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Mu J, Wang T, Ji M, Yin Q, Wang Z. Tracheostomy care of non-ventilated patients and COVID considerations: A scoping review of clinical practice guidelines and consensus statements. J Clin Nurs 2024; 33:3033-3055. [PMID: 38764213 DOI: 10.1111/jocn.17116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 02/06/2024] [Accepted: 03/05/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND The purpose of this study is to examine and evaluate the existing clinical practice guidelines and consensus statements regarding tracheostomy care for non-mechanically ventilated patients. METHODS A systematic search of databases, and professional organisations was conducted from inception to 19 March 2023. Two appraisers evaluated each guideline using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) and the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Text and Opinion Papers. RESULTS No specific clinical guidelines exist on airway management in non-mechanically ventilated patients. Of 6318 articles identified, we included 12 clinical practice guidelines, and 9 consensus statements, which were from China, the US, the UK, South Korea, Australia, France and Belgium. The AGREE II scores in six domains are (1) the scope and purpose, 70.30%; (2) stakeholder involvement, 37.61%; (3) rigor of development, 33.97%; (4) clarity of presentation, 68.16%; (5) applicability, 44.23% and (6) editorial independence, 40.06%. The overall quality of evidence was level B. The summarised recommendations for clinical practice encompass the following six areas: airway humidification, management of the trach cuff, management of inner cannula, tracheostoma care, tracheostomy suctioning and management and prevention of common post-operative complications. CONCLUSIONS The overall quality of the clinical guidelines on non-ventilated tracheostomy care was moderate, and further improvements are needed in domains of stakeholder involvement, applicability, clarity of presentation and editorial independence. Recommendations on non-ventilated tracheostomy care are often embedded in the guidelines on ventilated tracheostomy. Specific clinical guidelines are needed to provide a standardised approach to tracheostomy care for non-ventilated patients. RELEVANCE TO CLINICAL PRACTICE Patients with non-ventilated tracheostomy need specialised airway management. Improving patient outcomes requires standardised protocols, patient involvement, quality evaluation, and interdisciplinary approaches. NO PATIENT OR PUBLIC CONTRIBUTION The study reviewed clinical practice guidelines and consensus statements, therefore patient or public input was not needed.
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Affiliation(s)
- Juan Mu
- School of Nursing, Peking University, Beijing, China
| | - Tongyao Wang
- School of Nursing, LKS Faculty of Medicine, The University Hong Kong, Pokfulam, Hong Kong
| | - Mengmeng Ji
- School of Nursing, Peking University, Beijing, China
| | - Qian Yin
- Aviation General Hospital Beijing, Beijing, China
| | - Zhiwen Wang
- School of Nursing, Peking University, Beijing, China
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2
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Cleere EF, Read C, Prunty S, Duggan E, O'Rourke J, Moore M, Vasquez P, Young O, Subramaniam T, Skinner L, Moran T, O'Duffy F, Hennessy A, Dias A, Sheahan P, Fitzgerald CWR, Kinsella J, Lennon P, Timon CVI, Woods RSR, Shine N, Curley GF, O'Neill JP. Airway decision making in major head and neck surgery: Irish multicenter, multidisciplinary recommendations. Head Neck 2024. [PMID: 38984517 DOI: 10.1002/hed.27868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 06/21/2024] [Accepted: 06/30/2024] [Indexed: 07/11/2024] Open
Abstract
Major head and neck surgery poses a threat to perioperative airway patency. Adverse airway events are associated with significant morbidity, potentially leading to hypoxic brain injury and even death. Following a review of the literature, recommendations regarding airway management in head and neck surgery were developed with multicenter, multidisciplinary agreement among all Irish head and neck units. Immediate extubation is appropriate in many cases where there is a low risk of adverse airway events. Where a prolonged definitive airway is required, elective tracheostomy provides increased airway security postoperatively while delayed extubation may be appropriate in select cases to reduce postoperative morbidity. Local institutional protocols should be developed to care for a tracheostomy once inserted. We provide guidance on decision making surrounding airway management at time of head and neck surgery. All decisions should be agreed between the operating, anesthetic, and critical care teams.
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Affiliation(s)
- Eoin F Cleere
- Department of Otolaryngology - Head and Neck Surgery, Beaumont Hospital, Dublin, Ireland
| | - Christopher Read
- Department of Anaesthesia and Critical Care, Beaumont Hospital, Dublin, Ireland
| | - Sarah Prunty
- Department of Otolaryngology - Head and Neck Surgery, Beaumont Hospital, Dublin, Ireland
| | - Edel Duggan
- Department of Anaesthesia and Critical Care, Beaumont Hospital, Dublin, Ireland
| | - James O'Rourke
- Department of Anaesthesia and Critical Care, Beaumont Hospital, Dublin, Ireland
| | - Michael Moore
- Department of Anaesthesia and Critical Care, Beaumont Hospital, Dublin, Ireland
| | - Pedro Vasquez
- Department of Physiotherapy, Beaumont Hospital, Dublin, Ireland
| | - Orla Young
- Department of Otolaryngology - Head and Neck Surgery, Galway University Hospital, Galway, Ireland
| | - Thavakumar Subramaniam
- Department of Otolaryngology - Head and Neck Surgery, Galway University Hospital, Galway, Ireland
| | - Liam Skinner
- Department of Otolaryngology - Head and Neck Surgery, University Hospital Waterford, Waterford, Ireland
| | - Tom Moran
- Department of Otolaryngology - Head and Neck Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
- Department of Otolaryngology - Head and Neck Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - Fergal O'Duffy
- Department of Otolaryngology - Head and Neck Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
- Department of Otolaryngology - Head and Neck Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - Anthony Hennessy
- Department of Anaesthesiology, South Infirmary Victoria University Hospital, Cork, Ireland
| | - Andrew Dias
- Department of Otolaryngology - Head and Neck Surgery, South Infirmary Victoria University Hospital, Cork, Ireland
| | - Patrick Sheahan
- Department of Otolaryngology - Head and Neck Surgery, South Infirmary Victoria University Hospital, Cork, Ireland
- ENTO Research Unit, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Conall W R Fitzgerald
- Department of Otolaryngology - Head and Neck Surgery, St James's Hospital, Dublin, Ireland
| | - John Kinsella
- Department of Otolaryngology - Head and Neck Surgery, St James's Hospital, Dublin, Ireland
| | - Paul Lennon
- Department of Otolaryngology - Head and Neck Surgery, St James's Hospital, Dublin, Ireland
| | - Conrad V I Timon
- Department of Otolaryngology - Head and Neck Surgery, St James's Hospital, Dublin, Ireland
| | - Robbie S R Woods
- Department of Otolaryngology - Head and Neck Surgery, Beaumont Hospital, Dublin, Ireland
| | - Neville Shine
- Department of Otolaryngology - Head and Neck Surgery, Beaumont Hospital, Dublin, Ireland
| | - Gerard F Curley
- Department of Anaesthesia and Critical Care, Beaumont Hospital, Dublin, Ireland
- Department of Anaesthesia and Critical Care, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - James P O'Neill
- Department of Otolaryngology - Head and Neck Surgery, Beaumont Hospital, Dublin, Ireland
- Department of Otolaryngology - Head and Neck Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
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3
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Hassan B, Tawfik MM, Schiff E, Mosavian R, Kelly Z, Li D, Petti A, Bangar M, Schiff BA, Yang CJ. Harnessing In Situ Simulation to Identify Human Errors and Latent Safety Threats in Adult Tracheostomy Care. Jt Comm J Qual Patient Saf 2024; 50:279-284. [PMID: 38171951 PMCID: PMC10978288 DOI: 10.1016/j.jcjq.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Tracheostomies are associated with high rates of complications and preventable harm. Safe tracheostomy management requires highly functioning teams and systems, but health care providers are poorly equipped with tracheostomy knowledge and resources. In situ simulation has been used as a quality improvement tool to audit multidisciplinary team emergency response in the actual clinical environment where care is delivered but has been underexplored for tracheostomy care. METHODS From July 2021 to May 2022, the study team conducted in situ simulations of a tracheostomy emergency scenario at Montefiore Medical Center to identify human errors and latent safety threats (LSTs). Simulations included structured debriefs as well as audiovisual recording that allowed for blind rating of these human errors and LSTs. Provider knowledge deficits were further characterized using pre-simulation quizzes. RESULTS Twelve human errors and 15 LSTs were identified over 20 simulations with 88 participants overall. LSTs were divided into the following categories: communication, equipment, and infection control. Only 50.0% of teams successfully replaced the tracheostomy tube within the scenario's five-minute time limit. In addition, knowledge gaps were highly prevalent, with a median pre-simulation quiz score of 46% (interquartile range 36-64) among participants. CONCLUSION An in situ simulation-based quality improvement approach shed light on human errors and LSTs associated with tracheostomy care across multiple settings in one health system. This method of engaging frontline health care provider key stakeholders will inform the development, adaptation, and implementation of interventions.
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Morris K, Taylor NF, Freeman-Sanderson A. Safety-related outcomes for patients with a tracheostomy and the use of flexible endoscopic evaluation of swallowing (FEES) for assessment and management of swallowing: A systematic review. INTERNATIONAL JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2024:1-11. [PMID: 38462820 DOI: 10.1080/17549507.2023.2293633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
PURPOSE The purpose of this systematic review was to examine safety-related outcomes for patients with tracheostomy after flexible endoscopic evaluation of swallowing (FEES) to assess and manage their swallow, when compared to other non-instrumental swallow assessments such as clinical swallowing examination (CSE) and/or a modified Evans blue dye test (MEBDT). METHOD Three databases were searched for articles referring to safety-related outcome data for adults with a tracheostomy, who underwent FEES and CSE and/or MEBDT. Articles were screened using predefined inclusion/exclusion criteria. RESULT The search strategy identified 2097 articles; following abstract and full-text screening, seven were included for review. The summary of evidence found low to very low certainty that FEES was associated with improved outcomes across swallow safety, physiological outcomes, tracheostomy cannulation duration, functional outcomes, and detection of upper airway pathologies. CONCLUSION This systematic review demonstrated low to very low certainty evidence from seven heterogeneous studies with low sample sizes that incorporating FEES may be associated with improved safety-related outcomes. There is less evidence supporting the accuracy of other swallow assessments conducted at the point of care (i.e. CSE and MEBDT). Future research requires studies with larger sample sizes and routine reporting of safety-related outcomes with use of FEES.
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Affiliation(s)
- Katherine Morris
- Speech Pathology Department, Eastern Health, Melbourne, Australia
- School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Australia
| | - Nicholas F Taylor
- School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Australia
- Allied Health Clinical Research Office, Eastern Health, Box Hill, Australia
| | - Amy Freeman-Sanderson
- Graduate School of Health, University of Technology Sydney, Sydney, Australia
- Speech Pathology Department, Royal Prince Alfred Hospital, Sydney, Australia
- Critical Care Division, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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5
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Epperson MV, Mahajan A, Sethia R, Seim N, VanKoevering K, Morrison RJ. A deployable curriculum with 3D printed skills trainers for altered airway management. BMC MEDICAL EDUCATION 2024; 24:39. [PMID: 38191417 PMCID: PMC10773045 DOI: 10.1186/s12909-023-05013-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 12/26/2023] [Indexed: 01/10/2024]
Abstract
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.
