The Epidemiology of Adult Tracheostomy in the United States 2002-2017: A Serial Cross-Sectional Study

Predicting Tracheostomy Need on Admission to the Intensive Care Unit-A Multicenter Machine Learning Analysis

OBJECTIVE

It is difficult to predict which mechanically ventilated patients will ultimately require a tracheostomy which further predisposes them to unnecessary spontaneous breathing trials, additional time on the ventilator, increased costs, and further ventilation-related complications such as subglottic stenosis. In this study, we aimed to develop a machine learning tool to predict which patients need a tracheostomy at the onset of admission to the intensive care unit (ICU).

STUDY DESIGN

Retrospective Cohort Study.

SETTING

Multicenter Study of 335 Intensive Care Units between 2014 and 2015.

METHODS

The eICU Collaborative Research Database (eICU-CRD) was utilized to obtain the patient cohort. Inclusion criteria included: (1) Age >18 years and (2) ICU admission requiring mechanical ventilation. The primary outcome of interest included tracheostomy assessed via a binary classification model. Models included logistic regression (LR), random forest (RF), and Extreme Gradient Boosting (XGBoost).

RESULTS

Of 38,508 invasively mechanically ventilated patients, 1605 patients underwent a tracheostomy. The XGBoost, RF, and LR models had fair performances at an AUROC 0.794, 0.780, and 0.775 respectively. Limiting the XGBoost model to 20 features out of 331, a minimal reduction in performance was observed with an AUROC of 0.778. Using Shapley Additive Explanations, the top features were an admission diagnosis of pneumonia or sepsis and comorbidity of chronic respiratory failure.

CONCLUSIONS

Our machine learning model accurately predicts the probability that a patient will eventually require a tracheostomy upon ICU admission, and upon prospective validation, we have the potential to institute earlier interventions and reduce the complications of prolonged ventilation.

Impact of tracheostomy tube modalities on ventilatory mechanics: a bench study

PURPOSE

Tracheostomized patients often present with muscle weakness, altered consciousness, or swallowing difficulties. Hence, the literature is scarce regarding the challenging management of tracheostomy weaning. There is a need to strengthen the understanding of respiratory mechanisms with the different tracheostomy tube modalities that compose this weaning pathway. We aimed to evaluate the impact of these modalities on the work of breathing (WOB), total positive end-expiratory pressure (PEEPtot), and tidal volume (VT).

METHODS

With a three-dimensional (3D) printed head mimicking human upper airways, we added a tracheal extension, and pierced to allow insertion of a size 7.0 tracheostomy cannula. The whole was connected to an artificial lung. Three lung mechanics were simulated (normal, obstructive and restrictive). We compared five different tracheostomy tube modalities to a control scenario in which the tube was capped and the cuff was deflated.

RESULTS

A marginal difference was observed on the WOB within conditions with a slight increase + 0.004 [95% CI (0.003-0.004); p < 0.001] when the cuff was inflated in the normal and restrictive models and a slight decrease in the obstructive model. The highest PEEPtot that was reached was + 1 cmH2O [95% CI (1-1.1); p < 0.001] with high-flow therapy (HFT) with the cuff inflated in the obstructive model. We observed a statistically significant reduction in VT [up to - 57 mL 95% CI (- 60 to - 54); p < 0.001] when the cuff was inflated, in both the normal and obstructive models.

CONCLUSIONS

Our results support the use of conditions that involve cuff deflation. Intermediate modalities with the cuff deflated produced similar results than cannula capping.

Early Deep Sedation Practices Worsened During the Pandemic Among Adult Patients Without COVID-19: A Retrospective Cohort Study

BACKGROUND

There is substantial evidence that patients with COVID-19 were treated with sustained deep sedation during the pandemic. However, it is unknown whether such guideline-discordant care had spillover effects to patients without COVID-19.

RESEARCH QUESTION

Did patterns of early deep sedation change during the pandemic for patients on mechanical ventilation without COVID-19?

STUDY DESIGN AND METHODS

We used electronic health record data from 4,237 patients who were intubated without COVID-19. We compared sedation practices in the first 48 h after intubation across prepandemic (February 1, 2018, to January 31, 2020), pandemic (April 1, 2020, to March 31, 2021), and late pandemic (April 1, 2021, to March 31, 2022) periods.

