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Yousef A, Soliman SI, Solomon I, Panuganti BA, Francis DO, Pang J, Klebaner D, Asturias A, Alattar A, Wood S, Terry M, Bryson PC, Tipton CB, Zhao EE, O'Rourke A, Santa Maria C, Grimm DR, Sung CK, Lao WP, Thompson JM, Crawley BK, Rosen S, Berezovsky A, Kupfer R, Hennesy TB, Clary M, Joseph IT, Sarhadi K, Kuhn M, Abdel-Aty Y, Kennedy MM, Lott DG, Weissbrod PA. Impact of Obesity on Timing of Tracheotomy: A Multi-institutional Retrospective Study. Laryngoscope 2024; 134:4674-4681. [PMID: 38895915 DOI: 10.1002/lary.31586] [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: 04/03/2024] [Revised: 05/08/2024] [Accepted: 06/03/2024] [Indexed: 06/21/2024]
Abstract
OBJECTIVE To examine the impact of increased body mass index (BMI) on (1) tracheotomy timing and (2) short-term surgical complications requiring a return to the operating room and 30-day mortality utilizing data from the Multi-Institutional Study on Tracheotomy (MIST). METHODS A retrospective analysis of patients from the MIST database who underwent surgical or percutaneous tracheotomy between 2013 and 2016 at eight institutions was completed. Unadjusted and adjusted logistic regression analyses were used to assess the impact of obesity on tracheotomy timing and complications. RESULTS Among the 3369 patients who underwent tracheotomy, 41.0% were obese and 21.6% were morbidly obese. BMI was associated with higher rates of prolonged intubation prior to tracheotomy accounting for comorbidities, indication for tracheotomy, institution, and type of tracheostomy (p = 0.001). Morbidly obese patients (BMI ≥35 kg/m2) experienced a longer duration of intubation compared with patients with a normal BMI (median days intubated [IQR 25%-75%]: 11.0 days [7-17 days] versus 9.0 days [5-14 days]; p < 0.001) but did not have statistically higher rates of return to the operating room within 30 days (p = 0.12) or mortality (p = 0.90) on multivariable analysis. This same finding of prolonged intubation was not seen in overweight, nonobese patients when compared with normal BMI patients (median days intubated [IQR 25%-75%]: 10.0 days [6-15 days] versus 10.0 days [6-15 days]; p = 0.36). CONCLUSION BMI was associated with increased duration of intubation prior to tracheotomy. Although morbidly obese patients had a longer duration of intubation, there were no differences in return to the operating room or mortality within 30 days. LEVEL OF EVIDENCE 3 Laryngoscope, 134:4674-4681, 2024.
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Affiliation(s)
- Andrew Yousef
- Department of Otolaryngology, University of California San Diego, La Jolla, California, U.S.A
| | - Shady I Soliman
- Department of Otolaryngology, University of California San Diego, La Jolla, California, U.S.A
| | - Isaac Solomon
- Department of Otolaryngology, University of California San Diego, La Jolla, California, U.S.A
| | - Bharat A Panuganti
- Department of Otolaryngology, The University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - David O Francis
- Division of Otolaryngology, Department of Surgery, University of Wisconsin, Madison, Wisconsin, U.S.A
| | - John Pang
- Department of Otolaryngology-Head & Neck Surgery, Louisiana State University, Shreveport, Louisiana, U.S.A
| | - Dasha Klebaner
- Department of Otolaryngology, University of California San Diego, La Jolla, California, U.S.A
| | - Alicia Asturias
- Department of Otolaryngology, University of California San Diego, La Jolla, California, U.S.A
| | - Ali Alattar
- Department of Otolaryngology, University of California San Diego, La Jolla, California, U.S.A
| | - Samuel Wood
- Department of Otolaryngology, University of California San Diego, La Jolla, California, U.S.A
| | - Morgan Terry
- Department of Otolaryngology, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Paul C Bryson
- Department of Otolaryngology, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Courtney B Tipton
- Department of Otolaryngology, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Elise E Zhao
- Department of Otolaryngology, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Ashli O'Rourke
- Department of Otolaryngology, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Chloe Santa Maria
- Department of Otolaryngology, Stanford University, Palo Alto, California, U.S.A
| | - David R Grimm
- Department of Otolaryngology, Stanford University, Palo Alto, California, U.S.A
| | - C K Sung
- Department of Otolaryngology, Stanford University, Palo Alto, California, U.S.A
| | - Wilson P Lao
- Department of Otolaryngology, Loma Linda University, Loma Linda, California, U.S.A
| | - Jordan M Thompson
- Department of Otolaryngology, Loma Linda University, Loma Linda, California, U.S.A
| | - Brianna K Crawley
- Department of Otolaryngology, Loma Linda University, Loma Linda, California, U.S.A
| | - Sarah Rosen
- Division of Otolaryngology, Department of Surgery, University of Wisconsin, Madison, Wisconsin, U.S.A
| | - Anna Berezovsky
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Robbi Kupfer
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Theresa B Hennesy
- Department of Otolaryngology, University of Colorado, Aurora, Colorado, U.S.A
| | - Matthew Clary
- Department of Otolaryngology, University of Colorado, Aurora, Colorado, U.S.A
| | - Ian T Joseph
- Department of Otolaryngology, University of California Davis, Sacramento, California, U.S.A
| | - Kamron Sarhadi
- Department of Otolaryngology, University of California Davis, Sacramento, California, U.S.A
| | - Maggie Kuhn
- Department of Otolaryngology, University of California Davis, Sacramento, California, U.S.A
| | - Yassmeen Abdel-Aty
- Department of Otolaryngology, Mayo Clinic Arizona, Phoenix, Arizona, U.S.A
| | - Maeve M Kennedy
- Department of Otolaryngology, Mayo Clinic Arizona, Phoenix, Arizona, U.S.A
| | - David G Lott
- Department of Otolaryngology, Mayo Clinic Arizona, Phoenix, Arizona, U.S.A
| | - Philip A Weissbrod
- Department of Otolaryngology, University of California San Diego, La Jolla, California, U.S.A
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Nguyen M, Amanian A, Wei M, Prisman E, Mendez-Tellez PA. Predicting Tracheostomy Need on Admission to the Intensive Care Unit-A Multicenter Machine Learning Analysis. Otolaryngol Head Neck Surg 2024. [PMID: 39077854 DOI: 10.1002/ohn.919] [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: 12/07/2023] [Revised: 06/12/2024] [Accepted: 07/06/2024] [Indexed: 07/31/2024]
Abstract
OBJECTIVE It is difficult to predict which mechanically ventilated patients will ultimately require a tracheostomy which further predisposes them to unnecessary spontaneous breathing trials, additional time on the ventilator, increased costs, and further ventilation-related complications such as subglottic stenosis. In this study, we aimed to develop a machine learning tool to predict which patients need a tracheostomy at the onset of admission to the intensive care unit (ICU). STUDY DESIGN Retrospective Cohort Study. SETTING Multicenter Study of 335 Intensive Care Units between 2014 and 2015. METHODS The eICU Collaborative Research Database (eICU-CRD) was utilized to obtain the patient cohort. Inclusion criteria included: (1) Age >18 years and (2) ICU admission requiring mechanical ventilation. The primary outcome of interest included tracheostomy assessed via a binary classification model. Models included logistic regression (LR), random forest (RF), and Extreme Gradient Boosting (XGBoost). RESULTS Of 38,508 invasively mechanically ventilated patients, 1605 patients underwent a tracheostomy. The XGBoost, RF, and LR models had fair performances at an AUROC 0.794, 0.780, and 0.775 respectively. Limiting the XGBoost model to 20 features out of 331, a minimal reduction in performance was observed with an AUROC of 0.778. Using Shapley Additive Explanations, the top features were an admission diagnosis of pneumonia or sepsis and comorbidity of chronic respiratory failure. CONCLUSIONS Our machine learning model accurately predicts the probability that a patient will eventually require a tracheostomy upon ICU admission, and upon prospective validation, we have the potential to institute earlier interventions and reduce the complications of prolonged ventilation.