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Affiliation(s)
- Madison V Epperson
- Department of Otolaryngology-Head & Neck Surgery, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-4241, USA.
| | - Arushi Mahajan
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Rishabh Sethia
- Department of Otolaryngology-Head & Neck Surgery, The Ohio State University, Columbus, OH, USA
| | - Nolan Seim
- Department of Otolaryngology-Head & Neck Surgery, The Ohio State University, Columbus, OH, USA
| | - Kyle VanKoevering
- Department of Otolaryngology-Head & Neck Surgery, The Ohio State University, Columbus, OH, USA
| | - Robert J Morrison
- Department of Otolaryngology-Head & Neck Surgery, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-4241, USA
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6
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Ear, nose and throat emergencies. ANAESTHESIA & INTENSIVE CARE MEDICINE 2023. [DOI: 10.1016/j.mpaic.2022.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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7
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Front-of-neck airway: percutaneous tracheostomy and cricothyrotomy. ANAESTHESIA & INTENSIVE CARE MEDICINE 2023. [DOI: 10.1016/j.mpaic.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
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8
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St-Laurent A, Zielinski D, Qazi A, AlAwadi A, Almajed A, Adamko DJ, Alabdoulsalam T, Chiang J, Derynck M, Gerdung C, Kam K, Katz SL, MacLusky I, Mehta K, Mateos D, Nguyen TTD, Praud JP, Proulx F, Seear M, Smith MJ, Wensley D, Amin R. Chronic tracheostomy care of ventilator-dependent and -independent children: Clinical practice patterns of pediatric respirologists in a publicly funded (Canadian) healthcare system. Pediatr Pulmonol 2023; 58:140-151. [PMID: 36178281 DOI: 10.1002/ppul.26171] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 09/06/2022] [Accepted: 09/25/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To describe the current clinical practice patterns of Canadian pediatric respirologists at pediatric tertiary care institutions regarding chronic tracheostomy tube care and management of home invasive ventilation. METHODS A pediatric respirologist/pediatrician with expertise in tracheostomy tube care and home ventilation was identified at each Canadian pediatric tertiary care center to complete a 59-item survey of multiple choice and short answer questions. Domains assessed included tracheostomy tube care, caregiver competency and home monitoring, speaking valves, medical management of tracheostomy complications, decannulation, and long-term follow-up. RESULTS The response rate was 100% (17/17) with all Canadian tertiary care pediatric centers represented and heterogeneity of practice was observed in all domains assessed. For example, though most centers employ Bivona™ (17/17) and Shiley™ (15/17) tracheostomy tubes, variability was observed around tube change, re-use, and cleaning practices. Most centers require two trained caregivers (14/17) and recommend 24/7 eyes on care and oxygen saturation monitoring. Discharge with an emergency tracheostomy kit was universal (17/17). Considerable heterogeneity was observed in the timing and use of speaking valves and speech-language assessment. Inhaled anti-pseudomonal antibiotics are employed by most centers (16/17) though the indication, agent, and protocol varied by center. Though decannulation practices varied considerably, the requirement of upper airway patency was universally required to proceed with decannulation (17/17) independent of ongoing ventilatory support requirements. CONCLUSION Considerable variability in pediatric tracheostomy tube care practice exists across Canada. These results will serve as a starting point to standardize and evaluate tracheostomy tube care nationally.
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Affiliation(s)
- Aaron St-Laurent
- Department of Paediatrics, Division of Respiratory Medicine, Children's Hospital-London Health Sciences Centre, London, Ontario, Canada
| | - David Zielinski
- Division of Pediatric Respirology, Department of Pediatrics, Montreal Children's Hospital/McGill University, Montreal, Quebec, Canada.,Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Adam Qazi
- Department of Pediatrics, The Division of Respiratory Medicine, Toronto, The Hospital for Sick Children, Ontario, Canada
| | - Aceel AlAwadi
- Mubarak Al-Kabeer Hospital, Ministry of Health of Kuwait, Jabriya, Kuwait
| | - Athari Almajed
- Mubarak Al-Kabeer Hospital, Ministry of Health of Kuwait, Jabriya, Kuwait
| | - Darryl J Adamko
- Department of Pediatrics, Division of Respiratory Medicine, Jim Pattison's Children's Hospital, Saskatoon, Saskatchewan, Canada
| | - Tareq Alabdoulsalam
- Section of Pediatric Respirology, Department of Pediatrics and Child Health, HSC Winnipeg Children's Hospital/University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jackie Chiang
- Department of Pediatrics, The Division of Respiratory Medicine, Toronto, The Hospital for Sick Children, Ontario, Canada
| | - Michael Derynck
- Department of Pediatrics, Kingston Health Sciences Centre/Queen's University, Kingston, Ontario, Canada
| | - Chris Gerdung
- Stollery Children's Hospital, Department of Pediatrics, The Division of Respiratory Medicine, University of Alberta, Edmonton Alberta, Canada
| | - Karen Kam
- Department of Pediatrics, Section of Respiratory Medicine, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Sherri L Katz
- Department of Pediatrics, Division of Respiratory Medicine, Children's Hospital of Eastern Ontario/University of Ottawa, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Ian MacLusky
- Department of Pediatrics, Division of Respiratory Medicine, Children's Hospital of Eastern Ontario/University of Ottawa, Ottawa, Ontario, Canada
| | - Kevan Mehta
- Department of Pediatrics, Division of Respirology, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Dimas Mateos
- Department of Pediatrics, Pediatric Respirology, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - The Thanh D Nguyen
- Department of Pediatrics, Division of Respirology, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Jean-Paul Praud
- Division of Respiratory Medicine, Department of Pediatrics, University of Sherbrooke, Quebec, Canada
| | - Frederic Proulx
- Department of Pediatrics, Division of Respirology, CHUL et Centre Mère-Enfant Soleil, Quebec, Quebec, Canada
| | - Michael Seear
- Division of Pediatric Respiratory Medicine, Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Mary Jane Smith
- Department of Pediatrics, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Canada
| | - David Wensley
- Division of Pediatric Respiratory Medicine, Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Reshma Amin
- Department of Pediatrics, The Division of Respiratory Medicine, Toronto, The Hospital for Sick Children, Ontario, Canada
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9
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Boggiano S, Williams T, Gill SE, Alexander PDG, Khwaja S, Wallace S, McGrath BA. Multidisciplinary management of laryngeal pathology identified in patients with COVID-19 following trans-laryngeal intubation and tracheostomy. J Intensive Care Soc 2022; 23:425-432. [PMID: 36751349 PMCID: PMC9679906 DOI: 10.1177/17511437211034699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background COVID-19 disease often requires invasive ventilatory support. Trans-laryngeal intubation of the trachea may cause laryngeal injury, possibly compounded by coronavirus infection. Fibreoptic Endoscopic Evaluation of Swallowing (FEES) provides anatomical and functional assessment of the larynx, guiding multidisciplinary management. Our aims were to observe the nature of laryngeal abnormalities in patients with COVID-19 following prolonged trans-laryngeal intubation and tracheostomy, and to describe their impact on functional laryngeal outcomes, such as tracheostomy weaning. Methods A retrospective observational cohort analysis was undertaken between March and December 2020, at a UK tertiary hospital. The Speech and Language Therapy team assessed patients recovering from COVID-19 with voice/swallowing problems identified following trans-laryngeal intubation or tracheostomy using FEES. Laryngeal pathology, treatments, and outcomes relating to tracheostomy and oral feeding were noted. Results Twenty-five FEES performed on 16 patients identified a median of 3 (IQR 2-4) laryngeal abnormalities, with 63% considered clinically significant. Most common pathologies were: oedema (n = 12, 75%); abnormal movement (n = 12, 75%); atypical lesions (n = 11, 69%); and erythema (n = 6, 38%). FEES influenced management: identifying silent aspiration (88% of patients who aspirated (n = 8)), airway patency issues impacting tracheostomy weaning (n = 8, 50%), targeted dysphagia therapy (n = 7, 44%); ENT referral (n = 6, 38%) and reflux management (n = 5, 31%). Conclusions FEES is beneficial in identifying occult pathologies and guiding management for laryngeal recovery. In our cohort, the incidence of laryngeal pathology was higher than a non-COVID-19 cohort with similar characteristics. We recommend multidisciplinary investigation and management of patients recovering from COVID-19 who required prolonged trans-laryngeal intubation and/or tracheostomy to optimise laryngeal recovery.
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Affiliation(s)
- Sarah Boggiano
- Department of Speech, Voice and Swallowing, Wythenshawe
Hospital, Wythenshawe, UK,Manchester University NHS Foundation Trust, Manchester, UK
| | - Thomas Williams
- University Hospitals of Morecambe Bay NHS Foundation Trust,
Lancaster, UK,Thomas Williams, University Hospitals of
Morecambe Bay NHS Foundation Trust, Lancaster, UK.
| | - Sonya E Gill
- Manchester University NHS Foundation Trust, Manchester, UK,Acute Intensive Care Unit, Wythenshawe Hospital, Wythenshawe,
UK
| | - Peter DG Alexander
- Manchester University NHS Foundation Trust, Manchester, UK,Acute Intensive Care Unit, Wythenshawe Hospital, Wythenshawe,
UK,Manchester Academic Critical Care, Division of Infection,
Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of
Biology, Medicine and Health, the University of Manchester, Manchester Academic
Health Science Centre, Manchester, UK
| | - Sadie Khwaja
- Manchester University NHS Foundation Trust, Manchester, UK,Department of Head & Neck Surgery, Wythenshawe Hospital,
Wythenshawe, UK
| | - Sarah Wallace
- Department of Speech, Voice and Swallowing, Wythenshawe
Hospital, Wythenshawe, UK,Manchester University NHS Foundation Trust, Manchester, UK,Acute Intensive Care Unit, Wythenshawe Hospital, Wythenshawe,
UK
| | - Brendan A McGrath
- Manchester University NHS Foundation Trust, Manchester, UK,Acute Intensive Care Unit, Wythenshawe Hospital, Wythenshawe,
UK,Manchester Academic Critical Care, Division of Infection,
Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of
Biology, Medicine and Health, the University of Manchester, Manchester Academic
Health Science Centre, Manchester, UK
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10
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Park BC, Mallemat H. Special Procedures for Pulmonary Disease in the Emergency Department. Emerg Med Clin North Am 2022; 40:583-602. [PMID: 35953218 DOI: 10.1016/j.emc.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In the emergency department, there are infrequent but essential procedures related to pulmonary diseases that emergency physicians must be able to perform. These include thoracentesis, chest tube thoracostomy, tracheostomy manipulation, and fiberoptic intubation.
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Affiliation(s)
- Brian C Park
- Critical Care Medicine Program, Cooper Medical School of Rowan University, Cooper University Hospital, 1 Cooper Plaza, Dorrance 4th Floor, Suite D427, Camden, NJ 08103, USA.
| | - Haney Mallemat
- Emergency Medicine/Critical Care Medicine Program, Cooper Medical School of Rowan University, Cooper University Hospital, 1 Cooper Plaza, Dorrance 4th Floor, Suite D427, Camden, NJ 08103, USA. https://twitter.com/CritCareNow
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11
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Akhtar AB, Khan A, Saleem H, Mannan Z, Azhar MN. Emergency Management of Ventilation Failure Through Blocked Tracheostomy Tube in a Paediatric Patient. Cureus 2022; 14:e26873. [PMID: 35978764 PMCID: PMC9375839 DOI: 10.7759/cureus.26873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2022] [Indexed: 11/05/2022] Open
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12
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Kristinsdottir EA, Sigvaldason K, Karason S, Jonasdottir RJ, Bodvarsdottir R, Olafsson O, Tryggvason G, Gudbjartsson T, Sigurdsson MI. Utilization and outcomes of tracheostomies in the intensive care unit in Iceland in 2007-2020: A descriptive study. Acta Anaesthesiol Scand 2022; 66:996-1002. [PMID: 35704855 DOI: 10.1111/aas.14105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 05/17/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Tracheostomies are commonly utilized in ICU patients due to prolonged mechanical ventilation, upper airway obstruction, or surgery in the face/neck region. However, practices regarding the timing of placement and utilization vary. This study provides a nationwide overview of tracheostomy utilization and outcomes in the ICU over a 14-year period. METHODS A retrospective study including all patients that received a tracheostomy during their ICU stay in Iceland between 2007 and 2020. Data were retrieved from hospital records on admission cause, comorbidities, indication for tracheostomy insertion, duration of mechanical ventilation before and after tracheostomy placement, extubation attempts, complications, length of ICU and hospital stay and survival. Descriptive statistics were provided, and survival analysis was performed using Cox regression. RESULTS A total of 336 patients (median age 64 years, 33% females) received a tracheostomy during the study period. The most common indication for tracheostomy insertion was respiratory failure, followed by neurological disorders. The median duration of mechanical ventilation prior to tracheostomy insertion was 9 days and at least one extubation had been attempted in 35% of the cases. Percutaneous tracheostomies were 32%. The overall rate of complications was 25% and the most common short-term complication was bleeding (5%). In-hospital mortality was 33%. The one- and five-year survival rate was 60% and 44%, respectively. CONCLUSIONS We describe a whole-nation practice of tracheostomies. A notable finding is the relatively low rate of extubation attempts prior to tracheostomy insertion. Future work should focus on standardization of assessing the need for tracheostomy and the role of extubation attempts prior to tracheostomy placement.