RESULTS

In the prepandemic period, patients spent an average of 13.0 h deeply sedated in the first 48 h after intubation. This increased 1.9 h (95% CI, 1.0-2.8) during the pandemic period and 2.9 h (95% CI, 2.0-3.8) in the late pandemic period. The proportion of patients that spent over one-half of the first 48 h deeply sedated was 18.9% in the prepandemic period, 22.3% during the pandemic period, and 25.9% during the late pandemic period. Ventilator-free days decreased during the pandemic, with a subdistribution hazard ratio of being alive without mechanical ventilation at 28 days of 0.87 (95% CI, 0.79-0.95) compared with the prepandemic period. Tracheostomy placement increased during the pandemic period compared with the prepandemic period (OR, 1.41; 95% CI, 1.08-1.82). In the medical ICU, early deep sedation increased 2.5 h (95% CI, 0.6-4.4) during the pandemic period and 4.9 h (95% CI, 3.0-6.9) during the late pandemic period, compared with the prepandemic period.

INTERPRETATION

We found that among patients on mechanical ventilation without COVID-19, sedation use increased during the pandemic. In the subsequent year, these practices did not return to prepandemic standards.

A Tracheostomy Support Device to Reduce Tracheostomy-Related Pressure Injury

BACKGROUND

Tracheostomies provide many advantages for the care of patients who are critically ill but may also result in complications, including tracheostomy-related pressure injuries. Research efforts into the prevention of these pressure injuries has resulted in specialized clinical care teams and pathways. These solutions are expensive and labor intensive, and fail to target the root cause of these injuries; namely, pressure at the device-skin interface. Here we measure that pressure directly and introduce a medical device, the tracheostomy support system, to reduce it.

METHODS

This was a cross-sectional study of 21 subjects in the ICU, each with a tracheostomy tube connected to a ventilator. A force-sensing resistor was used to measure baseline pressures at the device-skin interface along the inferior flange. This pressure was then measured again with the use of the tracheostomy support system in the inactive and active states. Resultant pressures and demographics were compared.

RESULTS

Fifteen male and 6 female subjects, with an average age of 47 ± 14 (mean ± SD) years, were included in this study. Average pressures at the tracheostomy-skin interface at baseline in these 21 ICU subjects were 273 ± 115 (mean ± SD) mm Hg. Average pressures were reduced by 59% (median 62%, maximum 98%) with the active tracheostomy support system to 115 ± 83 mm Hg (P < .001). All the subjects tolerated the tracheostomy support system without issue.

CONCLUSIONS

Despite best clinical practice, pressure at the tracheostomy-skin interface can remain quite high. Here we provide measures of this pressure directly and show that a tracheostomy support system can be effective at minimizing that pressure.

Aerosol Delivery to Simulated Spontaneously Breathing Tracheostomized Adult Model With and Without Humidification

BACKGROUND

Optimal aerosol delivery methods for spontaneously breathing patients with a tracheostomy remain unclear. Thus, we aimed to assess the impact of nebulizer placement, flow settings, and interfaces on aerosol delivery by using a vibrating mesh nebulizer and a jet nebulizer in line with unheated humidification.

METHODS

An 8.0-mm tracheostomy tube was connected to the lung model that simulates adult breathing parameters via a collecting filter. Albuterol sulfate (2.5 mg/3 mL) was administered via a vibrating mesh nebulizer and a jet nebulizer, which was placed in line with unheated humidification provided by a large-volume nebulizer, with FIO2 set at 0.28, with gas flows of 2 L/min versus 6 L/min. Nebulizers were placed in line distal and proximal to the lung model by using a tracheostomy collar and a T-piece. Conventional nebulization was tested using a vibrating mesh nebulizer and a jet nebulizer directly connected to the tracheostomy tube bypassing the humidification device. The drug was eluted from the collecting filter and assayed with ultraviolet spectrophotometry (276 nm).