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Affiliation(s)
| | - Ameen Amanian
- Department of Surgery, Division of Otolaryngology-Head & Neck Surgery, University of British Columbia, Vancouver, Canada
| | - Meihan Wei
- Department of Biomedical Engineering-Whiting School of Engineering, Johns Hopkins University, Baltimore, USA
| | - Eitan Prisman
- Department of Surgery, Division of Otolaryngology-Head & Neck Surgery, University of British Columbia, Vancouver, Canada
| | - Pedro Alejandro Mendez-Tellez
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
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Iokura D, Okanoue Y, Otsuki S, Oe K, Takata K, Tarui A, Kojima T. Safety and efficacy of high tracheostomy with inferior retraction of the thyroid isthmus. Auris Nasus Larynx 2024; 51:231-235. [PMID: 37926659 DOI: 10.1016/j.anl.2023.10.007] [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: 04/27/2023] [Revised: 09/05/2023] [Accepted: 10/26/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE In typical surgical tracheostomy, the thyroid isthmus is divided or retracted superiorly and preserved. However, at our institution, the thyroid isthmus is retracted inferiorly and preserved. Thereafter, a tracheal incision is made above the thyroid isthmus. This method, hereinafter defined as high tracheostomy, has the advantage of facilitating immediate access to the trachea in a superficial position; moreover, it can be quickly replaced with cricothyrotomy in emergency situations. However, tracheotomies placed too high can potentially damage the cricoid cartilage, thereby causing subglottic granulation and tracheal stenosis. We aimed to validate the safety and efficacy of high tracheostomy with inferior retraction of the thyroid isthmus. METHODS This was a retrospective cohort analysis. We analyzed the operative method and other relevant characteristics of 90 patients who underwent surgical tracheostomy between April 2016 and June 2022. For those who underwent high tracheostomies, we analyzed the duration of surgery, amount of intraoperative bleeding, occurrence of complications, problems with stoma closure, and perioperative mortality. RESULTS High tracheostomy was performed in 73 patients. Subglottic granulation occurred in one patient, and the granulation tissue spontaneously shrank. Subcutaneous emphysema occurred in two patients. No patient developed wound infection or tracheoinnominate artery fistula. Moreover, no patient experienced false route tracheotomy tube insertion because the thyroid glands were located under the stoma. CONCLUSION The frequency of complications was comparable to that reported in other studies on tracheostomy. Additionally, no patient developed tracheal stenosis secondary to tracheostomy above the thyroid isthmus. Therefore, high tracheostomy with inferior retraction and preservation of the thyroid isthmus is safe and advantageous.
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Affiliation(s)
- Daisuke Iokura
- Department of Otolaryngology, Tenri Hospital, Tenri, Nara, Japan
| | - Yusuke Okanoue
- Department of Otolaryngology, Tenri Hospital, Tenri, Nara, Japan
| | - Shuya Otsuki
- Department of Otolaryngology, Tenri Hospital, Tenri, Nara, Japan
| | - Kengo Oe
- Department of Otolaryngology, Tenri Hospital, Tenri, Nara, Japan
| | - Kuniaki Takata
- Department of Otolaryngology, Tenri Hospital, Tenri, Nara, Japan
| | - Akihito Tarui
- Department of Otolaryngology, Tenri Hospital, Tenri, Nara, Japan
| | - Tsuyoshi Kojima
- Department of Otolaryngology, Tenri Hospital, Tenri, Nara, Japan; Department of Otolaryngology-Head and Neck Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
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The Need to Routinely Convert Emergency Cricothyroidotomy to Tracheostomy: A Systematic Review and Meta-Analysis. J Am Coll Surg 2022; 234:947-952. [DOI: 10.1097/xcs.0000000000000114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Šifrer R, Urbančič J, Piazza C, van Weert S, García-Purriños F, Benedik J, Tancer I, Aničin A. Emergent tracheostomy during the pandemic of COVID-19: Slovenian National Recommendations. Eur Arch Otorhinolaryngol 2021; 278:2209-2217. [PMID: 32889621 PMCID: PMC7473826 DOI: 10.1007/s00405-020-06318-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 08/21/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE Emergent tracheostomy under local anaesthesia is a reliable method of airway management when orotracheal intubation is not possible. COVID-19 is spread through aerosol making the emergent tracheostomy a high-risk procedure for surgeons. The surgical establishment of the air conduit in emergency scenarios must be adjusted for safety reasons. METHODS To establish the Slovenian National Guidelines for airway management in cannot intubate-cannot ventilate situations in COVID-19 positive patients. RESULTS Good communication and coordination between surgeon and anaesthesiologist is absolutely necessary. Deep general anaesthesia, full muscle relaxation and adequate preoxygenation without intubation are initial steps. The surgical cricothyrotomy is performed quickly, the thin orotracheal tube is inserted, the cuff is inflated and ventilation begins. Following patient stabilisation, the conversion to the tracheostomy is undertaken with the following features: skin infiltration with vasoconstrictor, a vertical incision, avoidance of electrical devices in favour of classical manners of haemostasis, the advancement of the tube towards the carina, performing the tracheal window in complete apnoea following adequate oxygenation, the insertion of non-fenestrated canulla attached to a heat and moisture exchanger, the fixation of canulla with stitches and tapes, and the cricothyrotomy entrance closure. Appropriate safety equipment is equally important. CONCLUSION The goal of the guidelines is to make the procedure safer for medical teams, without harming the patients. Further improvements of the guidelines will surely appear as COVID-19 is a new entity and there is not yet much experience in handling it.
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Affiliation(s)
- Robert Šifrer
- University Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Centre Ljubljana, Zaloška 2, 1000, Ljubljana, Slovenia.