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Affiliation(s)
- Eyrun A Kristinsdottir
- Division of Anaesthesia and Intensive Care, Perioperative Services at Landspitali, the National University Hospital of Iceland, Reykjavik, Iceland
| | - Kristinn Sigvaldason
- Division of Anaesthesia and Intensive Care, Perioperative Services at Landspitali, the National University Hospital of Iceland, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Sigurbergur Karason
- Division of Anaesthesia and Intensive Care, Perioperative Services at Landspitali, the National University Hospital of Iceland, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Rannveig J Jonasdottir
- Division of Anaesthesia and Intensive Care, Perioperative Services at Landspitali, the National University Hospital of Iceland, Reykjavik, Iceland
| | - Regina Bodvarsdottir
- Division of Anaesthesia and Intensive Care, Perioperative Services at Landspitali, the National University Hospital of Iceland, Reykjavik, Iceland
| | - Oddur Olafsson
- Division of Anaesthesia and Intensive Care, Perioperative Services at Akureyri Hospital, Akureyri, Iceland
| | - Geir Tryggvason
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Otorhinolaryngology at Landspitali, the National University Hospital of Iceland, Reykjavik, Iceland
| | - Tomas Gudbjartsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Cardiothoracic Surgery at Landspitali, the National University Hospital of Iceland, Reykjavik, Iceland
| | - Martin I Sigurdsson
- Division of Anaesthesia and Intensive Care, Perioperative Services at Landspitali, the National University Hospital of Iceland, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
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13
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Budde AM, Kadar RB, Jabaley CS. Airway misadventures in adult critical care: a concise narrative review of managing lost or compromised artificial airways. Curr Opin Anaesthesiol 2022; 35:130-136. [PMID: 35131969 DOI: 10.1097/aco.0000000000001105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Loss or compromise of artificial airways in critically ill adults can lead to serious adverse events, including death. In contrast to primary emergency airway management, the optimal management of such scenarios may not be well defined or appreciated. RECENT FINDINGS Endotracheal tube cuff leaks may compromise both oxygenation and ventilation, and supraglottic cuff position must first be recognized and distinguished from other reasons for gas leakage during positive pressure ventilation. Although definitive management involves tube exchange, if direct visualization is possible temporizing measures can often be considered. Unplanned extubation confers variable and context-specific risks depending on patient anatomy and physiological status. Because risk factors for unplanned extubation are well established, bundled interventions can be employed for mitigation. Tracheostomy tube dislodgement accounts for a substantial proportion of death and disability related to airway management in critical care settings. Consensus guidelines and algorithmic management of such scenarios are key elements of risk mitigation. SUMMARY Management of lost or otherwise compromised artificial airways is a key skill set for adult critical care clinicians alongside primary emergency airway management.
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Affiliation(s)
- Anna M Budde
- Division of Critical Care Medicine, Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Rachel B Kadar
- Section of Critical Care Medicine, Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Craig S Jabaley
- Division of Critical Care Medicine, Department of Anesthesiology, Emory University School of Medicine
- Emory Critical Care Center, Atlanta, GA
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14
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Gardner LA, Jones R, Rassekh C, Atkins J. Tracheostomy and Laryngectomy Airway Safety Events: An Analysis of Patient Safety Reports From 84 Hospitals. PATIENT SAFETY 2022. [DOI: 10.33940/data/2022.3.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Tracheostomy- and laryngectomy-related airway safety events can lead to life-threatening situations, permanent harm, or death. We conducted a statewide population-based study to learn about these events and the relationship with associated factors, interventions, and outcomes to identify potential areas for improvement.
Methods: We queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) to find tracheostomy- and laryngectomy-related airway safety event reports involving adults age 18 years and older that occurred between January 1, 2018, and December 31, 2020.
Results: Reports related to tracheostomies and laryngectomies accounted for 97.3% and 2.7% of the total, respectively. The four most frequent tracheostomy-related complications were unplanned decannulations, 71.4%; uncontrolled bleeding/hemorrhage, 9.2%; and partial/total occlusion and mucus plug/thick secretions, which each accounted for 6.9%.
Conclusions: Safe airway management for patients with a tracheostomy or laryngectomy requires staff who are knowledgeable and confident, and have the necessary skills and equipment to provide immediate attention when complications arise. We discuss potential safety strategies to reduce the risk of unplanned decannulations, uncontrolled bleeding/hemorrhage, and partial/total occlusions, as well as issues related to equipment, knowledge/training, and communication.
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15
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Atkins J, Lambe L, Marchiano L, Gardner LA, Lam D, Rassekh C. System-Based Multidisciplinary Initiatives for Improvement in Tracheostomy Care and Safety: Experience of an Academic Health Institution Hospital Network. PATIENT SAFETY 2022. [DOI: 10.33940/med/2022.3.4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Tracheostomized patients represent a unique patient population at risk of life-threatening airway compromise. There can be a presumption that these patients have a “safe” or low-risk airway. Clinicians and other care providers may be unfamiliar with both tracheostomy tubes and best practices for tracheostomy maintenance, assessment, and emergency triage or resuscitation. A review of the highest- acuity emergency airway calls at our university hospital revealed that well over 20% of the emergencies that triggered these activations were in patients with existing tracheostomy tubes. Further analysis of the tracheostomy-related airway emergencies at that time was very informative.
Under the auspices of our multidisciplinary airway safety committee, we developed a core tracheostomy-focused team and implemented numerous quality and safety initiatives. Here we present a focused review and discussion of tracheostomy-related clinical issues at the University of Pennsylvania Health System (UPHS) and a summary of quality and safety improvement efforts related to the care of tracheostomized patients based on responses to locally identified safety opportunities.
Our experience with tracheostomy-related quality improvement (QI) efforts led us to reach out to the Patient Safety Authority. The Pennsylvania Patient Safety Reporting System (PA-PSRS) data presented by Gardner et al. highlights the categories of airway-related events documented across a range of facilities in the Commonwealth of Pennsylvania. We frame our efforts in the context of both the PA-PSRS data and international perspectives from the U.K. and highlight barriers to implementation and learnings from our iterative and interdisciplinary approach to tracheostomy-related challenges.
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16
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Quinton BA, Tierney WS, Bryson PC, Bribriesco A, Gillespie CT, Hopkins BD. An institution-wide tracheostomy rounding team: Initial caregiver perceptions. Am J Otolaryngol 2022; 43:103367. [PMID: 34991021 DOI: 10.1016/j.amjoto.2021.103367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 12/13/2021] [Accepted: 12/18/2021] [Indexed: 11/01/2022]
Abstract
PURPOSE To analyze and present the initial findings of provider perceptions regarding the impact of the implementation of a hospital-wide Tracheostomy Rounding Team (TRT) on the delivery of tracheostomy care at the Cleveland Clinic. MATERIALS AND METHODS Based on prior literature, a novel multidisciplinary TRT was designed and implemented at the Cleveland Clinic in December of 2018. After the TRT began clinical care, a previously validated RedCap survey was administered anonymously to 358 caregivers to assess provider experience, comfort, and prior education regarding tracheostomy management. Survey results were collected, and descriptive statistics were applied. Answers were compared between providers who interacted with the TRT clinically and those who did not. RESULTS 42.9% of providers who interacted with the TRT clinically reported that the TRT improved hands-on assistance with tracheostomy care, and 36.7% reported that the TRT improved the identification of safety concerns. Similarly, 34.7% reported that the TRT improved the overall quality of tracheostomy care at the Cleveland Clinic. Providers with active exposure to the TRT additionally reported statistically higher comfort with multiple topics surrounding tracheostomy care. CONCLUSIONS The implementation of this team improved provider comfort in managing patients with tracheostomies both qualitatively and quantifiably. This intervention offered a perceived benefit to patient care at our institution. Further study of the impact of this team on quantitative patient outcomes is forthcoming.
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Affiliation(s)
- Brooke A Quinton
- Case Western Reserve University School of Medicine, 10900 Euclid Ave, Cleveland, OH 44106, USA
| | - William S Tierney
- Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Paul C Bryson
- Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | | | - Colin T Gillespie
- Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Brandon D Hopkins
- Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, USA..
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17
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Iliff HA, El-Boghdadly K, Ahmad I, Davis J, Harris A, Khan S, Lan-Pak-Kee V, O'Connor J, Powell L, Rees G, Tatla TS. Management of haematoma after thyroid surgery: systematic review and multidisciplinary consensus guidelines from the Difficult Airway Society, the British Association of Endocrine and Thyroid Surgeons and the British Association of Otorhinolaryngology, Head and Neck Surgery. Anaesthesia 2021; 77:82-95. [PMID: 34545943 PMCID: PMC9291554 DOI: 10.1111/anae.15585] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2021] [Indexed: 12/16/2022]
Abstract
Haematoma after thyroid surgery can lead to airway obstruction and death. We therefore developed guidelines to improve the safety of peri‐operative care of patients undergoing thyroid surgery. We conducted a systematic review to inform recommendations, with expert consensus used in the absence of high‐quality evidence, and a Delphi study was used to ratify recommendations. We highlight the importance of multidisciplinary team management and make recommendations in key areas including: monitoring; recognition; post‐thyroid surgery emergency box; management of suspected haematoma following thyroid surgery; cognitive aids; post‐haematoma evacuation care; day‐case thyroid surgery; training; consent and pre‐operative communication; postoperative communication; and institutional policies. The guidelines support a multidisciplinary approach to the management of suspected haematoma following thyroid surgery through oxygenation and evaluation; haematoma evacuation; and tracheal intubation. They have been produced with materials to support implementation. While these guidelines are specific to thyroid surgery, the principles may apply to other forms of neck surgery. These guidelines and recommendations provided are the first in this area and it is hoped they will support multidisciplinary team working, improving care and outcomes for patients having thyroid surgery.
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Affiliation(s)
- H A Iliff
- Department of Anaesthesia, Cwm Taf Morgannwg University Health Board, Merthyr, UK.,Health Education and Improvement Wales, Cardiff, UK
| | - K El-Boghdadly
- Department of Anaesthesia and Peri-operative Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London, London, UK
| | - I Ahmad
- Department of Anaesthesia and Peri-operative Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London, London, UK
| | - J Davis
- Department of Otolaryngology Head and Neck Surgery, Medway NHS Foundation Trust, Gillingham, UK
| | - A Harris
- Patient Representative, London, UK
| | - S Khan
- Department of Endocrine Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - V Lan-Pak-Kee
- Department of Anaesthesia, Barts Health NHS Trust, London, UK
| | - J O'Connor
- Department of Otolaryngology Head and Neck Surgery, London North West University Healthcare NHS Trust, London, UK
| | - L Powell
- Department of Anaesthesia, Cwm Taf Morgannwg University Health Board, Merthyr, UK.,Health Education and Improvement Wales, Cardiff, UK
| | - G Rees
- Department of Anaesthesia, Cwm Taf Morgannwg University Health Board, Merthyr, UK
| | - T S Tatla
- Department of Otolaryngology Head and Neck Surgery, London North West University Healthcare NHS Trust, London, UK
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18
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Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2021. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2021 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
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Affiliation(s)
- Thomas Williams
- Academic Foundation Trainee, University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, UK
| | - Brendan A McGrath
- Acute Intensive Care Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.
- Manchester Academic Critical Care, Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.
