasibility and possible complications from this balloon dilatation.

RESULTS

Tracheostomy surgery lasted on average 3.3+/-1.9 min. It caused no bleeding requiring treatment nor injuries to the posterior tracheal wall. One fracture of a single tracheal cartilage ring was revealed, and one patient developed subcutaneous emphysema during the balloon dilatation. No wound infection was observed.

CONCLUSION

Balloon dilatational tracheostomy proved to be feasible, easy, and safe in the hands of experienced users. Its mainly radial force may reduce typical complications such as fracture of tracheal cartilage rings or injuries to the posterior tracheal wall.

Percutaneous tracheostomy after mechanical ventricular assist device implantation

BACKGROUND

Several studies have shown that percutaneous dilational tracheostomy (PDT) is safe and cost-effective for patients recovering from surgery that requires a median sternotomy. We report our experience with PDT in patients receiving mechanical cardiac assistance.

METHODS

We reviewed the medical records of all patients who underwent ventricular assist device implantation at our institution between July 2000 and July 2003, and who subsequently required long-term ventilatory support during the same hospital admission. Data obtained from the records included demographic and biometric information, primary diagnosis, early (< or =30days) and late (>30days) complications, date and cause of death, type of anti-coagulation used at the time of tracheostomy, and various coagulation measures.

RESULTS

Thirty-one consecutive patients (29 men, 2 women; mean age, 56 years) had PDT after ventricular assist device implantation. Four minor complications occurred among 3 of the patients (10%), including 3 early complications (2 peristomal oozing and 1 peristomal cellulitis) and 1 late complication (recurrent peristomal cellulitis), none of which affected long-term outcome. No major adverse events, long-term complications, or deaths resulted from the PDT procedure.

CONCLUSIONS

PDT is feasible for patients with mechanical support devices who require long-term ventilatory support. Although some of these patients are coagulopathic, our results indicate that PDT is safe and effective in this challenging patient population.

Comparison of Open Versus Bedside Percutaneous Dilatational Tracheostomy in the Cardiothoracic Surgical Patient: Outcomes and Financial Analysis

BACKGROUND

The clinical and financial outcomes of a change in practice from traditional tracheostomy (open) to bedside percutaneous dilatational tracheostomies (PDT) was evaluated in patients who underwent cardiothoracic surgery.

METHODS

During 3 years, 86 tracheostomies were performed in more than 4,000 patients who underwent cardiac surgery, 59 open and 27 PDT. A retrospective analysis was performed comparing clinical and financial outcomes of the two groups.

RESULTS

There were no significant differences in demographics, medical histories, operations, or complications between open and PDT except the open group experienced more postoperative arrhythmias (70% [41 of 59] versus 44% [12 of 27], p < 0.05). Total savings associated with 1 year of PDT was $84,000, for a projected discounted savings of $283,000 during the study period. A sensitivity analysis of critical economic variables (number of tracheostomies per year, cost of operating room per minute, cost of intensive care unit bed per day) was included to evaluate the impact on cost savings. The net present value analysis, which discounts future savings by an appropriate interest rate, yielded a range of projected savings of PDT more than 5 years of $73,000 to $541,000 with a best estimate of $304,000 using figures established from our 3-year experience with PDT. Sensitivity analysis of the net present value for each critical variable was $227,000 per day of reduced intensive care unit length of stay, $180,000 per cost of operating room avoidance, $100,000 per intensive care unit bed cost per day, and $11,000 per additional tracheostomy per year.

CONCLUSIONS

There were no significant clinical differences between open and PDT in cardiac surgery patients during the 3-year study period; however, PDT offered significant cost savings.

Long-term care of the tracheostomy patient

Care of the long-term tracheostomy patient is changing. By moving the initiation of tracheostomy out of the operating room and shifting responsibility for the procedure to the medical specialist, more patients are undergoing tracheostomy for a wider spectrum of diagnoses. With much of the aftercare now directed by the medical specialist, successful reintegration of the long-term tracheostomy patient into a productive life is dependent upon the collaborative care of several disciplines directed by the specialist. To effectively care for these challenging patients, it is critical for the physician who performs tracheostomy to be aware of the new caregiving role that is now theirs.

Tracheotomy application and timing

Tracheotomy is one of the most commonly performed surgical procedures among critically ill patients. In the past, tracheotomy was delayed as long as possible in ventilator-dependent patients because of concerns regarding injury to the airway from the surgical procedure. Greater recognition of the benefits of tracheotomy in terms of greater patient comfort and mobility has promoted its earlier performance. No data identify an ideal time for tracheotomy. The decision to convert a patient from translaryngeal intubation to a tracheostomy requires anticipation of the duration of expected mechanical ventilation and the weighing of the expected benefits and risks of the procedure. The convenience of percutaneous tracheotomy performed in the ICU by critical care specialists without formal surgical training has further promoted the adoption of tracheotomy for ventilator-dependent patients. Regardless of the method for performing tracheotomy, meticulous surgical technique and careful postoperative management are necessary to maintain the excellent safety record of tracheotomy for critically ill patients.