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1104, Ljubljana, Slovenia.
| | - Jure Urbančič
- University Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Centre Ljubljana, Zaloška 2, 1000, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1104, Ljubljana, Slovenia
| | - Cesare Piazza
- Department of Otorhinolaryngology, Maxillofacial and Thyroid Surgery, National Cancer Institute of Milan, Via Giacomo Venezian 1, Milan, Italy
- Department of Oncology and Oncohematology, University of Milan, Via Festa del Perdono 7, Milan, Italy
| | - Stijn van Weert
- Department of Otolaryngology - Head and Neck Surgery, Amsterdam UMC, Locatie VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Francisco García-Purriños
- Servicio de Otorrinolaringología, Hospital Universitario Los Arcos del Mar Menor, Paraje Torre Octavio 54, 30739, Pozo Aledo, Murcia, Spain
| | - Janez Benedik
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1104, Ljubljana, Slovenia
- Department of Anaesthesiology and Surgical Intensive Therapy, University Medical Centre Ljubljana, Zaloška 2, 1000, Ljubljana, Slovenia
| | - Ivana Tancer
- University Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Centre Ljubljana, Zaloška 2, 1000, Ljubljana, Slovenia
| | - Aleksandar Aničin
- University Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Centre Ljubljana, Zaloška 2, 1000, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1104, Ljubljana, Slovenia
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Knewitz A, Nanda N, Hoffman MR, Dailey SH, Wieland AM, McCulloch TM. Pre-tracheotomy for Potentially Emergent Airway Scenarios: Indications and Outcomes. Laryngoscope 2021; 131:E2802-E2809. [PMID: 34021601 DOI: 10.1002/lary.29612] [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: 01/15/2021] [Revised: 04/19/2021] [Accepted: 04/28/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS Airway access in the setting of unsuccessful ventilation and intubation typically involves emergent cricothyrotomy or tracheotomy, procedures with associated significant risk. The potential for such emergent scenarios can often be predicted based on patient and disease factors. Planned tracheotomy can be performed in these cases but is not without its own risks. We previously described a technique of pre-tracheotomy or exposing the tracheal framework without entering the trachea, as an alternative to planned tracheostomy in such cases. In this way, a tracheotomy can be easily completed if needed, or the wound can be closed if it is not needed. This procedure has since been used in an array of indications. We describe the clinical situations where pre-tracheotomy was performed as well as subsequent patient outcomes. METHODS Retrospective series of patients undergoing a pre-tracheotomy from 2015 to 2020. Records were reviewed for patient characteristics, indication, whether the procedure was converted to tracheotomy or closed at the bedside, and any post-procedural complications. RESULTS Pre-tracheotomy was performed in 18 patients. Indications included failed extubation after head and neck reconstruction, subglottic stenosis, laryngeal masses, laryngeal edema, thyroid masses, and an oropharyngeal bleed requiring operative intervention. Tracheotomy was avoided in 10 patients with wound closed at the bedside; procedure was converted to tracheotomy in the remaining eight. There were no complications. Indications for conversion included failed extubation, intraoperative hemorrhage, significant stridor with dyspnea, and inability to ventilate. CONCLUSION Pre-tracheotomy offers simplified airway access and provides a valuable option in scenarios where tracheotomy may, but not necessarily, be needed. LEVEL OF EVIDENCE 4 Laryngoscope, 2021.
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Affiliation(s)
- Allison Knewitz
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A
| | - Nainika Nanda
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A
| | - Matthew R Hoffman
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A.,Department of Otolaryngology - Head and Neck Surgery, University of Alabama, Birmingham, Alabama, U.S.A
| | - Seth H Dailey
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A
| | - Aaron M Wieland
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A
| | - Timothy M McCulloch
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A
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Zasso FB, You-Ten KE, Ryu M, Losyeva K, Tanwani J, Siddiqui N. Complications of cricothyroidotomy versus tracheostomy in emergency surgical airway management: a systematic review. BMC Anesthesiol 2020; 20:216. [PMID: 32854626 PMCID: PMC7450579 DOI: 10.1186/s12871-020-01135-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 08/23/2020] [Indexed: 11/25/2022] Open
Abstract
Background Airway guidelines recommend an emergency surgical airway as a potential life-saving treatment in a “Can’t Intubate, Can’t Oxygenate” (CICO) situation. Surgical airways can be achieved either through a cricothyroidotomy or tracheostomy. The current literature has limited data regarding complications of cricothyroidotomy and tracheostomy in an emergency situation. The objective of this systematic review is to analyze complications following cricothyroidotomy and tracheostomy in airway emergencies. Methods This synthesis of literature was exempt from ethics approval. Eight databases were searched from inception to October 2018, using a comprehensive search strategy. Studies were included if they were randomized controlled trials or observational studies reporting complications following emergency surgical airway. Complications were classified as minor (evolving to spontaneous remission or not requiring intervention or not persisting chronically), major (requiring intervention or persisting chronically), early (from the start of the procedure up to 7 days) and late (beyond 7 days of the procedure). Results We retrieved 2659 references from our search criteria. Following the removal of duplicates, title and abstract review, 33 articles were selected for full-text reading. Twenty-one articles were finally included in the systematic review. We found no differences in minor, major or early complications between the two techniques. However, late complications were significantly more frequent in the tracheostomy group [OR (95% CI) 0.21 (0.20–0.22), p < 0.0001]. Conclusions Our results demonstrate that cricothyroidotomies performed in emergent situations resulted in fewer late complications than tracheostomies. This finding supports the recommendations from the latest Difficult Airway Society (DAS) guidelines regarding using cricothyroidotomy as the technique of choice for emergency surgical airway. However, emergency cricothyroidotomies should be converted to tracheostomies in a timely fashion as there is insufficient evidence to suggest that emergency cricothyrotomies are long term airways.
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Affiliation(s)
- Fabricio Batistella Zasso
- MD, Department of Anaesthesia, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.
| | - Kong Eric You-Ten
- MD, Department of Anaesthesia, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Ryu
- MLIS, Information Specialist, Sidney Liswood Health Science Library, Sinai Health System, University of Toronto, Toronto, Ontario, Canada
| | - Khrystyna Losyeva
- Summer Research Student, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jaya Tanwani
- Medical Student, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Naveed Siddiqui
- MD, Department of Anaesthesia, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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DeVore EK, Redmann A, Howell R, Khosla S. Best practices for emergency surgical airway: A systematic review. Laryngoscope Investig Otolaryngol 2019; 4:602-608. [PMID: 31890877 PMCID: PMC6929583 DOI: 10.1002/lio2.314] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 09/11/2019] [Accepted: 09/18/2019] [Indexed: 11/10/2022] Open
Abstract
Objective In the case of an emergency surgical airway, current guidelines state that surgical cricothyrotomy is preferable to tracheotomy. However, complications associated with emergency cricothyrotomy may be more frequent and severe. We systematically reviewed the English literature on emergency surgical airway to elicit best practices. Methods PubMed, Embase, MEDLINE, and the Cochrane Library were searched from inception to January 2019 for studies reporting emergency cricothyrotomy and tracheotomy outcomes. All English-language retrospective analyses, systematic reviews, and meta-analyses were included. Case reports were excluded, as well as studies with pediatric, nonhuman, or nonliving subjects. Results We identified 783 articles, and 20 met inclusion criteria. Thirteen evaluated emergency cricothyrotomy and included 1,219 patients (mean age = 39.8 years); 4 evaluated emergency tracheotomy and included 342 patients (mean age = 46.0 years); 2 evaluated both procedures. The rate of complications with both cricothyrotomy and tracheotomy was comparable. The most frequent early complications were failure to obtain an airway (1.6%) and hemorrhage (5.6%) for cricothyrotomy and tracheotomy, respectively. Airway stenosis was the most common long-term complication, occurring at low rates in both procedures (0.22-7.0%). Conclusions Complications associated with emergency cricothyrotomy may not occur as frequently as presumed. Tracheotomy is an effective means of securing the airway in an emergent setting, with similar risk for intraoperative and postoperative complications compared to cricothyrotomy. Ultimately, management should depend on clinician experience and patient characteristics. Level of Evidence IV.