RESULTS

During in-line nebulizer placement with unheated humidification, the inhaled dose was 2-4 times higher with a gas flow of 2 L/min than 6 L/min, regardless of nebulizer type, placement, or interface (all P < .05). At 6 L/min, the inhaled dose was higher with proximal than distal placement when using both interfaces, but, at 2 L/min, the inhaled dose was lower with proximal placement. With a jet nebulizer, the tracheostomy collar generated a higher inhaled dose at proximal placement compared with the T-piece, whereas the T-piece resulted in a higher inhaled dose than the tracheostomy collar with distal placement, regardless of the flow settings. Compared with conventional nebulization using a vibrating mesh nebulizer, an in-line vibrating mesh nebulizer with a large-volume nebulizer at 2 L/min had a similar inhaled dose, regardless of nebulizer placement and interface. In contrast, the in-line jet nebulizer was influenced by both placement and interface.

CONCLUSIONS

Aerosol delivery with an in-line vibrating mesh nebulizer and jet nebulizer with unheated humidification was affected by nebulizer placement, interface, and gas flow settings.

Impact of Obesity on Timing of Tracheotomy: A Multi-institutional Retrospective Study

OBJECTIVE

To examine the impact of increased body mass index (BMI) on (1) tracheotomy timing and (2) short-term surgical complications requiring a return to the operating room and 30-day mortality utilizing data from the Multi-Institutional Study on Tracheotomy (MIST).

METHODS

A retrospective analysis of patients from the MIST database who underwent surgical or percutaneous tracheotomy between 2013 and 2016 at eight institutions was completed. Unadjusted and adjusted logistic regression analyses were used to assess the impact of obesity on tracheotomy timing and complications.

RESULTS

Among the 3369 patients who underwent tracheotomy, 41.0% were obese and 21.6% were morbidly obese. BMI was associated with higher rates of prolonged intubation prior to tracheotomy accounting for comorbidities, indication for tracheotomy, institution, and type of tracheostomy (p = 0.001). Morbidly obese patients (BMI ≥35 kg/m2) experienced a longer duration of intubation compared with patients with a normal BMI (median days intubated [IQR 25%-75%]: 11.0 days [7-17 days] versus 9.0 days [5-14 days]; p < 0.001) but did not have statistically higher rates of return to the operating room within 30 days (p = 0.12) or mortality (p = 0.90) on multivariable analysis. This same finding of prolonged intubation was not seen in overweight, nonobese patients when compared with normal BMI patients (median days intubated [IQR 25%-75%]: 10.0 days [6-15 days] versus 10.0 days [6-15 days]; p = 0.36).

CONCLUSION

BMI was associated with increased duration of intubation prior to tracheotomy. Although morbidly obese patients had a longer duration of intubation, there were no differences in return to the operating room or mortality within 30 days.

LEVEL OF EVIDENCE

III Laryngoscope, 2024.

Tracheostomy Incidence and Complications: A National Database Analysis

OBJECTIVE

To describe the incidence of tracheostomy-related complications and identify prognostic risk factors.

STUDY DESIGN

Administrative database analysis.

SETTING

Outpatient and inpatient insurance claims records obtained from a national database.

METHODS

PearlDiver, a private analytics database of insurance claims from Medicare, Medicaid, and commercial insurance companies, was used to identify patients who underwent tracheostomies and associated complications between January 2010 and October 2021 by CPT and ICD-9/ICD-10 codes.

RESULTS

A total of 198,143 tracheostomies were identified from PearlDiver, and at least 1 tracheostomy-related complication occurred within 90 days of the procedure in 22,802 (10.3%) of these cases. The proportion of tracheostomy-related complications was 2.3 times higher in 2019 compared to 2010 (95% confidence interval [CI]: 2.18-2.52). The risk of developing tracheostomy-complications was associated with the hospital region (highest in the Midwest as compared to the West [odds ratio [OR] = 1.32; 95% CI: 1.25-1.39]), provider specialty (highest for otolaryngologists as compared to nonsurgical physicians [OR = 2.22; 95% CI: 2.10-2.34]), insurance plan type (lowest for cash payment compared to Medicaid [OR = 0.70, 95% CI: 0.50-0.94]), and Elixhauser Comorbidity Index (ECI) (highest in patients with ECI of 7+ compared to 0-1 [OR = 2.96; 95% CI: 2.17-3.24]), but was not significantly associated with patient age (OR = 0.99; 95% CI: 0.99-0.99), or gender (OR = 1.04; 95% CI: 1.01-1.07).