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19
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Khanum T, Zia S, Khan T, Kamal S, Khoso MN, Alvi J, Ali A. Assessment of knowledge regarding tracheostomy care and management of early complications among healthcare professionals. Braz J Otorhinolaryngol 2021; 88:251-256. [PMID: 34419386 PMCID: PMC9422647 DOI: 10.1016/j.bjorl.2021.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 04/13/2021] [Accepted: 06/28/2021] [Indexed: 12/03/2022] Open
Abstract
Healthcare workers should be well versed in identifying tracheostomy management, its complications and responding accordingly. Doctors and nurses (131 = 52%) possessed good knowledge about various aspects of tracheostomy care and management. The poorest scores were regarding cuff pressure (38.9%), suction pressure (39.4%) and first response in tube blockade (31.1%). Higher scores were found in age group 26 to 30 years (54.2%) and those having 1-3 years of clinical experience (41.2%). No statistically significant assoiation of knowledge regarding tracheostomy care was apparent with age, gender or years of practice.
Introduction Tracheostomy is commonly performed surgical procedure in ENT practice. Postoperative care is the most important aspect for achieving good patient outcomes. Unavailability of standard guidelines on tracheostomy management and inadequate training can make this basic practice complex. The nursing staff and doctors play a very important role in bedside management, both in the ward and in the intensive care unit (ICU) setup. Therefore, it is crucial that all healthcare providers directly involved in providing postoperative care to such patients can do this efficiently. Objectives The objective of this study is to assess the knowledge regarding identification and management of tracheostomy-related emergencies and early complications among healthcare professionals so as to improve practice and further standardization. Methods Cross-sectional observational study included two hundred and fifty-four doctors and nurses from four large tertiary care hospitals. The questions used were simple and straightforward regarding tracheostomy suctioning, cuff care, cuff management, tube blockage, and feeding management in patients with tracheostomy. Results Based on evidence from our study, knowledge level regarding tracheostomy care ranges from 48% to 52% with knowledge scores above 50% being considered satisfactory. Significant gaps in knowledge exist in various aspects of tracheostomy care and management among healthcare professionals. Conclusion Our findings demonstrated an adequate knowledge level among health care professionals ranging from 48% to 52% with knowledge scores above 50% being considered satisfactory and revealed that gaps in knowledge still exist in various aspects of tracheostomy care and management.
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Affiliation(s)
- Tooba Khanum
- Department of Otolaryngology, Head & Neck Surgery (ENT), DIMC (Ohja Campus), DUHS, Karachi, Pakistan
| | - Sadaf Zia
- Department of Otolaryngology, Head & Neck Surgery (ENT), DIMC (Ohja Campus), DUHS, Karachi, Pakistan
| | - Tahseer Khan
- Department of Otolaryngology, Head & Neck Surgery (ENT), DIMC (Ohja Campus), DUHS, Karachi, Pakistan.
| | - Saima Kamal
- Department of Pulmonary and Critical Care, DIMC, DUHS (Ojha Campus), Karachi, Pakistan
| | - Muhammad Nasir Khoso
- Department of Critical Care Medicine, Department of Anesthesiology, Aga Khan University, Pakistan
| | - Javeria Alvi
- Department of Surgery, Jinnah Post Graduate Medical Centre, Karachi, Pakistan
| | - Arif Ali
- School of Public Health, Dow University of Health Sciences, Karachi, Pakistan
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20
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Tarver EM, Jefferson GD, Parker P, Readman K, Marocho SMS, Lerant AA. Modified Manikin for Tracheoinnominate Artery Fistula. JOURNAL OF EDUCATION & TEACHING IN EMERGENCY MEDICINE 2021; 6:I1-I8. [PMID: 37465073 PMCID: PMC10334440 DOI: 10.21980/j8z93h] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/15/2021] [Indexed: 07/20/2023]
Abstract
Audience This simulator is designed to instruct emergency medicine residents in tracheostomy training that involves bleeding from the tracheostomy site. Any resident, fellow, or attending physician who cares for patients with complications from their tracheostomy might benefit from this innovation. Introduction The emergency medicine provider must maintain proficiency in caring for patients with complications from their tracheostomy. In the United States, over 110,000 patients receive tracheostomies per year.1 A rare but catastrophic complication of tracheostomies, usually within the first month of placement, is a tracheoinnominate artery fistula (TIAF). This complication occurs in 0.7% of tracheostomy patients and carries a 50-70% mortality.1,2 We modified a low-fidelity tracheostomy manikin to instruct learners in the stepwise management of hemorrhage from a TIAF. Educational Objectives By the end of this educational session, learners will be able to:Perform a focused history and physical exam on any patient who presents with bleeding from the tracheostomy site.Describe the differential diagnosis of bleeding from a tracheostomy site, including a TIAF.Demonstrate the stepwise management of bleeding from a suspected TIAF, including cuff hyperinflation and the Utley Maneuver.Verify that definitive airway control via endotracheal intubation is only feasible in the tracheostomy patient when it is clear, upon history and exam, that the patient can be intubated from above.Demonstrate additional critical actions in the management of a patient with a TIAF, including early consultation with otolaryngology and cardiothoracic surgery as well as emergent blood transfusion and activation of a massive transfusion protocol. Educational Methods This modified manikin is a useful training tool for any healthcare provider who is involved in the treatment and stabilization of a variety of tracheostomy emergencies, from bleeding to infection to obstruction or dislodgement. Our case was presented on two separate occasions, to otolaryngology interns (PGY-1), and emergency medicine residents (PGY 1-3). It involved the care of a patient with a sentinel bleed and subsequent hemorrhage from a tracheoinnominate artery fistula (TIAF). This low-fidelity tracheostomy manikin provides the ideal platform for any complex, tracheostomy case, particularly where ongoing bleeding from the tracheostomy site might permanently damage the electrical circuitry of a high-fidelity model. We initially fashioned this modified manikin for tracheostomy training during a simulation "boot camp" for otolaryngology PGY-1 residents. Our use of this modified manikin for tracheostomy training was a useful teaching tool during our otolaryngology intern "boot camp." As a result, we organized a subsequent simulation training session with our PGY 1-3 emergency medicine residents to provide similar instruction in management of a TIAF. Research Methods We provided a pre- and a post-simulation survey for the 33 emergency medicine residents who participated in the TIAF simulation with our modified tracheostomy manikin. There were 11 residents from each of the PGY-1, PGY-2, and PGY-3 year-groups. Thirty-two residents (97%) completed the pre-simulation survey, and 33 residents (100%) completed the post-simulation survey. We used a 6-point Likert Scale from "strongly agree" to "strongly disagree" to assess a resident's knowledge of multiple learning objectives within this simulation. Results The pre- and post-simulation survey supported this simulation and manikin innovation as a useful teaching tool for tracheostomy emergencies such as a TIAF. Discussion This was a useful innovation for emergency provider training in the recognition and management of a TIAF, a rare but emergent tracheostomy complication. In addition to this bleeding complication, this innovation might be useful for a variety of tracheostomy emergencies such as site infection, obstruction, and tube dislodgement. We highly recommend the involvement of both an emergency medicine and otolaryngology content expert in the design and debriefing of tracheostomy cases with this modified manikin. In our experience, a facilitated debriefing by an experienced clinician and educator from both fields provided a diverse perspective for challenging cases such as bleeding from a TIAF. Topics Difficult airway, tracheostomy, tracheoinnominate fistula, hemorrhagic shock, tracheostomy complications, Utley Maneuver.
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Affiliation(s)
- Emily M Tarver
- University of Mississippi Medical Center, Department of Emergency Medicine, Jackson, MS
| | - Gina D Jefferson
- University of Mississippi Medical Center, Department of Otolaryngology, Jackson, MS
| | - Patrick Parker
- University of Mississippi Medical Center, Simulation and Interprofessional Education Center, Jackson, MS
| | - Kristina Readman
- University of Mississippi Medical Center, Simulation and Interprofessional Education Center, Jackson, MS
| | - Susana M Salazar Marocho
- University of Mississippi Medical Center, Department of Biomedical Materials Science, School of Dentistry, Jackson, MS
| | - Anna A Lerant
- University of Mississippi Medical Center, Simulation and Interprofessional Education Center, Jackson, MS
- University of Mississippi Medical Center, Department of Anesthesiology, Jackson, MS
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21
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Senior A, Chan J, Brookes K, Jolly K, Darr A, Ameen R. Emergency management of neck stoma patients during the coronavirus pandemic: a national nurse survey. ACTA ACUST UNITED AC 2021; 30:742-746. [PMID: 34170732 DOI: 10.12968/bjon.2021.30.12.742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Neck stoma patient care involves significant clinical complexity. Inadequate staff training, equipment provision and infrastructure have all been highlighted as causes for avoidable patient harm. AIMS To establish the perception of knowledge and confidence levels relating to the emergency management of neck stomas among UK nurses during the COVID-19 pandemic. METHOD A nationwide prospective electronic survey of both primary and secondary care nurses via the Royal College of Nursing and social media. FINDINGS 402 responses were collated: 81 primary care and 321 secondary care; the majority (n=130) were band 5. Forty-nine per cent could differentiate between a laryngectomy and a tracheostomy; ENT nurses scored highest (1.56; range 0-2) on knowledge. Fifty-seven per cent could oxygenate a tracheostomy stoma correctly and 54% could oxygenate a laryngectomy stoma correctly. Sixty-five per cent cited inadequate neck stoma training and 91% felt inclusion of neck stoma training was essential within the nursing curriculum. CONCLUSION Clinical deficiencies of management identified by nurses can be attributed to a lack of confidence secondary to reduced clinical exposure and education.
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Affiliation(s)
- Andrew Senior
- ENT Registrar, Birmingham Women's and Children's NHS Foundation Trust
| | | | - Kim Brookes
- Head and Neck Clinical Nurse Specialist, Royal Wolverhampton New Cross Hospital, Wolverhampton
| | - Karan Jolly
- ENT Registrar, Princess Royal Hospital, Telford
| | - Adnan Darr
- ENT Registrar, Princess Royal Hospital, Telford
| | - Rohan Ameen
- ENT Senior House Officer, Princess Royal Hospital, Telford
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22
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Stangoe D, Nikolaou K, Townsend J. Tracheostomy obstruction refractory to conventional management strategies. Anaesth Rep 2021; 9:95-96. [PMID: 34027409 PMCID: PMC8126893 DOI: 10.1002/anr3.12108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
- D Stangoe
- Department of Anaesthesia Kings College Hospital London UK
| | - K Nikolaou
- Department of Physiotherapy Walsall Manor Hospital Walsall UK
| | - J Townsend
- Department of Anaesthesia Kings College Hospital London UK
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23
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McGrath BA, Heaton TE. The role of algorithms in guiding emergency airway management. Anaesth Rep 2021; 9:85. [PMID: 33981999 PMCID: PMC8103083 DOI: 10.1002/anr3.12117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2021] [Indexed: 11/18/2022] Open
Affiliation(s)
- B A McGrath
- Department of Anaesthesia and Critical Care Manchester University NHS Foundation Trust Manchester UK
| | - T E Heaton
- Department of Anaesthesia and Critical Care Manchester University NHS Foundation Trust Manchester UK
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24
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Brenner MJ, Cramer JD, McGrath BA, Balakrishnan K, Stepan KO, Pandian V, Roberson DW, Shah RK, Chen AY, Brook I, Nussenbaum B. Oral Intubation Attempts in Patients With a Laryngectomy: A Significant Safety Threat. Otolaryngol Head Neck Surg 2021; 164:1040-1043. [PMID: 33048019 DOI: 10.1177/0194599820960728] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 08/23/2020] [Indexed: 01/05/2023]
Abstract
It is impossible to secure the airway of a patient with "neck-only" breathing transorally or transnasally. Surgical removal of the larynx (laryngectomy) or tracheal rerouting (tracheoesophageal diversion or laryngotracheal separation) creates anatomic discontinuity. Misguided attempts at oral intubation of neck breathers may cause hypoxic brain injury or death. We present national data from the American Academy of Otolaryngology-Head and Neck Surgery, the American Head and Neck Society, and the United Kingdom's National Reporting and Learning Service. Over half of US otolaryngologist respondents reported instances of attempted oral intubations among patients with laryngectomy, with a mortality rate of 26%. UK audits similarly revealed numerous resuscitation efforts where misunderstanding of neck breather status led to harm or death. Such data underscore the critical importance of staff education, patient engagement, effective signage, and systems-based best practices to reliably clarify neck breather status and provide necessary resources for safe patient airway management.