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Affiliation(s)
- Elliana K DeVore
- Department of Otolaryngology Harvard Medical School Boston Massachusetts U.S.A
| | - Andrew Redmann
- Department of Otolaryngology-Head and Neck Surgery University of Cincinnati Cincinnati Ohio U.S.A.,Division of Pediatric Otolaryngology Cincinnati Children's Hospital Medical Center Cincinnati Ohio U.S.A
| | - Rebecca Howell
- Department of Otolaryngology-Head and Neck Surgery University of Cincinnati Cincinnati Ohio U.S.A
| | - Sid Khosla
- Department of Otolaryngology-Head and Neck Surgery University of Cincinnati Cincinnati Ohio U.S.A
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Qureshi MSS, Shad ZS, Shoaib F, Munawar K, Saeed ML, Hussain SW, Qadeer A, Khan MT, Masood H, Abdullah A. Early Versus Late Tracheostomy After Decompressive Craniectomy. Cureus 2018; 10:e3699. [PMID: 30788188 PMCID: PMC6372250 DOI: 10.7759/cureus.3699] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective The goal of this study was to determine the efficacy of early tracheostomy (i.e., ≤ 10 days of intubation) compared with a late tracheostomy (> 10 days of intubation) with regards to timing, frequency of ventilator-associated pneumonia (VAP), mortality rate, and hospital stay in patients who received decompressive craniectomy. Study design We conducted a retrospective study of data from 168 patients who underwent decompression in the department of critical care medicine at Shifa International Hospital, Islamabad, Pakistan, from January 2017 to December 2017. Materials and methods The study included men and women over the age of 18 years who had undergone tracheostomy following decompressive craniectomy in the intensive care unit as a result of stroke, traumatic brain injury, or acute severe injury. Data were analyzed using IBM SPSS Statistics for Windows, Version 23.0 (IBM Corp., Armonk, NY, US). We also applied the Chi-square test, and p ≤ 0.05 was considered significant. Results Of 168 patient records reviewed, tracheostomy was performed in 48 patients (21 men, 27 women). In the 48 tracheostomy patients, 15 (31%) were early tracheostomies and 33 (69%) were late tracheostomies. The mean age of patients was 44 ± 11 years. Twenty-eight patients (58.3%) were in the younger age group (age 18 to 45 years) and 20 patients (41.7%) were in the older age group (age > 45 years). Patients who received an early tracheostomy spent significantly less time on a ventilator (≤ 12 days) than those patients receiving a late tracheostomy (> 12 days, p = 0.004). The early tracheostomy group also had a lower incidence rate of VAP than patients with a late tracheostomy (𝑥2 = 7.855, p = 0.005). Patients who received an early tracheostomy had lower mortality rates than those who received late tracheostomies (𝑥2 = 6.158, p = 0.013). Finally, the length of hospital stay was ≤ 15 days for patients who received early tracheostomies; most patients who received a late tracheostomy had a hospital stay of > 15 days (𝑥2 =11.965, p = 0.001). Conclusions Performing a tracheostomy within 10 days of intubation following decompressive craniectomy significantly reduced ventilator time, mortality, the incidence of VAP, and length of hospital stay. Given the potential benefits of early tracheostomy in critical care patients following decompressive craniectomy, physicians should consider early tracheostomy in appropriate cases.
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Affiliation(s)
| | | | - Faghia Shoaib
- Pathology, Bahawal Victoria Hospital, Quaid-E-Azam Medical College, Bahawalpur, PAK
| | - Kamran Munawar
- Internal Medicine, Shifa College of Medicine, Islamabad, PAK
| | | | | | - Aayesha Qadeer
- Internal Medicine, Shifa International Hospital, Islamabad, PAK
| | | | - Hassan Masood
- Internal Medicine, Shifa International Hospital, Islamabad, PAK
| | - Azmat Abdullah
- Internal Medicine, Shifa International Hospital, Islamabad, USA
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Janik S, Kliman J, Hacker P, Erovic BM. Preserving the thyroidal isthmus during low tracheostomy with creation of a Björk flap. Laryngoscope 2018; 128:2783-2789. [PMID: 30284245 PMCID: PMC6585656 DOI: 10.1002/lary.27310] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 04/29/2018] [Accepted: 05/03/2018] [Indexed: 11/05/2022]
Abstract
OBJECTIVES/HYPOTHESIS Surgical tracheostomy (ST) with creation of an inferiorly based U-shaped tracheal flap, known as the Björk flap, is the most commonly performed. The purpose of this study was to evaluate whether outcome was different in patients who underwent low ST with retraction and preservation of the thyroid isthmus compared to those who underwent high ST with ligation of the thyroid isthmus. STUDY DESIGN Retrospective cohort study. METHODS We included 1,143 patients who underwent ST with creation of a Björk flap between 2008 and 2015. Different outcome parameters, including complications, decannulation, inpatient mortality, and surgical characteristics, such as length of surgery and height of tracheal incision, were assessed comparing low and high ST. RESULTS Complications occurred in 7.7% of patients, of which persistent stoma (4.1%) and hemorrhages (2.7%) were the most common. Low tracheostomy with retraction and preservation of thyroid isthmus was done in 31.4% of cases. Complications did not significantly differ between low and high tracheostomies (8.0% vs. 7.0%, P = .468). Moreover, decannulation rate and inpatient mortality were also not significantly different in low compared to high tracheostomies (P = .816 and P = .152, respectively). However, low tracheostomies were associated with significantly shorter operation times (33.0 ± 0.8 min vs. 38.7 ± 0.5 min, P < .001) and lower tracheal incisions for creation of a Björk flap (P < .001) compared to high tracheostomies. CONCLUSIONS Low tracheostomies are as safe as high tracheostomies regarding complications. Due to the fact that low tracheostomies are associated with shorter operation times and lower tracheal incisions, we recommend performong low tracheostomies whenever feasible. LEVEL OF EVIDENCE 4 Laryngoscope, 128:2783-2789, 2018.
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Affiliation(s)
- Stefan Janik
- Department of Otorhinolaryngology-Head and Neck Surgery , Medical University of Vienna, Vienna, Austria
| | - Jonathan Kliman
- Department of Otorhinolaryngology-Head and Neck Surgery , Medical University of Vienna, Vienna, Austria
| | - Philipp Hacker
- Department of Otorhinolaryngology-Head and Neck Surgery , Medical University of Vienna, Vienna, Austria
| | - Boban M Erovic
- Department of Otorhinolaryngology-Head and Neck Surgery , Medical University of Vienna, Vienna, Austria.,Institute for Head and Neck Diseases , Evangelical Hospital Vienna, Vienna, Austria
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Macêdo MB, Guimarães RB, Ribeiro SM, Sousa KMMDE. Emergency cricothyrotomy: temporary measure or definitive airway? A systematic review. Rev Col Bras Cir 2016; 43:493-499. [PMID: 28273224 DOI: 10.1590/0100-69912016006010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 09/29/2016] [Indexed: 11/22/2022] Open
Abstract
Being a fast and safe method in the hands of well trained professionals in both prehospital and intrahospital care, Cricothyrotomy has been broadly recommended as the initial surgical airway in the scenario "can't intubate, can't ventilate", and is particularly useful when the obstruction level is above or at the glottis. Its prolonged permanence, however, is an endless source of controversy. In this review we evaluate the complications of cricothyrotomy and the need of its routine conversion to tracheotomy through a search on PubMed, LILACS and SciELO electronic databases with no restriction to the year or language of the publication. In total, we identified 791 references, retrieved 20 full text articles, and included nine studies in our review. The incidence of short-term complications ranged from zero to 31.6%, and the long-term complications, from zero to 7.86%. Subglotic stenosis was the main long-term reported complication, even though it was quite infrequent, occurring only in 2.9 to 5%. The frequency of conversion to tracheostomy varied from zero to 100%. Although a small frequency of long-term complications was found for emergency cricothyrotomy, the studies' low level of evidence does not allow the recommendation of routine use of cricothyrotomy as a secure definitive airway.