CONCLUSIONS

Complications after tracheostomy are common and sicker patients are at higher risk for complications. Identifying factors associated with increased risk for complications could help to improve patient and family counseling, guide quality improvement initiatives, and inform future studies on tracheostomy outcomes.

Palliative Care as a Component of High-Value and Cost-Saving Care During Hospitalization for Metastatic Cancer

PURPOSE

Randomized controlled trials have demonstrated that palliative care (PC) can improve quality of life and survival for outpatients with advanced cancer, but there are limited population-based data on the value of inpatient PC. We assessed PC as a component of high-value care among a nationally representative sample of inpatients with metastatic cancer and identified hospitalization characteristics significantly associated with high costs.

METHODS

Hospitalizations of patients 18 years and older with a primary diagnosis of metastatic cancer from the National Inpatient Sample from 2010 to 2019 were analyzed. We used multivariable mixed-effects logistic regression to assess medical services, patient demographics, and hospital characteristics associated with higher charges billed to insurance and hospital costs. Generalized linear mixed-effects models were used to determine cost savings associated with provision of PC.

RESULTS

Among 397,691 hospitalizations from 2010 to 2019, the median charge per admission increased by 24.9%, from $44,904 in US dollars (USD) to $56,098 USD, whereas the median hospital cost remained stable at $14,300 USD. Receipt of inpatient PC was associated with significantly lower charges (odds ratio [OR], 0.62 [95% CI, 0.61 to 0.64]; P < .001) and costs (OR, 0.59 [95% CI, 0.58 to 0.61]; P < .001). Factors associated with high charges were receipt of invasive medical ventilation (P < .001) or systemic therapy (P < .001), Hispanic patients (P < .001), young age (18-49 years, P < .001), and for-profit hospitals (P < .001). PC provision was associated with a $1,310 USD (-13.6%, P < .001) reduction in costs per hospitalization compared with no PC, independent of the receipt of invasive care and age.

CONCLUSION

Inpatient PC is associated with reduced hospital costs for patients with metastatic cancer, irrespective of age and receipt of aggressive interventions. Integration of inpatient PC may de-escalate costs incurred through low-value inpatient interventions.

Association of Discharge Location Following Pediatric Tracheostomy with Social Determinants of Health: A National Analysis

OBJECTIVE

To evaluate the breakdown of discharge locations among pediatric tracheostomy patients and determine the impact of demographic variables and social determinants of health.

STUDY DESIGN

Retrospective review of the 2016 and 2019 Healthcare Cost and Utilization Project Kids' Inpatient Database (HCUP KID).

SETTING

A total of 4000 United States community hospitals, defined as short-term, non-Federal, general, and specialty hospitals.

METHODS

ICD-10-PCS, ICD-10 CM codes, and HCUP data elements were selected for patients and variables of interest. Bivariate comparisons were performed using Rao-Scott Chi-square tests; significance levels in post hoc pairwise testing were adjusted using Bonferroni adjustment. Multinomial generalized logistic regression models were used to determine the average annual odds ratio (OR) of 3 dispositions at discharge relative to discharge home for self-care.

RESULTS

Patients aged 11-17, patients from large metropolitan areas, and patients of "Other" race have an increased odds of discharge to a short- or long-term care facility (all P < .001). Weekend admissions, nonelective admissions, patients in Northeast hospitals, and patients at urban nonteaching hospitals are also more likely to be discharged to a short- or long-term care facility (all P < .001). Mean and median total costs of admission were $424,387 and $243,479, respectively, with a median total charge of $854,499.

CONCLUSION

Among pediatric tracheostomy patients, demographic factors that affect discharge disposition include age, community type, and race, and significant hospital factors include day and type of admission, geographic region, and hospital type. Hospitalizations are associated with high overall costs and charges to the patient, which are increasing over time.

Tracheostomies for respiratory failure are associated with a high inpatient mortality: a potential trigger to reconsider goals of care

Introduction

Acute care surgeons are frequently consulted for tracheostomy placement in the intensive care unit (ICU). Tracheostomy may facilitate ventilator weaning and improve physical comfort. Short-term outcomes after tracheostomy are not well studied. We hypothesize that a high proportion of ICU patients who underwent tracheostomy died prior to discharge. These data will help guide clinical decision-making at a key pivot point in care.

