How to care for a patient with a tracheostomy

Comparison of Ventilator-Associated Pneumonia and Surgical Site Infection between Two Methods of Tracheostomy

Objective

To compare the incidence of ventilator-associated pneumonia (VAP) and surgical site infection (SSI) between percutaneous dilatational tracheostomy (PDT) and surgical tracheostomy (ST).

Methods

Data on 487 patients undergoing tracheostomy between 1st January 2014 and 30th September 2020 were reviewed. Patients were divided according to the surgical techniques. Clinical characteristics and postoperative care were compared to explore the risk factors for SSI and VAP. All tracheostomies were performed by intensivists who had completed at least ten tracheostomies. ST was performed using standard techniques. PDT was performed according to a modification technique described by Ciaglia. All procedures were performed at the bedside in the ICU.

Results

Of all, 344 patients (70.6%) were men and 143 (29.4%) were women, and the mean age was 56 years (standard derivation [SD] 12 years). Two hundred and sixty-six patients (54.6%) received PDT, and 221 (45.4%) received SY. Patients in the PDT group had a significantly lower rate of SSI (3.4% vs. 8.5%, P = 0.01) compared with the ST group. Multivariate analysis revealed that comorbidities (P = 0.003), surgical type (P = 0.01), and cluster nursing (P < 0.001) were independent risk factors for SSI; age (P = 0.005), comorbidities (P < 0.001), smoking (P = 0.008), and cluster nursing (P = 0.01) were independent risk factors for VAP.

Conclusion

PDT significantly reduces the risk of SSI. Proper care should be administrated in patients with one or more risk factors of SSI or VAP to prevent the occurrence of complications.

Wound care management: tracheostomy and gastrostomy

Percutaneous dilatational tracheostomy (PDT) and percutaneous endoscopic gastrostomy (PEG) tube placements are routine procedures performed in the intensive care units (ICUs). They are performed to facilitate care and promote healing. They also help prevent complications from prolonged endotracheal intubation and malnutrition. In most cases, both are performed simultaneously. Physicians performing them require knowledge of local anatomy, tissue and vascular relationships, along with advance bronchoscopy and endoscopy skills. Although PDTs and PEGs are considered relatively low-risk procedures, operators need to have the knowledge and skill to recognize and prevent adverse outcomes. Current published literature on post-procedural care and stoma wound management was reviewed. Available recommendations for the routine care of tracheostomy and PEG tubes are included in this review. Signs and symptoms of early PDT- and PEG-related complications and their management are discussed in detail. These include hemorrhage, infection, accidental decannulation, tube obstruction, clogging, and dislodgement. Rare, life-threatening complications are also discussed. Multidisciplinary teams are needed for improved patient care, and members should be aware of all pertinent care aspects and potential complications related to PDT and PEG placement. Each institute is strongly encouraged to have detailed protocols to standardize care. This review provides a state-of-the-art guidance on the care of patients with tracheostomies and gastrostomies specifically in the ICU setting.

Tracheostomy care and complications in the intensive care unit

Tracheotomy is a common procedure in intensive care units, and nurses must provide proper care to tracheostomy patients to prevent complications. One of the most important considerations is effective mobilization of secretions, and a suction catheter is the most important tool for that purpose. Each bedside should be equipped with a functional suctioning system, an oxygen source, a manual resuscitation bag, and a complete tracheostomy kit, which should accompany patients wherever they go in the hospital. Complications include infection, tracheomalacia, skin breakdown, and tracheoesophageal fistula. Tracheostomy emergencies include hemorrhage, tube dislodgement and loss of airway, and tube obstruction; such emergencies are managed more effectively when all necessary supplies are readily available at the bedside. This article describes how to provide proper care in the intensive care unit, strategies for preventing complications, and management of tracheostomy emergencies.