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Abstract
Tracheostomy is the most common surgical procedure performed on critically ill patients. For those who survive their critical illnesses but remain ventilator-dependent, tracheostomy provides patients with a secure airway that frees the mouth for oral nutrition, enhances verbalized speech, and promotes generalized comfort. Avoiding complications from tracheostomy requires a skilled multi-disciplinary approach to ensure that the benefits outweigh the risks of the procedure.
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Affiliation(s)
- J E Heffner
- Medical University of South Carolina, 169 Ashley Avenue, PO Box 250332, Charleston, South Carolina 29425, USA.
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Akulian JA, Yarmus L, Feller-Kopman D. The role of cricothyrotomy, tracheostomy, and percutaneous tracheostomy in airway management. Anesthesiol Clin 2016; 33:357-67. [PMID: 25999008 DOI: 10.1016/j.anclin.2015.02.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Cricothyrotomy, percutaneous dilation tracheostomy, and surgical tracheostomy are cost-effective and safe techniques employed in the management of critically ill patients requiring insertion of an artificial airway. These procedures have been well characterized and studied in the surgical, emergency medicine, and critical care literature. This article focuses on the role of each of these modalities in airway management, specifically comparing the data for each procedure in regard to procedural outcomes. The authors discuss the techniques available and the relevant background data regarding choice of each method and its integration into clinical practice.
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Affiliation(s)
- Jason A Akulian
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, 8007 Burnett Womack, CB 7219, Chapel Hill, NC 27599-7219, USA
| | - Lonny Yarmus
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care, Johns Hopkins Hospital, Johns Hopkins University, 1800 Orleans Street, Suite 7125, Baltimore, MD 21287, USA
| | - David Feller-Kopman
- Bronchoscopy and Interventional Pulmonology, Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Johns Hopkins University, Baltimore, MD 21287, USA.
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A fatal case of iatrogenic aortic arch rupture occurred during a tracheostomy. Forensic Sci Int 2015; 259:e5-8. [PMID: 26709098 DOI: 10.1016/j.forsciint.2015.11.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 11/27/2015] [Accepted: 11/28/2015] [Indexed: 11/20/2022]
Abstract
The authors illustrate a rare case of aortic arch rupture in a 60-year-old woman, occurred during a tracheostomy performed using the Griggs method. The autopsy examination showed an aortic arch rupture in an intermediate position situated in the area between the brachiocephalic artery ostium and the left common carotid artery ostium, associated to a hemorrhage filling of the adjacent connective and muscular tissue. The death was therefore determined by cardiac arrest secondary to massive hemorrhagic hypovolemic shock caused by the aortic arch rupture. The lethal iatrogenic lesion was determined by the aortic arch traction caused by the dilatation. The surgeon's incautious use of the Howard-Kelly forceps introduced in the mediastinum was therefore hypothesized.
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Uehara M, Kokuryo S, Sasaguri M, Tominaga K. Emergency Cricothyroidotomy for Difficult Airway Management After Asynchronous Bilateral Neck Dissections: A Case Report and Literature Review. J Oral Maxillofac Surg 2015; 73:2066.e1-7. [PMID: 26126919 DOI: 10.1016/j.joms.2015.06.152] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 06/06/2015] [Accepted: 06/07/2015] [Indexed: 11/24/2022]
Abstract
PURPOSE This report describes a case that required emergency cricothyroidotomy for an upper airway obstruction owing to laryngeal edema after asynchronous bilateral neck dissections. PATIENT AND METHODS A 57-year-old man was diagnosed with multicentric squamous cell carcinoma of the tongue (T1 and 2N0M0), and partial glossectomy with primary closure was performed. Three months after surgery, secondary metastases in the right cervical lymph nodes were detected, and a right radical neck dissection was performed. Contrast-enhanced computed tomographic (CT) scan taken 2 weeks after the right neck dissection visualized a possible third metastasis in the left cervical lymph node. Four weeks after the right radical neck dissection, left supraomohyoid neck dissection was carried out. In this surgery, the left internal jugular vein (IJV) was preserved. Nine hours after surgery, severe swelling of the face and pharynx was recognized, resulting in a stoppage of respiration and then an emergency cricothyroidotomy. RESULTS The patient's life was saved without any encephalopathy or airway trouble. Contrast-enhanced CT scan taken the next day confirmed the preserved left IJV patency. CONCLUSION Oral and maxillofacial surgeons should be aware of the possibility of life-threatening laryngeal edema associated with bilateral neck dissections even if the unilateral IJV is preserved and should know the procedure for emergency cricothyroidotomy.
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Affiliation(s)
- Masataka Uehara
- Lecturer, Division of Maxillofacial Surgery, Department of Science of Physical Functions, Kyushu Dental University, Fukuoka, Japan.
| | - Shinya Kokuryo
- Lecturer, Division of Oral Medicine, Department of Science of Physical Functions, Kyushu Dental University, Fukuoka, Japan
| | - Masaaki Sasaguri
- Associate Professor, Division of Maxillofacial Surgery, Department of Science of Physical Functions, Kyushu Dental University, Fukuoka, Japan
| | - Kazuhiro Tominaga
- Professor and Chairman, Division of Maxillofacial Surgery, Department of Science of Physical Functions, Kyushu Dental University, Fukuoka, Japan
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Ferraro F, Marullo L, d'Elia A, Izzo G. Elective tracheostomy in intensive care unit: Looking between techniques, a three cases report. Indian J Anaesth 2014; 58:190-2. [PMID: 24963186 PMCID: PMC4050938 DOI: 10.4103/0019-5049.130826] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
There is no optimal tracheostomy (TS) technique, proved to be the best. For this reason, operators’ skills, clinical anatomical and physio-pathological features of the patient should be considered as discriminating factors in the choice of percutaneous dilation tracheostomy (PDT) technique. This article includes reports of three cases of PDT: In the first case distance between jugular notch and the first tracheal ring was too long, the second case involving a patient with mild ectasia of the ascending aorta and aortic regurgitation with De Musset's sign with great risk of perioperative bleeding and a third case, of tracheomalacia with inflammatory stenosis at the 4th tracheal ring. All together, this case series describes how decisions were made by an experienced staff, in which the patient characteristics were assessed and techniques best suited for each case were implemented.