Methods

We identified 177 mixed ICU patients who received a tracheostomy for respiratory failure between January 2013 and December 2018. We excluded patients with trauma. Patient information was collected and comparisons made with univariable and multivariable statistics.

Results

Of the 177 patients who underwent a tracheostomy for respiratory failure, 45% were women, median age was 63 (51-71) years. Of this group 18% died prior to discharge, 63% were discharged to a care facility and only 16% discharged home. Compared with survivors, patients with tracheostomies who died during their admission were older, age 69 (64-76) versus 61 (49-71) years (p<0.01) on univariable analysis. In this model, no single comorbid condition or length of stay (LOS) variable was predictive of death before discharge. A multivariable model controlling for covariation similarly identified age, as well as a longer ICU LOS of 34 (20-49) versus 23 (16-31) days (p=0.003) as factors associated with increased likelihood of death before discharge.

Conclusions

Tracheostomy placement in a mixed ICU population is associated with a nearly 20% inpatient mortality and the vast majority of surviving patients were discharged to a care facility. This suggests that the need for tracheostomy could be considered a trigger for re-evaluation of patient goals. The high risk of death due to underlying illness and high intensity care after their hospitalization emphasize the need for clear advanced care planning discussions around the time of tracheostomy placement.

Level of Evidence

Level IV, Retrospective cohort study.

A deployable curriculum with 3D printed skills trainers for altered airway management

BACKGROUND

Altered Airway Anatomy (AAA), including tracheostomies and laryngectomies, may represent an area of unease for non-Otolaryngology trainees, due to a lack of exposure, structured education, or dedicated training in altered airway management. Inability to effectively stabilize an altered airway is associated with significant risk of patient morbidity and mortality. This study aims to assess the efficacy of a concise curriculum using three-dimensional (3D) printed airway models for skill training in improving Anesthesiology trainees' competency in AAA management.

METHODS

A prospective cohort of 42 anesthesiology residents at a tertiary care institution were guided through a 75-min curriculum on AAA, including case discussion, surgical video, and hands-on practice with tracheostomy and laryngectomy skills trainers. Pre- and post- course surveys assessing provider confidence (Likert scale) and knowledge (multiple choice questions) were administered. Additionally, an observed skills competency assessment was performed.

RESULTS

Self-perceived confidence improved from a summative score across all domains of 23.65/40 pre-course to 36.39/40 post-course (n = 31, p < 0.001). Technical knowledge on multiple choice questions improved from 71 to 95% (n = 29, p < 0.001). In the completed skills competency assessment, 42/42 residents completed 5/5 assessed tasks successfully, demonstrating objective skills-based competency.

CONCLUSIONS

This study demonstrates an improvement in anesthesiology resident self-assessed confidence, objective knowledge, and skills based competency surrounding management of patients with AAA following a 75-min simulation-based curriculum.

Implementation of Above-Cuff Vocalization After Tracheostomy Is Feasible and Associated With Earlier Speech

PURPOSE

The purpose of this study was to assess the feasibility of hospital-wide implementation of an above-cuff vocalization (ACV) protocol using ACV-capable tracheostomy tubes and its impact on patient speech in four intensive care unit (ICU) patient populations.

METHOD

This research was an observational pre-post study that was conducted over a 26-month period and included 323 critically ill adult ICU patients who underwent tracheostomy in a 365-bed academic tertiary care hospital. ACV was assessed using a protocol developed by a multidisciplinary team. Presence of speech was defined as at least one comprehensible word spoken during a speech-language pathologist evaluation.

RESULTS

Median time-to-speech was 13 days (interquartile range [IQR]: 8-20 days) before the intervention, compared to 9 days (IQR: 6-16 days) after the intervention (p = .0017). In the pre-intervention group, 101 out of 167 (60.5%) patients achieved speech within 60 days, compared to 83 out of 133 (62.4%) patients in the post-intervention group (p = .12). Of the 83 patients who achieved speech in the post-intervention group, 24 (28.9%) did so via ACV, with the remainder using a speaking valve or digital occlusion. Of those 24 patients, seven did not progress to using a speaking valve within the follow-up period. The median number of speech days gained by using ACV was 8 (IQR: 5-18 days). ACV was successful in facilitating speech in 24 out of 29 (82.8%) patients trialed, with no major complications.

