Can we improve teaching and learning of percutaneous dilatational tracheostomy's bronchoscopic guidance?

Role of Prolonged Intubation in Vocal Fold Motion Impairment in Critically Ill Patients

OBJECTIVE

COVID-19 upsurge in orotracheal intubation (OTI) has opened a new opportunity for studying associated complications. Vocal fold motion impairment (VFMI) is a known complication of OTI. The present study sought to determine the impact of OTI and prolonged OTI on the risk of developing VFMI; to identify both risk and protective factors associated with it.

STUDY DESIGN

Retrospective cohort study.

SETTING

Multicenter.

METHODS

Medical charts were reviewed for all patients that received invasive mechanical ventilation with a subsequent flexible laryngoscopic assessment between March 2020 and March 2022. The main outcomes were the presence of VFMI, including immobility (VFI) and hypomobility (VFH).

RESULTS

A total of 155 patients were included, 119 (76.8%) COVID-19 and 36 (23.2%) non-COVID-19 patients; overall 82 (52.9%) were diagnosed with VFMI. Eighty (52.3%) patients underwent a tracheostomy. The median (IQR) intubation duration was 18 (11-24.25) days, while the median (IQR) time to tracheostomy was 22 (16-29). In the adjusted model, we observed there was a 68% increased risk for VFMI from day 21 of intubation (RR: 1.68; 95% CI 1.07-2.65; P = 0.025).

CONCLUSIONS

VFMI is a frequent complication in severely ill patients that undergo intubation. A prolonged OTI was associated with an increased risk of VFMI, highlighting the importance of timely tracheostomy. Further research is needed to confirm these findings in other subsets of critically ill patients.

A Retrospective Review of 589 Percutaneous Tracheostomies in a Canadian Community Teaching Hospital

OBJECTIVE

The primary objective of this study was to review the complication rate of percutaneous tracheostomies performed by a single surgeon in a community teaching hospital.

METHODS

This retrospective study reviewed the patients who underwent percutaneous tracheostomy with bronchoscopic guidance in a community hospital setting between 2009 and 2017. Patients older than the age of 18 requiring percutaneous tracheostomy were chosen for this retrospective study. Patients who were medically unstable, had no palpable neck landmarks, and inadequate neck extension were excluded. Indications for percutaneous tracheostomy included patients who had failed to wean from mechanical ventilation, required pulmonary toileting, or in whom airway protection was required.

RESULTS

Of the 600 patients who received percutaneous tracheostomy, 589 patients were included in the study. Intraoperative complication (2.6%) and postoperative complication rates (11.4%) compared similarly to literature reported rates. The most common intraoperative complications were bleeding, technical difficulties, and accidental extubation. Bleeding, tube obstruction, and infection were the most common postoperative complications. Overall burden of comorbidity, defined by Charlson Comorbidity Index, and coagulopathy were also found to be associated with higher complication rates. The decannulation rate at discharge was 46.3%.

CONCLUSION

Percutaneous tracheostomy is a safe alternative to open tracheostomies in the community setting for appropriately selected patients.

Bronchoscopy-guided percutaneous tracheostomy during the COVID-19 pandemic

BACKGROUND

Assessment of the efficacy and complications associated with performing bronchoscopy-guided percutaneous tracheostomy in COVID-19 and non-COVID-19 patients.

METHODS

Prospective observational study conducted between March of 2020 and February of 2022. All adult patients who underwent elective bronchoscopy-guided percutaneous tracheostomy were included. The efficacy of the procedure was evaluated based either on the success rate in the execution or on the need for conversion to open technique. Percutaneous tracheostomy-related complications were registered during the procedure. We performed 6-month follow-up for identifying late complications.

RESULTS

During the study period, 312 bronchoscopy-guided percutaneous tracheostomies were analyzed. One hundred and eighty-three were performed in COVID-19 patients and 129 among non-COVID-19 patients. Overall, 64.1% (200) of patients were male, with a median age of 66 (interquartile range 54-74), and 65% (205) presented at least 1 comorbidity. Overall, oxygen desaturation was the main complication observed (20.8% [65]), being more frequent in the COVID-19 group occurring in 27.3% (50) with a statistically significant difference versus the non-COVID-19 patients' group (11.6% [15]); P < .01). Major complications such as hypotension, arrhythmias, and pneumothorax were more frequently observed among COVID-19 patients as well but with no significant differences. Percutaneous tracheostomy could be executed quickly and satisfactorily in all the patients with no need for conversion to the open technique. Likewise, no suspension of the procedure was required in any case. During 6-month follow-up, we found an incidence of 0.96% (n = 3) late complications, 2 tracheal granulomas, and 1 ostomal infection.

CONCLUSION

Bronchoscopy-guided percutaneous tracheostomy can be considered an effective and safe procedure in COVID-19 patients. Nevertheless, it is highly remarkable that in the series under study, a great number of COVID-19 patients presented oxygen desaturation during the procedure.