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Affiliation(s)
- Fausto Ferraro
- Department of Anaesthesiology, Surgical and Emergency Science, Second University of Naples, Piazza Miraglia 2, 80138 Naples, Italy
| | - Lucia Marullo
- Department of Anaesthesiology, Surgical and Emergency Science, Second University of Naples, Piazza Miraglia 2, 80138 Naples, Italy
| | - Anna d'Elia
- Department of Anaesthesiology, Surgical and Emergency Science, Second University of Naples, Piazza Miraglia 2, 80138 Naples, Italy
| | - Giuseppe Izzo
- Department of Anaesthesiology, Surgical and Emergency Science, Second University of Naples, Piazza Miraglia 2, 80138 Naples, Italy
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Marullo L, Izzo G, Orsini A, Petruzzi J, d’Elia A, Vessicchio L, Ferraro F. Clinical features as discriminating factors in the choice of tracheostomy techniques. BMC Surg 2013. [PMCID: PMC3847276 DOI: 10.1186/1471-2482-13-s1-a28] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Schaefer SD. Management of acute blunt and penetrating external laryngeal trauma. Laryngoscope 2013; 124:233-44. [PMID: 23804493 DOI: 10.1002/lary.24068] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 01/22/2013] [Accepted: 01/31/2013] [Indexed: 01/27/2023]
Abstract
OBJECTIVES/HYPOTHESIS Improve the care of acute external laryngeal trauma by reviewing controversies and the evolution of treatment. DATA SOURCE Internet-based search engines, civilian and military databases, and manual search of references from these sources over the past 90 years. REVIEW METHODS Utilizing the above-mentioned sources, electronic and manual searches of primary topics such as laryngeal trauma or injury, emergency tracheotomy, airway trauma, intubation versus tracheotomy, cricothyrotomy, esophageal trauma, and emergent management of airway injuries in civilian and combat zones. Citations were reviewed, selected reports analyzed, and the most relevant articles referenced. RESULTS Optimal treatment of acute laryngeal trauma includes early identification of injuries utilizing a directed history and physical examination. Timely management of the wounded airway is essential. The choice of intubation, tracheotomy, or cricothyrotomy must be individualized. Computed tomography (CT) may assist in differentiating patients who can be observed versus those who require surgical exploration. In selected patients, laryngeal electromyography and stroboscopy may also be useful. Surgery should begin with direct laryngoscopy and rigid esophagoscopy to evaluate the hard and soft tissues of the larynx, and to visualize the pharynx and esophagus. Minor endolaryngeal lacerations and abrasions may be observed, whereas more significant injuries require primary closure via a thyrotomy. Laryngeal skeletal fractures should be reduced and fixated. Endolaryngeal stenting is reversed for massive mucosal trauma, comminuted fractures, and traumatic anterior commissure disruption. CONCLUSIONS Acute external injury to the larynx is both life threatening and a potential long-term management challenge. Although a rare injury, sufficient experience now exists to recommend specific treatments, and to preserve voice and airway function.
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Affiliation(s)
- Steven D Schaefer
- New York Head and Neck Institute, Department of Otolaryngology-Head and Neck Surgery, Lenox Hill Hospital of the North Shore Long Island Jewish Health System and New York Medical College, New York, New York, U.S.A
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Teo N, Garrahy A. Elective surgical cricothyroidotomy in oral and maxillofacial surgery. Br J Oral Maxillofac Surg 2013; 51:779-82. [PMID: 23668941 DOI: 10.1016/j.bjoms.2013.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 04/01/2013] [Indexed: 11/28/2022]
Abstract
Surgical Cricothyroidotomy is regarded as an emergency procedure today even though it has a good evidential record as an elective surgical airway. A misunderstanding of Jackson's landmark paper in 1921 has made the simple and safe procedure unpopular because of the fear of subglottic stenosis. We present the incidence of subglottic stenosis after surgical cricothyroidotomy, discuss evidence for elective surgical cricothyroidotomy, and suggest potential applications in oral and maxillofacial surgery.
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Affiliation(s)
- Noah Teo
- Department of Oral and Maxillofacial Surgery, The Ulster Hospital, Upper Newtownards Road, Belfast, BT16 1RH, Northern Ireland, UK.
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Use of the Trachlight in securing the airway due to accidental dislodgement of a tracheostomy tube. J Clin Anesth 2012; 24:433-4. [PMID: 22626678 DOI: 10.1016/j.jclinane.2011.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Revised: 08/03/2011] [Accepted: 08/16/2011] [Indexed: 10/28/2022]
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Graham DB, Eastman AL, Aldy KN, Carroll EA, Minei JP, Brakenridge SC, Phelan HA. Outcomes and long term follow-up after emergent cricothyroidotomy: is routine conversion to tracheostomy necessary? Am Surg 2012; 77:1707-11. [PMID: 22273235 DOI: 10.1177/000313481107701248] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The purpose of this study is to identify factors associated with survival after cricothyroidotomy (CRIC), and to ascertain long-term outcomes in patients simply decannulated after CRIC versus those revised to tracheostomy. All CRICs between October 1, 1995 and June 20, 2010 were reviewed. Patients were contacted by phone, visited at their last known address, or queried in the Center for Disease Control's National Death Index. DECAN were those CRICs decannulated without revision. TRACH were those revised to a tracheostomy at any point. Ninety-five CRIC patients were identified. In 94 per cent of survivors of initial admission, a Glasgow Coma Score (GCS) of 15 was noted at disposition. Cardiopulmonary resuscitation before or during CRIC performance was strongly associated with all-cause death during index admission, and increasing head Abbreviated Injury Score was associated with lower odds of a neurologically intact survival. Of survivors, 82 per cent of DECAN and 57 per cent of TRACH patients were followed-up with at medians of 48 (interquartile range 19-57) and 53 (20-119) months, respectively. DECAN occurred at a median of 4 days (2-7) whereas TRACH revision occurred at a median of 2 days (1-7). Endoscopy was performed on 36 per cent of DECAN patients and 22 per cent of TRACH patients. Two DECAN patients with acute subglottic edema/stenosis decannulated successfully on days 9 and 15 postinjury and had no problems at 54 and 91 months postinjury. At follow-up, no patient in either group had suffered a clinically evident airway complication. The need for cardiopulmonary resuscitation before or during CRIC portends poorly for neurologically intact survival. Simple decannulation is appropriate for CRIC patients when their need for airway protection has resolved.
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Affiliation(s)
- David B Graham
- Department of Surgery, University of Texas-Southwestern Medical Center, 5323 Harry Hines Boulevard, E5.508A, Dallas, TX 75390-9158, USA
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Donat A, Petitjeans F, Précloux P, Puidupin M, Escarment J. La cricothyrotomie : données actuelles et intérêt de cette technique en médecine de guerre. ACTA ACUST UNITED AC 2012; 31:141-51. [DOI: 10.1016/j.annfar.2011.10.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2010] [Accepted: 10/26/2011] [Indexed: 11/25/2022]
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Retrospective study of tracheostomy indications and perioperative complications on oral and maxillofacial surgery service. J Oral Maxillofac Surg 2011; 70:890-5. [PMID: 22197004 DOI: 10.1016/j.joms.2011.09.022] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2011] [Revised: 09/19/2011] [Accepted: 09/20/2011] [Indexed: 11/23/2022]
Abstract
PURPOSE Tracheostomy is an extremely common procedure performed by a variety of surgical specialties. The purpose of the present study was to review the intraoperative and perioperative management and complications, present our surgical technique, and discuss the role of our service in providing this care within a large community hospital setting. PATIENTS AND METHODS The 112 patients in our retrospective study were divided into 3 subsets: those referred by medical specialties, tumor/reconstructive surgery patients, and trauma victims. Cases of percutaneous dilational and intensive care unit bedside tracheostomy were excluded. Intraoperative and immediately postoperative complications were included. Bleeding complications were defined as those necessitating a return to the operating room. The patients were followed up for a 24-hour period postoperatively. RESULTS The medical referral, tumor/reconstructive, and trauma patients made up 55%, 29%, and 16% of the included patients, respectively. The overall complication rate was 2.7%. CONCLUSIONS Conventional open tracheostomy in an operating room is associated with a low complication rate. The low incidence of perioperative bleeding can be attributed to the use of electrocautery in the division of the thyroid isthmus. This service provided an exceedingly safe and efficient surgical treatment by focusing on precise surgical protocols in an operating room setting. Intense coordination of consultation response, operating room scheduling, and communication with other services involved in these patients' care is critical to develop and maintain the privilege to provide this treatment. Our report can be used to educate the medical community regarding the role of an oral and maxillofacial surgery service in providing tracheostomy.