CONCLUSIONS

Routine implementation of ACV after tracheostomy is feasible, safe, and associated with earlier speech in a diverse population of critically ill patients. ACV is an important method to facilitate communication in patients requiring mechanical ventilation with tracheostomy cuff inflation.

Comparison of Mechanical Forces used in Open Tracheotomy versus Percutaneous Tracheotomy Techniques

OBJECTIVE

To understand the etiology of tracheotomy-induced tracheal stenosis by comparing the differences in techniques and mechanical force applied with open tracheotomy (OT) versus percutaneous tracheotomy (PCT) placement.

METHODS

This study is an unblinded, experimental, randomized controlled study in an ex-vivo animal model. Simulated tracheostomies were performed on 10 porcine tracheas, 5 via a tracheal window technique (OT) and 5 using the Ciaglia technique (PCT). The applied weight during the simulated tracheostomy and the compression of the trachea were recorded at set times during the procedure. The applied weight during tracheostomy was used to calculate the tissue force in Newtons. Tracheal compression was measured by anterior-posterior distance compression and as percent change.

RESULTS

Average forces for scalpel (OT) versus trocar (PCT) were 2.6 N and 12.5 N (p < 0.01), with the dilator (PCT) it was 22.02 N (p < 0.01). The tracheostomy placement with OT required an average force of 10.7 N versus 23.2 N (p < 0.01) with PCT. The average change in AP distance when using the scalpel versus trocar was 21%, and 44% (p < 0.01), with the dilator it was 75% (p < 0.01). The trach placement with OT versus PCT had an average AP distance change of 51% and 83% respectively (p < 0.01).

CONCLUSION

This study demonstrated that PCT required more force and caused more tracheal lumen compression when compared to the OT technique. Based on the increased force required for PCT, we suspect there could also be an increased risk for tracheal cartilage trauma.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:103-107, 2024.

Educational Quality of YouTube Videos for Patients Undergoing Elective Procedures

INTRODUCTION

YouTube has become a main resource used by patients for self-education on medicine. It is important for surgeons to understand the quality and reliability of videos that patients are likely to view about elective procedures.

METHODS

Videos were categorized by view count and content creators. The top 20 videos for each term, sorted by relevance, were evaluated using DISCERN criteria, a question set externally validated to assess the quality of information regarding health treatment choices. DISCERN score (DS) closer to 5 indicate higher quality information and 1 indicates the opposite. Total scores were given: 15-26 (very poor), 27-38 (poor), 39-50 (fair), 51-62 (very good), and 63-75 (excellent). Search terms included "Wound Care", "Skin Grafting", "Tracheostomy", and "percutaneous endoscopic gastrostomy tube placement".

RESULTS

In total, 80 unique videos were evaluated with a total view of 8,848,796. The mean overall DS was 2.15 and a mean bias DS was 2.46. The median DISCERN total score for each key term was Tracheostomy: 35 (poor), Skin Grafting 26 (very poor), percutaneous endoscopic gastrostomy: 32 (poor), and Wound Care: 40 (fair).

CONCLUSIONS

YouTube videos surrounding elective procedures should be viewed cautiously in patient education despite wide availability. The videos in this study show high levels of bias and low DS. Healthcare providers should be aware of poor-quality consumer health information often disseminated in online media such as YouTube.

Effectiveness of interprofessional tracheostomy teams: A systematic review

AIM(S)

To systematically locate, evaluate and synthesize evidence regarding effectiveness of interprofessional tracheostomy teams in increasing speaking valve use and decreasing time to speech and decannulation, adverse events, lengths of stay (intensive care unit (ICU) and hospital) and mortality. In addition, to evaluate facilitators and barriers to implementing an interprofessional tracheostomy team in hospital settings.

DESIGN

Systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Johns Hopkins Nursing Evidence-Based Practice Model's guidance.

METHODS

Our clinical question: Do interprofessional tracheostomy teams increase speaking valve use and decrease time to speech and decannulation, adverse events, lengths of stay and mortality? Primary studies involving adult patients with a tracheostomy were included. Eligible studies were systematically reviewed by two reviewers and verified by another two reviewers.

DATA SOURCES

MEDLINE, CINAHL and EMBASE.