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Affiliation(s)
- Michael J Brenner
- Department of Otolaryngology-Head and Neck Surgery, Medical School, University of Michigan, Ann Arbor, Michigan, USA
| | - John D Cramer
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Wayne State University, Detroit, Michigan, USA
| | - Brendan A McGrath
- National Tracheostomy Safety Project, National Health System, Manchester, UK
- Anaesthesia and Intensive Care Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - Karthik Balakrishnan
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Stanford University, Stanford, California, USA
| | - Katelyn O Stepan
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Vinciya Pandian
- Society of Otorhinolaryngology and Head-Neck Nurses, School of Nursing, Johns Hopkins University
| | | | - Rahul K Shah
- Children's National Medical Center, Washington, DC, USA
| | - Amy Y Chen
- Department of Otolaryngology-Head and Neck Surgery, Winship Cancer Institute, School of Medicine, Emory University, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | - Brian Nussenbaum
- American Board of Otolaryngology-Head and Neck Surgery, Houston, Texas, USA
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25
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Abstract
ZusammenfassungIm Rahmen des nichttraumatologischen Schockraummanagements zur Versorgung kritisch kranker Patienten werden akute Störungen der Vitalfunktionen rasch detektiert und interdisziplinär behandelt. Beim „primary survey“ dient das etablierte ABCDE-Schema der strukturierten Untersuchung aller relevanten Vitalparameter, Störungen werden hierbei sofort therapiert. „A-Probleme“ gehen mit einer drohenden Atemwegsverlegung und damit einer konsekutiven Hypoxie einher. Unterschiedlichste Pathologien können hier zugrunde liegen, meist ist aber zunächst eine symptomatische Therapie, also die Sicherung der Atemwege, die entscheidende Notfallmaßnahme. Ein strukturiertes Konzept zum Atemwegsmanagement unter Berücksichtigung lokaler Gegebenheiten sollte in jeder Notaufnahme etabliert sein und regelmäßig trainiert werden.
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26
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Graham JM, Fisher CM, Cameron TS, Streader TG, Warrillow SJ, Chao C, Chong CK, Ellard L, Hamoline JL, McMurray KA, Phillips DJ, Ross JM, Vu Q. Emergency tracheostomy management cognitive aid. Anaesth Intensive Care 2021; 49:227-231. [PMID: 33887975 PMCID: PMC8258718 DOI: 10.1177/0310057x21989722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
| | - Caleb M Fisher
- Intensive Care Department, Austin Health, Melbourne, Australia
| | - Tanis S Cameron
- Tracheostomy Review and Management Service, Austin Health, Melbourne, Australia
| | | | | | - Caroline Chao
- Tracheostomy Review and Management Service, Austin Health, Melbourne, Australia
| | | | - Louise Ellard
- Department of Anaesthesia, Austin Health, Melbourne, Australia
| | - Jerome L Hamoline
- Tracheostomy Review and Management Service, Austin Health, Melbourne, Australia
| | - Kristy A McMurray
- Yooralla Ventilator Accommodation Support Service, Melbourne, Australia
| | - Damien J Phillips
- Department of ENT Surgery, Austin Health, Melbourne, Australia.,Department of ENT Surgery, The Royal Children's Hospital Melbourne, Melbourne, Australia
| | - Jacqueline M Ross
- Tracheostomy Review and Management Service, Austin Health, Melbourne, Australia
| | - Quevy Vu
- Tracheostomy Review and Management Service, Austin Health, Melbourne, Australia
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Rosero EB, Corbett J, Mau T, Joshi GP. Intraoperative Airway Management Considerations for Adult Patients Presenting With Tracheostomy: A Narrative Review. Anesth Analg 2021; 132:1003-1011. [PMID: 33369928 DOI: 10.1213/ane.0000000000005330] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Tracheotomy is a surgical procedure through which a tracheostomy, an opening into the trachea, is created. Indications for tracheostomy include facilitation of airway management during prolonged mechanical ventilation, treatment of acute upper airway obstruction when tracheal intubation is unfeasible, management of chronic upper airway obstructive conditions, and planned airway management for major head and neck surgery. Patients who have a recent or long-term tracheostomy may present for a variety of surgical or diagnostic procedures performed under general anesthesia or sedation/analgesia. Airway management of these patients can be challenging and should be planned ahead of time. Anesthesia personnel should be familiar with the different components of cuffed and uncuffed tracheostomy devices and their connectivity to the anesthesia circuits. An appropriate airway management plan should take into account the indication of the tracheostomy, the maturity status of the stoma, the type and size of tracheostomy tube, the expected patient positioning, and presence of patient's concurrent health conditions. Management of the patient with a T-tube is highlighted. Importantly, there is a need for multidisciplinary care involving anesthesiologists, surgical specialists, and perioperative nurses. The aim of this narrative review is to discuss the anesthesia care of patients with a tracheostomy. Key aspects on relevant tracheal anatomy, tracheostomy tubes/devices, alternatives of airway management, and possible complications related to tracheostomy are summarized with a recommendation for an algorithm to manage intraoperative tracheostomy tube dislodgement.
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Affiliation(s)
- Eric B Rosero
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas
| | - John Corbett
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas
| | - Ted Mau
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Girish P Joshi
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas
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Srinivasan S, Senthilnathan M, Sivakumar RK, Mishra SK. A novel manoeuvre in succeeding rail-roading of tracheostomy tube. Indian J Anaesth 2021; 65:174-176. [PMID: 33776102 PMCID: PMC7983812 DOI: 10.4103/ija.ija_886_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/24/2020] [Accepted: 09/29/2020] [Indexed: 11/22/2022] Open
Affiliation(s)
- Suganya Srinivasan
- Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Muthapillai Senthilnathan
- Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Ranjith Kumar Sivakumar
- Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Sandeep Kumar Mishra
- Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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Chrimes N, Higgs A, Law JA, Baker PA, Cooper RM, Greif R, Kovacs G, Myatra SN, O'Sullivan EP, Rosenblatt WH, Ross CH, Sakles JC, Sorbello M, Hagberg CA. Project for Universal Management of Airways - part 1: concept and methods. Anaesthesia 2020; 75:1671-1682. [PMID: 33165958 PMCID: PMC7756721 DOI: 10.1111/anae.15269] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2020] [Indexed: 12/17/2022]
Abstract
Multiple professional groups and societies worldwide have produced airway management guidelines. These are typically targeted at the process of tracheal intubation by a particular provider group in a restricted category of patients and reflect practice preferences in a particular geographical region. The existence of multiple distinct guidelines for some (but not other) closely related circumstances, increases complexity and may obscure the underlying principles that are common to all of them. This has the potential to increase cognitive load; promote the grouping of ideas in silos; impair teamwork; and ultimately compromise patient care. Development of a single set of airway management guidelines that can be applied across and beyond these domains may improve implementation; promote standardisation; and facilitate collaboration between airway practitioners from diverse backgrounds. A global multidisciplinary group of both airway operators and assistants was assembled. Over a 3-year period, a review of the existing airway guidelines and multiple reviews of the primary literature were combined with a structured process for determining expert consensus. Any discrepancies between these were analysed and reconciled. Where evidence in the literature was lacking, recommendations were made by expert consensus. Using the above process, a set of evidence-based airway management guidelines was developed in consultation with airway practitioners from a broad spectrum of disciplines and geographical locations. While consistent with the recommendations of the existing English language guidelines, these universal guidelines also incorporate the most recent concepts in airway management as well as statements on areas not widely addressed by the existing guidelines. The recommendations will be published in four parts that respectively address: airway evaluation; airway strategy; airway rescue and communication of airway outcomes. Together, these universal guidelines will provide a single, comprehensive approach to airway management that can be consistently applied by airway practitioners globally, independent of their clinical background or the circumstances in which airway management occurs.
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Affiliation(s)
- N. Chrimes
- Department of AnaesthesiaMonash Medical CentreMelbourneAustralia
| | - A. Higgs
- Department of Anaesthesia and Intensive CareWarrington Hospitals NHS Foundation TrustCheshireUK
| | - J. A. Law
- Department of AnesthesiaPain Management and Peri‐operative MedicineDalhousie UniversityHalifaxCanada
| | - P. A. Baker
- Department of AnaesthesiologyUniversity of AucklandAucklandNew Zealand
- Department of AnaesthesiologyStarship Children's HospitalAucklandNew Zealand
| | - R. M. Cooper
- Department of Anesthesiology and Pain MedicineUniversity of TorontoTorontoCanada
| | - R. Greif
- Department of Anesthesiology and Pain MedicineBern University HospitalBernSwitzerland
- Sigmund Freud University ViennaViennaAustria
| | - G. Kovacs
- Departments of Emergency MedicineAnesthesiaMedical Neurosciences and Division of Medical EducationDalhousie UniversityHalifaxCanada
| | - S. N. Myatra
- Department of AnaesthesiologyCritical Care and PainTata Memorial HospitalHomi Bhabha National InstituteMumbaiIndia
| | | | | | - C. H. Ross
- Department of Emergency MedicineMercy HealthJavon Bea HospitalRockton and Riverside CampusesRockfordILUSA
- Department of SurgeryUniversity of Illinois College of MedicineChicagoILUSA
| | - J. C. Sakles
- Department of Emergency MedicineUniversity of Arizona College of MedicineTucsonAZUSA
| | - M. Sorbello
- Anesthesia and Intensive CareAOU Policlinico San Marco University HospitalCataniaItaly
| | - C. A. Hagberg
- AnesthesiologyCritical Care and Pain MedicineBud Johnson Clinical Distinguished ChairDepartment of Anaesthesiology and Peri‐operative MedicineUniversity of Texas MD Anderson Cancer CenterHoustonTXUSA
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30
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DeVictor S, Ong AA, Kelly AP, Burke MS. Postoperative Management After Tracheostomy and Laryngectomy: Improving Nursing Knowledge With Bedside Posters. OTO Open 2020; 4:2473974X20971185. [PMID: 33225200 PMCID: PMC7649854 DOI: 10.1177/2473974x20971185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 09/14/2020] [Indexed: 11/17/2022] Open
Abstract
This study sought to improve nursing staff understanding regarding the differences in postoperative management between patients who have undergone tracheostomy and laryngectomy. The intervention involved a brief didactic session followed by the placement of an informative poster and anatomic diagram above the bed of tracheostomy and laryngectomy patients over a 6-month period. Data were collected before and after the didactic session and poster implementation. Of the 50 nurses surveyed, 32% believed oral ventilation is appropriate for laryngectomy patients compared to 0% of nurses after the intervention. The percentage of nursing staff reporting self-assessed clear understanding of the patient care differences between laryngectomy and tracheostomy improved after the intervention. The use of informational posters and didactic sessions significantly improves nursing staff understanding of the differences between tracheostomy and laryngectomy patients. Level of Evidence: IV.