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Abstract
OBJECTIVE To review and compare the complications of percutaneous tracheotomy (TP) and cricothyroidotomy (CT) used to perform tracheal intubation in patients requiring prolonged mechanical ventilation. DESIGN A prospective, observational study performed from October 2004 to October 2006, and follow-up of course until May 2007. SETTING Intensive care service from a university-affiliated teaching hospital. PATIENTS A total of 82 patients in which CT or TP were necessary. Forty-three TP and 39 CT were performed. MAIN MEASUREMENTS Reason for TP or CT, demographic data, severity scores, ICU length of stay, orotracheal intubation (OTI) days, CT/TP early and late complications and in-hospital evolution were collected. RESULTS TP/CT were performed due to prolonged ventilation in 62 (76%) patients and because of impaired neurological status in the remaining patients. There were no differences between TP/CT in gender, APACHE II, ICU length of stay, previous OTI days. Patients in the CT group were older (68 +/- 9 vs 54 +/- 15 years, p < 0.001). There were 5 mild adverse events (3 guide angulations and 2 lateral tracheal punctions) after TP, and 1 severe adverse event (pulmonary ventilation problem) after CT. There were no fatal event related with TP/CT. Thirty-four patients were decanulated. Mild local injuries were seen in 8 patients (6 TP vs 2 CT). Only 1 subglottic granuloma was seen late in CT group. CONCLUSIONS In our experience CT constitutes a safety and feasible alternative to TP when TP is counter-indicated.
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Abstract
INTRODUCTION The difficult airway is a common problem in adult critical care patients. However, the challenge is not just the establishment of a safe airway, but also maintaining that safety over days, weeks, or longer. AIMS This review considers the management of the difficult airway in the adult critical care environment. Central themes are the recognition of the potentially difficult airway and the necessary preparation for (and management of) difficult intubation and extubation. Problems associated with tracheostomy tubes and tube displacement are also discussed. RESULTS All patients in critical care should initially be viewed as having a potentially difficult airway. They also have less physiological reserve than patients undergoing airway interventions in association with elective surgery. Making the critical care environment as conducive to difficult airway management as the operating room requires planning and teamwork. Extubation of the difficult airway should always be viewed as a potentially difficult reintubation. Tube displacement or obstruction should be strongly suspected in situations of new-onset difficult ventilation. CONCLUSIONS Critical care physicians are presented with a significant number of difficult airway problems both during the insertion and removal of the airway. Critical care physicians need to be familiar with the difficult airway algorithms and have skill with relevant airway adjuncts.
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Patel KG, Zdanski CJ. Cricothyroidotomy vs. sternal tracheotomy for challenging airway anatomy. Laryngoscope 2008; 118:1827-9. [PMID: 18607301 DOI: 10.1097/mlg.0b013e31817dace0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Although tracheotomies are the standard procedure for elective surgical airways, some patients present with challenging anatomy. In circumstances of abnormal skeletal deformities, such as kyphoscoliosis, the airway is also often tortuous and access to the trachea may be difficult. In the situation of severely distorted tracheal anatomy, where access to the trachea may require a mediansternotomy, a cricothyroidotomy may be the safer option. This article details the technique involved in approaching a substernal larynx and stomatizing a cricothyroidotomy for a patient who required a long-term surgical airway secondary to severe kyphoscoliosis from Proteus syndrome and failure to extubate.
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Affiliation(s)
- Krishna G Patel
- Department of Otolaryngology, University of North Carolina Hospitals, G0412 Neurosciences Hospital, Chapel Hill, North Carolina, USA.
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Lavery G, Jamison C. Airway Management in the Critically Ill Adult. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50004-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Perfeito JAJ, Mata CASD, Forte V, Carnaghi M, Tamura N, Leão LEV. Traqueostomia na UTI: vale a pena realizá-la? J Bras Pneumol 2007; 33:687-90. [DOI: 10.1590/s1806-37132007000600012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2006] [Accepted: 03/29/2007] [Indexed: 11/21/2022] Open
Abstract
OBJETIVO: Analisar a viabilidade, as complicações e a mortalidade da traqueostomia realizada em ambiente de unidade de terapia intensiva (UTI). MÉTODOS: Análise retrospectiva dos prontuários médicos dos 73 pacientes que foram submetidos à traqueostomia nos leitos das UTIs do Hospital São Paulo da Universidade Federal de São Paulo no período de janeiro a novembro de 2003. Os procedimentos foram realizados sempre por um residente de cirurgia, sob a orientação de um cirurgião torácico, utilizando a técnica aberta sistematizada no serviço. RESULTADOS: A idade média dos pacientes foi de 55,2 anos, sendo que 47 eram do sexo masculino (64,4%) e 26 eram do sexo feminino (35,6%). A indicação mais freqüente foi a intubação orotraqueal prolongada (76,7%). Não houve mortalidade relacionada ao procedimento, e em todos os pacientes o procedimento pôde ser realizado na UTI. As complicações imediatas ocorreram em 2 pacientes (2,7%), nos quais houve sangramento local aumentado que cessou com compressão local. A complicação tardia foi a infecção ao redor da ferida operatória, a qual ocorreu em 2 pacientes (2,7%) e foi tratada com curativos locais, sem maiores repercussões clínicas. CONCLUSÕES: Com base nos resultados de nossa análise, os quais são comparáveis aos resultados sobre traqueostomias realizadas no centro cirúrgico encontrados na literatura, concluímos que a traqueostomia na UTI é viável e apresenta baixo índice de complicações, mesmo quando realizada em pacientes graves por cirurgiões em treinamento. Portanto, a nosso ver, é possível afirmar que vale a pena realizar a traqueostomia na UTI.
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Affiliation(s)
| | | | - Vicente Forte
- Universidade Federal de São Paulo/Escola Paulista de Medicina, Brasil
| | - Martin Carnaghi
- Universidade Federal de São Paulo/Escola Paulista de Medicina, Brasil
| | - Nikei Tamura
- Universidade Federal de São Paulo/Escola Paulista de Medicina, Brasil
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Seow VK, Chong CF, Wang TL, You CF, Han HY, Chen CC. Ruptured left subclavian artery aneurysm presenting as upper airway obstruction in von Recklinghausen's disease. Resuscitation 2007; 74:563-6. [PMID: 17449164 DOI: 10.1016/j.resuscitation.2007.02.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2007] [Revised: 02/02/2007] [Accepted: 02/04/2007] [Indexed: 10/23/2022]
Abstract
Aneurysms arising from the subclavian artery are very rare vascular abnormalities in von Recklinghausen's disease, which often have a silent clinical presentation and are difficult to diagnose before rupture. We report a case of von Recklinghausen's disease with life-threatening upper airway obstruction caused by spontaneous rupture of the left subclavian artery aneurysm in a 46-year-old woman. The diagnosis was eventually confirmed by a reconstructed enhanced computed tomography of aorta. We emphasise the importance of it as a differential diagnosis because life-threatening upper airway obstruction may develop in such patient.