RESULTS

Fourteen studies met eligibility criteria; primarily pre-post intervention cohort studies. Percent increase in speaking valve use ranged 14%-275%; percent reduction in median days to speech ranged 33%-73% and median days to decannulation ranged 26%-32%; percent reduction in rate of adverse events ranged 32%-88%; percent reduction in median hospital length of stay days ranged 18-40 days; no significant change in overall ICU length of stay and mortality rates. Facilitators include team education, coverage, rounds, standardization, communication, lead personnel and automation, patient tracking; barrier is financial.

CONCLUSION

Patients with tracheostomy who received care from a dedicated interprofessional team showed improvements in several clinical outcomes.

IMPLICATIONS FOR PATIENT CARE

Additional high-quality evidence from rigorous, well-controlled and adequately powered studies are necessary, as are implementation strategies to promote broader adoption of interprofessional tracheostomy team strategies. Interprofessional tracheostomy teams are associated with improved safety and quality of care.

IMPACT

Evidence from review provides rationale for broader implementation of interprofessional tracheostomy teams.

REPORTING METHOD

PRISMA and Synthesis Without Meta-analysis (SWiM).

PATIENT/PUBLIC CONTRIBUTION

None.

Revision Tracheotomy Complicated by History of Follicular B-Cell Lymphoma

This case report presents a 65-year-old woman with multiple complications during a revision tracheotomy including subcutaneous emphysema and a pneumothorax. Management of her airway was complicated by a history of recurrent follicular B-cell lymphoma associated with extensive cervical lymphadenopathy. We detail the importance of heightened clinical awareness and the use of intraoperative safety adjuncts when performing revision tracheostomies.

Tracheal Transection After Prolonged Intubation and Tracheostomy: A Case Report

Tracheal transection is a rare, life-threatening complication after tracheal injury. Most commonly, tracheal transection presents after blunt trauma, but iatrogenic tracheal transection after tracheotomy has not been well described. Here, we present a case without a history of trauma that presented with signs of symptoms of tracheal stenosis. She was taken to the operating room for tracheal resection and anastomosis and was incidentally found to have a complete tracheal transection intraoperatively.

A user evaluation of speech/phrase recognition software in critically ill patients: a DECIDE-AI feasibility study

OBJECTIVES

Evaluating effectiveness of speech/phrase recognition software in critically ill patients with speech impairments.

DESIGN

Prospective study.

SETTING

Tertiary hospital critical care unit in the northwest of England.

PARTICIPANTS

14 patients with tracheostomies, 3 female and 11 male.

MAIN OUTCOME MEASURES

Evaluation of dynamic time warping (DTW) and deep neural networks (DNN) methods in a speech/phrase recognition application. Using speech/phrase recognition app for voice impaired (SRAVI), patients attempted mouthing various supported phrases with recordings evaluated by both DNN and DTW processing methods. Then, a trio of potential recognition phrases was displayed on the screen, ranked from first to third in order of likelihood.

RESULTS

A total of 616 patient recordings were taken with 516 phrase identifiable recordings. The overall results revealed a total recognition accuracy across all three ranks of 86% using the DNN method. The rank 1 recognition accuracy of the DNN method was 75%. The DTW method had a total recognition accuracy of 74%, with a rank 1 accuracy of 48%.

CONCLUSION

This feasibility evaluation of a novel speech/phrase recognition app using SRAVI demonstrated a good correlation between spoken phrases and app recognition. This suggests that speech/phrase recognition technology could be a therapeutic option to bridge the gap in communication in critically ill patients.

WHAT IS ALREADY KNOWN ABOUT THIS TOPIC

Communication can be attempted using visual charts, eye gaze boards, alphabet boards, speech/phrase reading, gestures and speaking valves in critically ill patients with speech impairments.

WHAT THIS STUDY ADDS

Deep neural networks and dynamic time warping methods can be used to analyse lip movements and identify intended phrases.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE AND POLICY

Our study shows that speech/phrase recognition software has a role to play in bridging the communication gap in speech impairment.

Sonochemical Deposition of Gentamicin Nanoparticles at the PCV Tracheostomy Tube Surface Limiting Bacterial Biofilm Formation

BACKGROUND

The use of nanotechnology in the production of medical equipment has opened new possibilities to fight bacterial biofilm developing on their surfaces, which can cause infectious complications. In this study, we decided to use gentamicin nanoparticles. An ultrasonic technique was used for their synthesis and immediate deposition onto the surface of tracheostomy tubes, and their effect on bacterial biofilm formation was evaluated.