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Affiliation(s)
- Sam DeVictor
- Department of Otolaryngology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, New York, USA
| | - Adrian A Ong
- Department of Otolaryngology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, New York, USA
| | - Andrew P Kelly
- Department of Otolaryngology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, New York, USA
| | - Mark S Burke
- Department of Otolaryngology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, New York, USA.,Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, New York, USA.,Department of Head and Neck and Plastic and Reconstructive Surgery, Erie County Medical Center, Buffalo, New York, USA
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31
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Pandolfini M, Di Stadio A, Brenner MJ, Pichi B, Pellini R, McGrath B, D'Ascanio L. Airway obstruction from tracheostomy balloon cuff herniation during oral cancer removal. Emergency successfully managed and lessons learnt from device malfunction. Oral Oncol 2020; 113:105048. [PMID: 33132056 DOI: 10.1016/j.oraloncology.2020.105048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 10/09/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Tracheostomy tube cuff balloon herniation is a rare event and can determine airway obstruction. Sometimes the obstruction is not very evident but, if it is not correctly solved, can determine a severe hypoxia with patient's death. MATERIAL AND METHODS We present a 49-year-old male patient, with cT4aN0M0 squamous cell carcinoma of the oral cavity, who was admitted to the hospital for definitive surgical resection. Due to mass an endo-oral intubation was not possible, so a surgical tracheotomy was performed. General anaesthesia was induced with Propofol (2 mg/kg) and Fentanil (1 mcg/kg) without gas. Surgery commenced via a trans-oral and trans-cervical approach, but it was halted after approximately 2 min as oximetry demonstrated a progressive fall from 98% to 78%. After confirmation of correct function of anaesthetic devices, the endotracheal cannula was tested; although surgeon deflated the tube cuff, repositioned the tube, and re-inflated the cuff, oxygen saturation did not change. So, the cannula was changed and patient's saturation increased up to normal value. RESULTS The balloon cuff of the cannula showed a herniation, responsible of insufficient ventilation. CONCLUSIONS Cuff herniation should be considered in case of unexpected airway obstruction, and a systematic, rapid approach to investigation and management should ensure timely identification and correction.
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Affiliation(s)
- Manlio Pandolfini
- Otolaryngology- Head and Neck Surgery Department, Santa Croce Hospital AORMN, Fano, Italy
| | | | - Michael J Brenner
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Barbara Pichi
- Otolaryngology-Head and Neck Surgery Department, IRCCS Regina Elena National Cancer Institute (IRE), Rome, Italy
| | - Raul Pellini
- Otolaryngology-Head and Neck Surgery Department, IRCCS Regina Elena National Cancer Institute (IRE), Rome, Italy
| | - Brendan McGrath
- Anaesthesia and Intensive Care Medicine, University Hospital South Manchester, Manchester, UK
| | - Luca D'Ascanio
- Otolaryngology- Head and Neck Surgery Department, Santa Croce Hospital AORMN, Fano, Italy
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Vergara J, Starmer HM, Wallace S, Bolton L, Seedat J, de Souza CM, Freitas SV, Skoretz SA. Swallowing and Communication Management of Tracheostomy and Laryngectomy in the Context of COVID-19: A Review. JAMA Otolaryngol Head Neck Surg 2020; 147:2771746. [PMID: 33057590 DOI: 10.1001/jamaoto.2020.3720] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
IMPORTANCE The care of patients with a surgically modified airway, such as tracheostomy or laryngectomy, represents a challenge for speech-language pathologists (SLPs) in the context of the coronavirus disease 2019 (COVID-19) pandemic. The objective was to review available publications and practice guidelines on management of tracheostomy and laryngectomy in the context of COVID-19. This study performed a review and synthesis of information available in the PubMed database and from national SLP organizations across 6 countries. OBSERVATIONS From the search, 22 publications on tracheostomy and 3 referring to laryngectomy were identified. After analysis of titles and abstracts followed by full-text review, 4 publications were identified as presenting guidelines for specific approaches to tracheostomy and were selected; all 3 publications on laryngectomy were selected. The main guidelines on tracheostomy described considerations during management (eg, cuff manipulation, suctioning, valve placement) owing to the increased risk of aerosol generation and transmission during swallowing and communication interventions in this population. Regarding laryngectomy, the guidelines focused on the care and protection of both the professional and the patient, offering recommendations on the management of adverse events and leakage of the tracheoesophageal prosthesis. CONCLUSIONS AND RELEVANCE Frequent guideline updates for SLPs are necessary to inform best practice and ensure patient and health care worker protection and safety while providing high-quality care and rehabilitation.
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Affiliation(s)
- José Vergara
- Department of Surgery, University of Campinas, Campinas, São Paulo, Brazil
| | - Heather M Starmer
- Division of Head and Neck Surgery, Department of Otolaryngology, Stanford University, Palo Alto, California
| | - Sarah Wallace
- Department of Speech, Voice and Swallowing, Manchester University NHS Foundation Trust, Manchester, England
| | - Lee Bolton
- Speech and Language Therapy Service, Imperial College Healthcare NHS Trust, London, England
| | - Jaishika Seedat
- Department of Speech and Hearing Therapy, University of Witwatersrand, Johannesburg, South Africa
| | | | - Susana Vaz Freitas
- Faculty of Health Sciences, Speech Therapy Department, University Fernando Pessoa, Porto, Portugal
- ENT Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
- Laboratório de Inteligência Artificial e Análise de Dados, LIAAD-INESCTEC, Porto, Portugal
| | - Stacey A Skoretz
- School of Audiology and Speech Sciences, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
- Centre for Heart Lung Innovation, St Paul's Hospital, Vancouver, British Columbia, Canada
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Meister KD, Pandian V, Hillel AT, Walsh BK, Brodsky MB, Balakrishnan K, Best SR, Chinn SB, Cramer JD, Graboyes EM, McGrath BA, Rassekh CH, Bedwell JR, Brenner MJ. Multidisciplinary Safety Recommendations After Tracheostomy During COVID-19 Pandemic: State of the Art Review. Otolaryngol Head Neck Surg 2020; 164:984-1000. [PMID: 32960148 DOI: 10.1177/0194599820961990] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE In the chronic phase of the COVID-19 pandemic, questions have arisen regarding the care of patients with a tracheostomy and downstream management. This review addresses gaps in the literature regarding posttracheostomy care, emphasizing safety of multidisciplinary teams, coordinating complex care needs, and identifying and managing late complications of prolonged intubation and tracheostomy. DATA SOURCES PubMed, Cochrane Library, Scopus, Google Scholar, institutional guidance documents. REVIEW METHODS Literature through June 2020 on the care of patients with a tracheostomy was reviewed, including consensus statements, clinical practice guidelines, institutional guidance, and scientific literature on COVID-19 and SARS-CoV-2 virology and immunology. Where data were lacking, expert opinions were aggregated and adjudicated to arrive at consensus recommendations. CONCLUSIONS Best practices in caring for patients after a tracheostomy during the COVID-19 pandemic are multifaceted, encompassing precautions during aerosol-generating procedures; minimizing exposure risks to health care workers, caregivers, and patients; ensuring safe, timely tracheostomy care; and identifying and managing laryngotracheal injury, such as vocal fold injury, posterior glottic stenosis, and subglottic stenosis that may affect speech, swallowing, and airway protection. We present recommended approaches to tracheostomy care, outlining modifications to conventional algorithms, raising vigilance for heightened risks of bleeding or other complications, and offering recommendations for personal protective equipment, equipment, care protocols, and personnel. IMPLICATIONS FOR PRACTICE Treatment of patients with a tracheostomy in the COVID-19 pandemic requires foresight and may rival procedural considerations in tracheostomy in their complexity. By considering patient-specific factors, mitigating transmission risks, optimizing the clinical environment, and detecting late manifestations of severe COVID-19, clinicians can ensure due vigilance and quality care.
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Affiliation(s)
- Kara D Meister
- Aerodigestive and Airway Reconstruction Center, Lucile Packard Children's Hospital, Stanford Children's Health, Palo Alto, California, USA.,Center for Pediatric Voice and Swallowing Disorders, Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Lucile Packard Children's Hospital, Stanford Children's Health, Palo Alto, California, USA
| | - Vinciya Pandian
- Department of Nursing Faculty, Johns Hopkins University, Baltimore, Maryland, USA.,Outcomes After Critical Illness and Surgery Research Group, Johns Hopkins University, Baltimore, Maryland, USA
| | - Alexander T Hillel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Brian K Walsh
- Department of Health Sciences, Liberty University, Lynchburg, Virginia, USA
| | - Martin B Brodsky
- Outcomes After Critical Illness and Surgery Research Group, Johns Hopkins University, Baltimore, Maryland, USA.,Department of Physical and Rehabilitation, Johns Hopkins University, Baltimore, Maryland, USA.,Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Karthik Balakrishnan
- Aerodigestive and Airway Reconstruction Center, Lucile Packard Children's Hospital, Stanford Children's Health, Palo Alto, California, USA.,Center for Pediatric Voice and Swallowing Disorders, Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Lucile Packard Children's Hospital, Stanford Children's Health, Palo Alto, California, USA
| | - Simon R Best
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Steven B Chinn
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Michigan, USA
| | - John D Cramer
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Wayne State University, Detroit, Michigan, USA
| | - Evan M Graboyes
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.,Hollings Cancer Center, Charleston, South Carolina, USA
| | - Brendan A McGrath
- University of Manchester, NHS Foundation Trust, National Tracheostomy Safety Project, Manchester, UK
| | - Christopher H Rassekh
- Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua R Bedwell
- Baylor College of Medicine, Houston, Texas, USA.,Division of Pediatric Otolaryngology-Head and Neck Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Michael J Brenner
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA; Global Tracheostomy Collaborative, Raleigh, North Carolina, USA
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Tokarz E, Szymanowski AR, Loree JT, Muscarella J. Gaps in Training: Misunderstandings of Airway Management in Medical Students and Internal Medicine Residents. Otolaryngol Head Neck Surg 2020; 164:938-943. [DOI: 10.1177/0194599820949528] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Objectives (1) Evaluate baseline airway knowledge of medical students (MSs) and internal medicine (IM) residents. (2) Improve MS and IM resident understanding of airway anatomy, general tracheostomy and laryngectomy care, and management of airway emergencies. Methods A before-and-after survey study was carried out over a single academic year. MS and IM resident knowledge was evaluated before and after an educational, grand rounds–style lecture reviewing airway anatomy, tracheostomy tube components, tracheostomy and laryngectomy care, and clinical vignettes. The primary outcome measure was change in pre- and postlecture survey scores. Results Prelecture surveys were completed by 90 participants, and 83 completed a postlecture assessment. Postlecture scores were statistically improved for all questions on the assessment ( P < .001). Level of training did not confer an improved pre- or postlecture survey score. Discussion While the majority of participants in our study had previously cared for patients with a tracheostomy or laryngectomy, less than half were able to correctly address basic airway emergencies. Senior IM residents were no more proficient than MSs in addressing airway emergencies. The lack of formal airway training places patients at risk with routine care and in emergencies, demonstrating the need for formal airway education for early medical trainees. Implications for Practice Our data demonstrate a serious gap in MS and IM resident knowledge with respect to emergent airway care in patients with tracheostomies and laryngectomies. An interdepartmental collaborative curriculum offers a realistic and potentially life-saving solution for medical trainees.
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Affiliation(s)
- Ellen Tokarz
- Department of Otolaryngology–Head and Neck Surgery, State University of New York at Buffalo, Buffalo, New York, USA
| | - Adam R. Szymanowski
- Department of Otolaryngology–Head and Neck Surgery, State University of New York at Buffalo, Buffalo, New York, USA
| | - John T. Loree
- State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Joseph Muscarella
- Department of Otolaryngology–Head and Neck Surgery, State University of New York at Buffalo, Buffalo, New York, USA
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Zaga CJ, Pandian V, Brodsky MB, Wallace S, Cameron TS, Chao C, Orloff LA, Atkins NE, McGrath BA, Lazarus CL, Vogel AP, Brenner MJ. Speech-Language Pathology Guidance for Tracheostomy During the COVID-19 Pandemic: An International Multidisciplinary Perspective. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2020; 29:1320-1334. [PMID: 32525695 DOI: 10.1044/2020_ajslp-20-00089] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Purpose As the COVID-19 pandemic has unfolded, there has been growing recognition of risks to frontline health care workers. When caring for patients with tracheostomy, speech-language pathologists have significant exposure to mucosal surfaces, secretions, and aerosols that may harbor the SARS-CoV-2 virus. This tutorial provides guidance on practices for safely performing patient evaluation and procedures, thereby reducing risk of infection. Method Data were collated through review of literature, guidelines, and consensus statements relating to COVID-19 and similar high-consequent infections, with a focus on mitigating risk of transmission to health care workers. Particular emphasis was placed on speech-language pathologists, nurses, and other allied health professionals. A multinational interdisciplinary team then analyzed findings, arriving at recommendations through consensus via electronic communications and video conference. Results Reports of transmission of infection to health care workers in the current COVID-19 pandemic and previous outbreaks substantiate the need for safe practices. Many procedures routinely performed by speech-language pathologists have a significant risk of infection due to aerosol generation. COVID-19 testing can inform level of protective equipment, and meticulous hygiene can stem spread of nosocomial infection. Modifications to standard clinical practice in tracheostomy are often required. Personal protective equipment, including either powered air-purifying respirator or N95 mask, gloves, goggles, and gown, are needed when performing aerosol-generating procedures in patients with known or suspected COVID-19 infection. Conclusions Speech-language pathologists are often called on to assist in the care of patients with tracheostomy and known or suspected COVID-19 infection. Appropriate care of these patients is predicated on maintaining the health and safety of the health care team. Careful adherence to best practices can significantly reduce risk of infectious transmission.