Long-term complications of artificial airways

In summary, long-term complications of artificial airways are rare but important sequelae of artificial airways. Many of the potential long-term complications of translaryngeal intubation and tracheotomy are similar and overlapping. Although most patients who undergo these procedures tend to tolerate them without difficulties, significant morbidity and mortality may occur. Identifying the exact cause of the complication may not be possible at times, due to the multiple risk factors involved in the pathogenesis. It is hoped that understanding these potential complications will lead to a more vigilant preventive measures during the institution of long-term artificial airways and a judicious early search for the underlying pathology when a complication is suspected.

Laryngotracheoscopic findings in long-term follow-up after Griggs tracheostomy

OBJECTIVE

Analysis of laryngotracheoscopic findings of the upper airway tract following percutaneous tracheostomy using the technique according to Griggs.

DESIGN

Retrospective cohort study

PATIENTS

Nineteen of 32 long-term surviving patients (mean follow-up duration, 17 months; range, 11 to 23 months) underwent a modified Griggs tracheostomy during their stay in the ICU following cardiothoracic surgery.

INTERVENTIONS

Nineteen patients gave their informed consent for laryngotracheoscopy to localize and assess the percutaneous dilatational tracheostomy (PDT) puncture site, to evaluate the laryngotracheal morphology, and to quantify tracheal stenosis if present. In addition, specific symptoms of the upper airway tract were evaluated.

RESULTS

At the time of examination, no clinically relevant cases of stenoses were found, although one patient had undergone surgical revision of the PDT for extensive granulation prior to our examination. The endoscopic examination revealed that 12 of 19 patients (63%) had tracheal stenoses > 10%, and 2 patients had tracheal stenoses > 25%. In 7 of 19 patients (32%), the cricoid cartilage was affected by the PDT site. Despite endoscopic guidance during PDT, the location of the puncture site was found to vary greatly.

CONCLUSION

In contrast to recent reports on the long-term outcome after Griggs PDT, we found tracheal stenoses > 10% in 63% of our patients. The grade of stenosis depended mainly on the puncture site of the PDT. Based on these results, we would emphasize the importance of adequate endoscopic guidance during PDT. Further studies are required in order to clarify the risk of long-term complications arising after PDT using the technique of Griggs.

Incidence of tracheal stenosis and other late complications after percutaneous tracheostomy

OBJECTIVE

To determine the incidence of tracheal stenosis, voice and breathing changes, and stomal complications after percutaneous dilatational tracheostomy (PDT).

METHODS

From December 1992 through June 1999, 420 critically ill patients underwent 422 PDTs. There were 340 (81%) long-term survivors, 100 (29%) of whom were interviewed and offered further evaluation by fiberoptic laryngotracheoscopy (FOL) and tracheal computed tomography (CT). Tracheal stenosis was defined as more than 10% tracheal narrowing on transaxial sections or coronal and sagittal reconstruction views. Forty-eight patients agreed to CT evaluation; 38 patients also underwent FOL. CT and FOL evaluations occurred at 30 +/- 25 (mean +/- standard deviation) months after PDT.

RESULTS

Twenty-seven (27%) patients reported voice changes and 2 (2%) reported persistent severe hoarseness. Vocal cord abnormalities occurred in 4/38 (11%) patients, laryngeal granuloma in 1 (3%) patient, focal tracheal mucosal erythema in 2 (5%) patients, and severe tracheomalacia/stenosis in 1 (2.6%) patient. CT identified mild (11-25%) stenosis in 10 (21%) asymptomatic patients, moderate (26-50%) stenosis in 4 (8.3%) patients, 2 who were symptomatic, and severe (>50%) stenosis in 1 (2%) symptomatic patient. Ten patients (10%) reported persistent respiratory problems after tracheal decannulation, but only four agreed to be studied. Two patients had moderate stenosis, and one had severe stenosis. One patient's CT scan was normal. No long-term stomal complications were identified or reported.

CONCLUSIONS

Subjective voice changes and tracheal abnormalities are common after endotracheal intubation followed by PDT. Long-term follow-up of critically ill patients identified a 31% rate of more than 10% tracheal stenosis after PDT. Symptomatic stenosis manifested by subjective respiratory symptoms after decannulation was found in 3 of 48 (6%) patients.