METHODS

Polyvinyl chloride was functionalized using oxygen plasma followed by sonochemical formation and the embedment of gentamicin nanoparticles. The resulting surfaces were characterized with the use of AFM, WCA, NTA, FTIR and evaluated for cytotoxicity with the use of A549 cell line and for bacterial adhesion using reference strains of S. aureus (ATCC^® 25923™) and E. coli (ATCC^® 25922™).

RESULTS

The use of gentamicin nanoparticles significantly reduced the adhesion of bacterial colonies on the surface of the tracheostomy tube for S. aureus from 6 × 10⁵ CFU/mL to 5 × 10³ CFU/mL and for E. coli from 1.655 × 10⁵ CFU/mL to 2 × 10¹ CFU/mL, and the functionalized surfaces did not show a cytotoxic effect on A549 cells (ATTC CCL 185).

CONCLUSIONS

The use of gentamicin nanoparticles on the polyvinyl chloride surface may be an additional supporting method for patients after tracheostomy in order to prevent the colonization of the biomaterial by potentially pathogenic microorganisms.

Updates in percutaneous tracheostomy and gastrostomy: should we strive for combined placement during one procedure?

PURPOSE OF REVIEW

Percutaneous tracheostomy and gastrostomy are minimally invasive procedures among the most common performed in intensive care units. Practices across centres vary considerably, and questions remain about the optimal timing, performance and postoperative care related to these procedures.

RECENT FINDINGS

The COVID-19 pandemic has triggered a reevaluation of the practice of percutaneous tracheostomy and gastrostomy in the ICU. Combined percutaneous tracheostomy and gastrostomy at the bedside has potential benefits, including improved nutrition, decreased exposure to anaesthetics, decreased patient transport and decreased hospital costs. Percutaneous ultrasound gastrostomy is a novel technique that eliminates the need for an endoscope that may allow intensivists to perform gastrostomy at the bedside.

SUMMARY

Multidisciplinary care is essential to the follow up of critically ill patients receiving tracheostomy and gastrostomy. Combined tracheostomy and gastrostomy has numerous potential benefits to patients and hospital systems. Interventional pulmonologists are uniquely qualified to perform both procedures and serve on a tracheostomy and gastrostomy team.

Amplifying patient voices amid pandemic: Perspectives on tracheostomy care, communication, and connection

OBJECTIVE

To investigate perspectives of patients, family members, caregivers (PFC), and healthcare professionals (HCP) on tracheostomy care during the COVID-19 pandemic.

METHODS

The cross-sectional survey investigating barriers and facilitators to tracheostomy care was collaboratively developed by patients, family members, nurses, speech-language pathologists, respiratory care practitioners, physicians, and surgeons. The survey was distributed to the Global Tracheostomy Collaborative's learning community, and responses were analyzed.

RESULTS

Survey respondents (n = 191) from 17 countries included individuals with a tracheostomy (85 [45 %]), families/caregivers (43 [22 %]), and diverse HCP (63 [33.0 %]). Overall, 94 % of respondents reported concern that patients with tracheostomy were at increased risk of critical illness from SARS-CoV-2 infection and COVID-19; 93 % reported fear or anxiety. With respect to prioritization of care, 38 % of PFC versus 16 % of HCP reported concern that patients with tracheostomies might not be valued or prioritized (p = 0.002). Respondents also differed in fear of contracting COVID-19 (69 % PFC vs. 49 % HCP group, p = 0.009); concern for hospitalization (55.5 % PFC vs. 27 % HCP, p < 0.001); access to medical personnel (34 % PFC vs. 14 % HCP, p = 0.005); and concern about canceled appointments (62 % PFC vs. 41 % HCP, p = 0.01). Respondents from both groups reported severe stress and fatigue, sleep deprivation, lack of breaks, and lack of support (70 % PFC vs. 65 % HCP, p = 0.54). Virtual telecare seldom met perceived needs.

CONCLUSION

PFC with a tracheostomy perceived most risks more acutely than HCP in this global sample. Broad stakeholder engagement is necessary to achieve creative, patient-driven solutions to maintain connection, communication, and access for patients with a tracheostomy.