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Affiliation(s)
- Charissa J Zaga
- Department of Speech Pathology, Austin Health, Melbourne, Victoria, Australia
- Centre for Neuroscience of Speech, University of Melbourne, Victoria, Australia
- Tracheostomy Review and Management Service, Austin Health, Melbourne, Victoria, Australia
| | - Vinciya Pandian
- Department of Nursing Faculty, Johns Hopkins University, Baltimore, MD
- Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, MD
| | - Martin B Brodsky
- Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, MD
- Department of Physical Medicine & Rehabilitation, Johns Hopkins University, Baltimore, MD
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Sarah Wallace
- Department of Speech Voice and Swallowing, Manchester University NHS Foundation Trust, United Kingdom
| | - Tanis S Cameron
- Tracheostomy Review and Management Service, Austin Health, Melbourne, Victoria, Australia
| | - Caroline Chao
- Tracheostomy Review and Management Service, Austin Health, Melbourne, Victoria, Australia
- Department of Physiotherapy, Austin Health, Melbourne, Victoria, Australia
| | - Lisa Ann Orloff
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, CA
| | - Naomi E Atkins
- Department of Respiratory Medicine, Austin Health, Melbourne, Victoria, Australia
| | - Brendan A McGrath
- Anaesthetics & Intensive Care Medicine, Manchester University NHS Foundation Trust, United Kingdom
| | - Cathy L Lazarus
- Department of Otolaryngology-Head & Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Adam P Vogel
- Centre for Neuroscience of Speech, University of Melbourne, Victoria, Australia
- Department of Neurodegeneration, Hertie Institute for Clinical Brain Research, Tübingen, Germany
- Redenlab, Melbourne, Victoria, Australia
| | - Michael J Brenner
- Department of Otolaryngology-Head & Neck Surgery, University of Michigan Medical School, Ann Arbor
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36
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Siddiqui A, Wolter NE, Matava C. Use of an Aortic Cannula for Tracheal Intubation in a Patient With Severe Tracheal Stenosis and Tracheoesophageal Fistula: A Case Report. Cureus 2020; 12:e9456. [PMID: 32760638 PMCID: PMC7392359 DOI: 10.7759/cureus.9456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
A one-day-old girl was brought to the OR for the repair of a type C esophageal atresia (EA) [EA with tracheoesophageal fistula (TEF)]. Rigid bronchoscopy was performed to locate the fistula, and it revealed a severe long-segment tracheal stenosis. Therefore, the airway could not have been secured past the fistula using normal-sized endotracheal tubes (ETTs). A nontraditional airway using an aortic cannula was used to intubate the stenotic tracheal segment, and the patient received ventilation during the TEF/EA repair.
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Affiliation(s)
- Asad Siddiqui
- Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, CAN
| | - Nikolaus E Wolter
- Otolaryngology - Head and Neck Surgery, Hospital for Sick Children, Toronto, CAN
| | - Clyde Matava
- Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, CAN.,Anesthesiology and Pain Medicine, University of Toronto, Toronto, CAN
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Brenner MJ, Pandian V, Milliren CE, Graham DA, Zaga C, Morris LL, Bedwell JR, Das P, Zhu H, Lee Y. Allen J, Peltz A, Chin K, Schiff BA, Randall DM, Swords C, French D, Ward E, Sweeney JM, Warrillow SJ, Arora A, Narula A, McGrath BA, Cameron TS, Roberson DW. Global Tracheostomy Collaborative: data-driven improvements in patient safety through multidisciplinary teamwork, standardisation, education, and patient partnership. Br J Anaesth 2020; 125:e104-e118. [DOI: 10.1016/j.bja.2020.04.054] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/17/2020] [Accepted: 04/17/2020] [Indexed: 01/15/2023] Open
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38
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Tracheostomy in the COVID-19 era: global and multidisciplinary guidance. THE LANCET. RESPIRATORY MEDICINE 2020; 8:717-725. [PMID: 32422180 PMCID: PMC7228735 DOI: 10.1016/s2213-2600(20)30230-7] [Citation(s) in RCA: 265] [Impact Index Per Article: 66.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 04/27/2020] [Accepted: 05/10/2020] [Indexed: 01/08/2023]
Abstract
Global health care is experiencing an unprecedented surge in the number of critically ill patients who require mechanical ventilation due to the COVID-19 pandemic. The requirement for relatively long periods of ventilation in those who survive means that many are considered for tracheostomy to free patients from ventilatory support and maximise scarce resources. COVID-19 provides unique challenges for tracheostomy care: health-care workers need to safely undertake tracheostomy procedures and manage patients afterwards, minimising risks of nosocomial transmission and compromises in the quality of care. Conflicting recommendations exist about case selection, the timing and performance of tracheostomy, and the subsequent management of patients. In response, we convened an international working group of individuals with relevant expertise in tracheostomy. We did a literature and internet search for reports of research pertaining to tracheostomy during the COVID-19 pandemic, supplemented by sources comprising statements and guidance on tracheostomy care. By synthesising early experiences from countries that have managed a surge in patient numbers, emerging virological data, and international, multidisciplinary expert opinion, we aim to provide consensus guidelines and recommendations on the conduct and management of tracheostomy during the COVID-19 pandemic.
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McGrath BA, Wallace S, Lynch J, Bonvento B, Coe B, Owen A, Firn M, Brenner MJ, Edwards E, Finch TL, Cameron T, Narula A, Roberson DW. Improving tracheostomy care in the United Kingdom: results of a guided quality improvement programme in 20 diverse hospitals. Br J Anaesth 2020; 125:e119-e129. [DOI: 10.1016/j.bja.2020.04.064] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/17/2020] [Accepted: 04/17/2020] [Indexed: 11/26/2022] Open
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Rovira A, Dawson D, Walker A, Tornari C, Dinham A, Foden N, Surda P, Archer S, Lonsdale D, Ball J, Ofo E, Karagama Y, Odutoye T, Little S, Simo R, Arora A. Tracheostomy care and decannulation during the COVID-19 pandemic. A multidisciplinary clinical practice guideline. Eur Arch Otorhinolaryngol 2020; 278:313-321. [PMID: 32556788 PMCID: PMC7299456 DOI: 10.1007/s00405-020-06126-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 06/09/2020] [Indexed: 12/11/2022]
Abstract
Purpose Traditional critical care dogma regarding the benefits of early tracheostomy during invasive ventilation has had to be revisited due to the risk of COVID-19 to patients and healthcare staff. Standard practises that have evolved to minimise the risks associated with tracheostomy must be comprehensively reviewed in light of the numerous potential episodes for aerosol generating procedures. We meet the urgent need for safe practise standards by presenting the experience of two major London teaching hospitals, and synthesise our findings into an evidence-based guideline for multidisciplinary care of the tracheostomy patient. Methods This is a narrative review presenting the extensive experience of over 120 patients with tracheostomy, with a pragmatic analysis of currently available evidence for safe tracheostomy care in COVID-19 patients. Results Tracheostomy care involves many potentially aerosol generating procedures which may pose a risk of viral transmission to staff and patients. We make a series of recommendations to ameliorate this risk through infection control strategies, equipment modification, and individualised decannulation protocols. In addition, we discuss the multidisciplinary collaboration that is absolutely fundamental to safe and effective practise. Conclusion COVID-19 requires a radical rethink of many tenets of tracheostomy care, and controversy continues to exist regarding the optimal techniques to minimise risk to patients and healthcare workers. Safe practise requires a coordinated multidisciplinary team approach to infection control, weaning and decannulation, with integrated processes for continuous prospective data collection and audit.
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Affiliation(s)
- Aleix Rovira
- Department of Otorhinolaryngology Head and Neck Surgery, St George's Hospital NHS Foundation Trust, London, UK.
| | - Deborah Dawson
- Department of Critical Care, St George's Hospital NHS Foundation Trust, London, UK
| | - Abigail Walker
- Department of Otorhinolaryngology Head and Neck Surgery, University Hospital Lewisham, London, UK
| | - Chrysostomos Tornari
- Department of Otorhinolaryngology Head and Neck Surgery, St George's Hospital NHS Foundation Trust, London, UK
| | - Alison Dinham
- Department of Physiotherapy, Guy's and St Thomas Hospital NHS Foundation Trust, London, UK
| | - Neil Foden
- Department of Otorhinolaryngology Head and Neck Surgery, St George's Hospital NHS Foundation Trust, London, UK
| | - Pavol Surda
- Department of Otorhinolayngology Head and Neck Surgery, Guy's and St Thomas Hospital NHS Foundation Trust, London, UK
| | - Sally Archer
- Speech and Language Therapy Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Dagan Lonsdale
- Critical Care Unit, St George's Hospital NHS Foundation Trust, London, UK
- St George's University of London, London, UK
| | - Jonathan Ball
- Critical Care Unit, St George's Hospital NHS Foundation Trust, London, UK
| | - Enyi Ofo
- Department of Otorhinolaryngology Head and Neck Surgery, St George's Hospital NHS Foundation Trust, London, UK
| | - Yakubu Karagama
- Department of Otorhinolayngology Head and Neck Surgery, Guy's and St Thomas Hospital NHS Foundation Trust, London, UK
| | - Tunde Odutoye
- Department of Otorhinolaryngology Head and Neck Surgery, St George's Hospital NHS Foundation Trust, London, UK
| | - Sarah Little
- Department of Otorhinolaryngology Head and Neck Surgery, St George's Hospital NHS Foundation Trust, London, UK
| | - Ricard Simo
- Department of Otorhinolayngology Head and Neck Surgery, Guy's and St Thomas Hospital NHS Foundation Trust, London, UK
| | - Asit Arora
- Department of Otorhinolayngology Head and Neck Surgery, Guy's and St Thomas Hospital NHS Foundation Trust, London, UK
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McGrath BA, Ashby N, Birchall M, Dean P, Doherty C, Ferguson K, Gimblett J, Grocott M, Jacob T, Kerawala C, Macnaughton P, Magennis P, Moonesinghe R, Twose P, Wallace S, Higgs A. Multidisciplinary guidance for safe tracheostomy care during the COVID-19 pandemic: the NHS National Patient Safety Improvement Programme (NatPatSIP). Anaesthesia 2020; 75:1659-1670. [PMID: 32396986 PMCID: PMC7272992 DOI: 10.1111/anae.15120] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2020] [Indexed: 12/18/2022]
Abstract
The COVID-19 pandemic is causing a significant increase in the number of patients requiring relatively prolonged invasive mechanical ventilation and an associated surge in patients who need a tracheostomy to facilitate weaning from respiratory support. In parallel, there has been a global increase in guidance from professional bodies representing staff who care for patients with tracheostomies at different points in their acute hospital journey, rehabilitation and recovery. Of concern are the risks to healthcare staff of infection arising from tracheostomy insertion and caring for patients with a tracheostomy. Hospitals are also facing extraordinary demands on critical care services such that many patients who require a tracheostomy will be managed outside established intensive care or head and neck units and cared for by staff with little tracheostomy experience. These concerns led NHS England and NHS Improvement to expedite the National Patient Safety Improvement Programme's 'Safe Tracheostomy Care' workstream as part of the NHS COVID-19 response. Supporting this workstream, UK stakeholder organisations involved in tracheostomy care were invited to develop consensus guidance based on: expert opinion; the best available published literature; and existing multidisciplinary guidelines. Topics with direct relevance for frontline staff were identified. This consensus guidance includes: infectivity of patients with respect to tracheostomy indications and timing; aerosol-generating procedures and risks to staff; insertion procedures; and management following tracheostomy.