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Affiliation(s)
- Vei-Ken Seow
- Emergency Department, Shin-Kong Wu Ho-Su Memorial Hospital, No.95 Wen Chang Road, Shih Lin District, Taipei City 111, Taiwan, ROC
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Tabaee A, Lando T, Rickert S, Stewart MG, Kuhel WI. Practice patterns, safety, and rationale for tracheostomy tube changes: a survey of otolaryngology training programs. Laryngoscope 2007; 117:573-6. [PMID: 17415123 DOI: 10.1097/mlg.0b013e318030455a] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Tracheotomy for long-term ventilation is a common surgical procedure in the hospital setting. Although the postoperative care is often perceived as routine, complications associated with tracheostomy changes may result in loss of airway and death. In addition, the practice patterns, rationale, and complications related to tube changes have been poorly described. STUDY DESIGN AND METHODS A survey of chief residents in accredited otolaryngology training programs was performed to determine the management strategies, rationale, and complications associated with postoperative tracheostomy tube changes. RESULTS The first tube change was performed after a mean of 5.3 (range, 3-7) days after the procedure, most frequently by junior residents. The first change was performed in a variety of locations including the intensive care unit (88%), step down unit (80%), and regular floor (78%). Twenty-five percent performed these changes at night or on weekends. The most frequently reported rationale for performing routine tracheotomy changes was examination of the stoma for maturity (46%), prevention of stomal infection (46%), and confirmation of stability for transport to a less monitored setting (41%). Twenty-five (42%) respondents reported awareness of a loss of airway, and nine (15%) respondents reported awareness of a death as a result of the first tube change at their institution during their residency. A statistically significant higher incidence of airway loss was reported by respondents who reported performing the first tube change on the floor (96.1% vs. 63.6%). CONCLUSION There is significant variability in the approach to postoperative tracheostomy tube management. The occurrence of major complications including deaths from routine tube changes requires an examination of the rationale and safety of this practice.
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Affiliation(s)
- Abtin Tabaee
- Department of Otorhinolaryngology, Weill Medical College of Cornell University, New York, New York, USA
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Serviá Goixart L, Badía M, Campi D, Trujillano J, Alcega R, Vilanova J. [Acute parotiditis after tracheostomy in Intensive Care]. Med Intensiva 2006; 30:26-9. [PMID: 16637429 DOI: 10.1016/s0210-5691(06)74459-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Post-anesthesic parotiditis is a little known entity related with anesthesic procedures but described in any situation that motivates manipulation of the oropharyngeal cavity. Its physiopathological mechanism is not well-defined, although it could have a multifactorial origin. A case of a male who was admitted for post-operative control of brain tumor exeresis and who had preauricular and submaxillary inflammation after a routinely performed tracheostomy is presented. Coincidence with the performing of a tracheostomy required us to propose the differential diagnosis with the complications associated to said surgical act. Post-anesthesic parotiditis, even though it is a rare complication and has no clinical significance, should be kept in mind when there is facial edema after any manipulation of the oropharyngeal cavity.
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Affiliation(s)
- L Serviá Goixart
- Servicio de Cuidados Intensivos, Hospital Universitario Arnau de Vilanova, Lleida, España.
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Frass M, Dielacher C, Linkesch M, Endler C, Muchitsch I, Schuster E, Kaye A. Influence of Potassium Dichromate on Tracheal Secretions in Critically Ill Patients. Chest 2005; 127:936-41. [PMID: 15764779 DOI: 10.1378/chest.127.3.936] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Stringy, tenacious tracheal secretions may prevent extubation in patients weaned from the respirator. This prospective, randomized, double-blind, placebo-controlled study with parallel assignment was performed to assess the influence of sublingually administered potassium dichromate C30 on the amount of tenacious, stringy tracheal secretions in critically ill patients with a history of tobacco use and COPD. METHODS In this study, 50 patients breathing spontaneously with continuous positive airway pressure were receiving either potassium dichromate C30 globules (group 1) [Deutsche Homoopathie-Union, Pharmaceutical Company; Karlsruhe, Germany] or placebo (group 2). Five globules were administered twice daily at intervals of 12 h. The amount of tracheal secretions on day 2 after the start of the study as well as the time for successful extubation and length of stay in the ICU were recorded. RESULTS The amount of tracheal secretions was reduced significantly in group 1 (p < 0.0001). Extubation could be performed significantly earlier in group 1 (p < 0.0001). Similarly, length of stay was significantly shorter in group 1 (4.20 +/- 1.61 days vs 7.68 +/- 3.60 days, p < 0.0001 [mean +/- SD]). CONCLUSION These data suggest that potentized (diluted and vigorously shaken) potassium dichromate may help to decrease the amount of stringy tracheal secretions in COPD patients.
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Affiliation(s)
- Michael Frass
- Ludwig Boltzmann Institute for Homeopathy, Duerergasse 4, A 8010 Graz, Austria.
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Abstract
INTRODUCTION Tracheotomy was initially described as a means to relieve acute upper airway obstruction. Indications for its use have changed and developed over time. STATE OF THE ART During the 1960's, tracheotomy was promoted as a treatment for ventilator-dependent patients but the complications reported in the 1970's and early 1980's both reduced its accepted indications and led to it being proposed later. During the last 20 years advances in intensive care medicine and a reduction in the rate of complications associated with the procedure have encouraged intensivists again to propose tracheotomy at an earlier stage. PERSPECTIVES Over the last 10 years, a new technique, percutaneous dilatational tracheotomy has gained widespread acceptance because of its simplicity of execution, its low cost and the low rate of postoperative complications that has been observed. CONCLUSIONS Although the ideal time to perform a tracheotomy has not yet been established, the benefits of this approach compared to prolonged laryngeal intubation, the low morbidity associated with modern surgical tracheotomy and the development of percutaneous techniques support the use of this procedure in the management of patients requiring prolonged ventilatory support.
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Affiliation(s)
- P Lothaire
- Service de Chirurgie, Institut Jules Bordet, Bruxelles, Belgique.
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Abstract
PURPOSE OF REVIEW Until the past 40 years, the timing of tracheotomy was of little concern. It was an emergency procedure developed for the relief of airway obstruction. Following the development of positive pressure ventilation, tracheotomy became an elective procedure. Today, the optimal time for tracheotomy is a subject of dispute and continued investigation. As this operation has become one of the most commonly performed procedures in the intensive care unit, nonoperative dilational methods have gained acceptability. The purpose of this review is to analyze the recent literature and draw insight into the timing and technique of the current state of tracheotomy. RECENT FINDINGS Individualized assessment of patients should guide the timing of tracheotomy, with a preference toward early tracheotomy. Percutaneous dilational tracheotomy (PDT) can be performed with equivalent safety to open tracheotomy. Bedside open tracheotomy negates the cost-saving benefits of PDT. Endoscopic guidance in PDT decreases complications with needle placement and posterior tracheal wall injury. Major complications of PDT usually are associated with displacement of the tracheotomy tube. SUMMARY Tracheotomy indications have remained unchanged, but the timing of the procedure has advanced to individualized assessment with a predilection for earlier tracheotomy. The traditional operative technique is a much safer procedure today. Percutaneous dilational tracheotomy has become an acceptable alternative with proper patient selection. A multidisciplinary team with a surgeon provides the best care for the patient undergoing percutaneous tracheotomy.
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Affiliation(s)
- Andrew J McWhorter
- Department of Otolaryngology--Head and Neck Surgery, LSU Health Sciences Center, New Orleans, Louisiana 70112, USA.
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