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Affiliation(s)
- B A McGrath
- Department of Intensive Care Medicine, Wythenshawe Hospital, Manchester University Hospital NHS Foundation Trust, National Tracheostomy Safety Project, Manchester, UK
| | - N Ashby
- Royal College of Nursing, University of Nottingham, Nottingham, UK
| | - M Birchall
- British Laryngological Association, University College London, London, UK
| | - P Dean
- Intensive Care Society, Royal Blackburn Teaching Hospital, Lancashire, UK
| | - C Doherty
- Royal Manchester Children's Hospital, National Tracheostomy Safety Project Paediatric Lead, Manchester University NHS Foundation Trust, Manchester, UK
| | - K Ferguson
- Aberdeen Royal Infirmary, Association of Anaesthetists, Aberdeen, UK
| | | | - M Grocott
- Anaesthesia and Critical Care, Royal College of Anaesthetists, University of Southampton, Southampton, UK
| | - T Jacob
- ENT & Head and Neck surgeon, Lewisham & Greenwich NHS Trust, ENT-UKt, London, UK
| | - C Kerawala
- Maxillofacial & Head and Neck Surgeon, The Royal Marsden Hospital, British Association of Head & Neck Oncologists, London, UK
| | - P Macnaughton
- Intensive Care Medicine at Derriford Hospital, Faculty of Intensive Care Medicine, Plymouth, UK
| | - P Magennis
- Oral and Maxillofacial Surgeon, Aintree University Hospital, NHS Foundation Trust, British Association of Oral and Maxillofacial Surgeons, Liverpool, UK
| | - R Moonesinghe
- Anaesthetics and Critical Care Medicine, NHS England & NHS Improvement, University College London Hospitals, London, UK
| | - P Twose
- Association of Chartered Physiotherapists in Respiratory Care, Cardiff and Vale University Health Board, Cardiff, UK
| | - S Wallace
- Speech & Language Therapist, Royal College of Speech & Language Therapists, Manchester University NHS Foundation Trust, Manchester, UK
| | - A Higgs
- Anaesthesia & Intensive Care Medicine, Warrington & Halton Teaching Hospitals NHS Foundation Trust, Difficult Airway Society, Warrington, UK
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Cherney RL, Pandian V, Ninan A, Eastman D, Barnes B, King E, Miller B, Judkins S, Smith AE, Smith NM, Hanley J, Creutz E, Carlson M, Schneider KJ, Shever LL, Casper KA, Davidson PM, Brenner MJ. The Trach Trail: A Systems-Based Pathway to Improve Quality of Tracheostomy Care and Interdisciplinary Collaboration. Otolaryngol Head Neck Surg 2020; 163:232-243. [PMID: 32450771 DOI: 10.1177/0194599820917427] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To implement a standardized tracheostomy pathway that reduces length of stay through tracheostomy education, coordinated care protocols, and tracking patient outcomes. METHODS The project design involved retrospective analysis of a baseline state, followed by a multimodal intervention (Trach Trail) and prospective comparison against synchronous controls. Patients undergoing tracheostomy from 2015 to 2016 (n = 60) were analyzed for demographics and outcomes. Trach Trail, a standardized care pathway, was developed with the Iowa Model of Evidence-Based Practice. Trach Trail implementation entailed monthly tracheostomy champion training at 8-hour duration and staff nurse didactics, written materials, and experiential learning. Trach Trail enrollment occurred from 2018 to 2019. Data on demographics, length of stay, and care outcomes were collected from patients in the Trach Trail group (n = 21) and a synchronous tracheostomy control group (n = 117). RESULTS Fifty-five nurses completed Trach Trail training, providing care for 21 patients placed on the Trach Trail and for synchronous control patients with tracheostomy who received routine tracheostomy care. Patients on the Trach Trail and controls had similar demographic characteristics, diagnoses, and indications for tracheostomy. In the Trach Trail group, intensive care unit length of stay was significantly reduced as compared with the control group, decreasing from a mean 21 days to 10 (P < .05). The incidence of adverse events was unchanged. DISCUSSION Introduction of the Trach Trail was associated with a reduction in length of stay in the intensive care unit. Realizing broader patient-centered improvement likely requires engaging respiratory therapists, speech language pathologists, and social workers to maximize patient/caregiver engagement. IMPLICATIONS FOR PRACTICE Standardized tracheostomy care with interdisciplinary collaboration may reduce length of stay and improve patient outcomes.
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Affiliation(s)
- Rebecca L Cherney
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA.,University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | | | - Ashly Ninan
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA.,Johns Hopkins School of Nursing, Baltimore, Maryland, USA
| | - Debra Eastman
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Brian Barnes
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Elizabeth King
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Brianne Miller
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Samantha Judkins
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Alfred E Smith
- Global Tracheostomy Quality Improvement Collaborative, Raleigh, North Carolina, USA
| | - Nan M Smith
- Global Tracheostomy Quality Improvement Collaborative, Raleigh, North Carolina, USA
| | - Julie Hanley
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Eileen Creutz
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Megan Carlson
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Kevin J Schneider
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Leah L Shever
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA.,University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | - Keith A Casper
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | | | - Michael J Brenner
- Global Tracheostomy Quality Improvement Collaborative, Raleigh, North Carolina, USA.,Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
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Abstract
Approximately half of all pediatric tracheostomies are performed in infants younger than 1 year. Most tracheostomies in patients in the NICU are performed in cases of chronic respiratory failure requiring prolonged mechanical ventilation or upper airway obstruction. With improvements in ventilation and management of long-term intubation, indications for tracheostomy and perioperative management in this population continue to evolve. Evidence-based protocols to guide routine postoperative care, prevent and manage tracheostomy emergencies including accidental decannulation and tube obstruction, and attempt elective decannulation are sparse. Clinician awareness of safe tracheostomy practices and larger, prospective studies in infants are needed to improve clinical care of this vulnerable population.
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Affiliation(s)
- Julia Chang
- Department of Otolaryngology, Head and Neck Surgery. Stanford University School of Medicine, Stanford, CA
| | - Douglas R Sidell
- Department of Otolaryngology, Head and Neck Surgery. Stanford University School of Medicine, Stanford, CA
- Stanford Pediatric Aerodigestive and Airway Reconstruction Center, Lucile Packard Children's Hospital, Stanford, CA
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Tara A, Kumaraswami S, Berzofsky C. From Tracheal Stenosis to Tracheostomy Displacement: A Case Report on a Seemingly Never-Ending Difficult Airway. A A Pract 2020; 14:e01185. [PMID: 32224697 DOI: 10.1213/xaa.0000000000001185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report a case of undiagnosed tracheal stenosis that culminated in acute respiratory failure in an inpatient unit. After failed intubation attempts, the placement of a supraglottic airway resulted in successful ventilation and was followed by a tracheostomy in the operating room. Postoperatively, the tracheostomy tube became accidentally dislodged necessitating emergency measures with eventual reinsertion of a longer tracheostomy tube. We present this case to highlight life-saving airway strategies that may be considered in such emergency situations and propose 2 simple algorithms to guide anesthesiologists in managing similar airway emergencies.
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Affiliation(s)
| | | | - Craig Berzofsky
- Otolaryngology, New York Medical College, Westchester Medical Center, Valhalla, New York
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Chrimes N, Higgs A, Sakles JC. Welcome to the era of universal airway management. Anaesthesia 2020; 75:711-715. [DOI: 10.1111/anae.14998] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2020] [Indexed: 12/11/2022]
Affiliation(s)
- N. Chrimes
- Department of Anaesthesia Monash Medical Centre Melbourne Australia
| | - A. Higgs
- Department of Intensive Care Medicine and Anaesthesia Warrington Teaching Hospitals NHS Foundation Trust Cheshire UK
| | - J. C. Sakles
- Department of Emergency Medicine University of Arizona College of Medicine Tucson AZ USA
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Hews J, El-Boghdadly K, Ahmad I. Difficult airway management for the anaesthetist. Br J Hosp Med (Lond) 2020; 80:432-440. [PMID: 31437036 DOI: 10.12968/hmed.2019.80.8.432] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
This article reviews the key considerations when managing a patient with a difficult airway. The difficult airway may be anticipated from preassessment allowing time for investigations and preparation. Alternatively, the unanticipated difficult airway can present in an emergency situation, or unexpectedly during a routine anaesthetic. The main airway management techniques are discussed with a description of their advantages and limitations. Current guidelines are included that demonstrate how the techniques are incorporated into an overall strategy with a plan A-D when failure occurs. It is critical to progress through such an algorithm in a timely manner to prevent the onset of hypoxia.
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Affiliation(s)
- J Hews
- Specialist Registrar, Department of Anaesthesia, Guy's & St Thomas' NHS Foundation Trust, London SE1 9RT
| | - K El-Boghdadly
- Consultant Anaesthetist, Department of Anaesthesia, Guy's & St Thomas' NHS Foundation Trust, London
| | - I Ahmad
- Consultant Anaesthetist, Department of Anaesthesia, Guy's & St Thomas' NHS Foundation Trust, London
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48
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Chandrasena AN, Goswamy J, Calder N, Khalil U, McGrath BA. Our experience: Quantifying changes in tracheostomy tube position and orientation with repositioning of 14 patients (the Lunar positioning study). Clin Otolaryngol 2019; 45:143-147. [PMID: 31705788 DOI: 10.1111/coa.13474] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 10/06/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Amali N Chandrasena
- Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Jay Goswamy
- Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | | | - Uzma Khalil
- Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Brendan A McGrath
- Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK.,Manchester Academic Critical Care, Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine & Health, School of Biological Sciences, The University of Manchester, Manchester, UK
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Using Didactics and Simulation to Enhance Comfort, Knowledge, and Skills of Nonsurgical Trainees Caring for Patients With Tracheostomy and Laryngectomy. Simul Healthc 2019; 14:384-390. [PMID: 31804423 DOI: 10.1097/sih.0000000000000392] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Management of tracheostomy and laryngectomy is an important skill for physicians who often care for patients with multiple, comorbid, chronic medical conditions. There is little published literature on training for tracheostomy and laryngectomy care during nonsurgical specialty residencies. This project was designed to assess and improve comfort with, knowledge of, proficiency in tracheostomy and laryngectomy care. METHODS This prospective observational study comprised 122 physician trainees from internal medicine, emergency medicine, and anesthesia training programs at the University of Arkansas for Medical Sciences participating in a simulation-based curriculum from April 2016 to December 2016. The curriculum included didactic session, hands-on experience performing a tracheostomy change, and practicing emergency scenarios on interactive, high-fidelity simulation mannequins. Preintervention and postintervention assessments of self-perceived comfort, objective knowledge, and tracheostomy change proficiency were performed and results compared. RESULTS Self-perceived comfort improved from a mean Likert score from 2.12 to 4.43 (P = 0.009). Knowledge mean scores improved from 57% to 82% (P < 0.001) on multiple-choice testing. Tracheostomy change proficiency mean scores improved from 41% to 84% (P < 0.001) of proficiencies correctly performed. Six-month follow-up assessment of comfort and knowledge showed statistically significant retention of comfort (P = 0.002) and knowledge (P = 0.026). CONCLUSIONS Comprehensive tracheostomy and laryngectomy education, which combines enhancement of knowledge with simulation of both routine and emergent aspects of care, is an effective strategy in improving confidence with, knowledge of, proficiency in tracheostomy and laryngectomy care. Retention of confidence and knowledge was demonstrated 6 months later.
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Lewith H, Athanassoglou V. Update on management of tracheostomy. BJA Educ 2019; 19:370-376. [PMID: 33456860 DOI: 10.1016/j.bjae.2019.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2019] [Indexed: 11/28/2022] Open
Affiliation(s)
- H Lewith
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, UK
| | - V Athanassoglou
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, UK
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