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Lui CG, Bensoussan Y, Pei M, Rodman J, O’Dell K. Factors Associated With Dysphagia in Patients Undergoing Tracheal Resection. JAMA Otolaryngol Head Neck Surg 2023; 149:505-511. [PMID: 37103929 PMCID: PMC10141266 DOI: 10.1001/jamaoto.2023.0588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 03/05/2023] [Indexed: 04/28/2023]
Abstract
Importance Patients undergoing tracheal resection commonly experience dysphagia postoperatively, and the patient factors that predict severity and duration of symptoms are currently unclear. Objective To determine the association of patient and surgical factors on postoperative dysphagia in adult patients undergoing tracheal resection. Design, Setting, and Participants This was a retrospective cohort study of patients undergoing tracheal resection at 2 tertiary academic centers from February 2014 to May 2021. The centers included LAC+USC (Los Angeles County + University of Southern California) Medical Center and Keck Hospital of USC, both tertiary care academic institutions. Patients involved in the study underwent a tracheal or cricotracheal resection. Exposures Tracheal or cricotracheal resection. Main Outcomes and Measures The main outcome was dysphagia symptoms as measured by the functional oral intake scale (FOIS) on postoperative days (PODs) 3, 5, and 7, on the day of discharge, and at the 1-month follow-up visit. Demographics, medical comorbidities, and surgical factors were evaluated for association with FOIS scores at each time period using Kendall rank correlation and Cliff delta. Results The study cohort consisted of 54 patients, with a mean (SD) age of 47 (15.7) years old, of whom 34 (63%) were male. Length of resection segment ranged from 2 to 6 cm, with a mean (SD) length of 3.8 (1.2) cm. The median (range) FOIS score was 4 (1-7) on PODs 3, 5, 7. On the day of discharge and at 1-month postoperative follow-up, the median (range) FOIS score was 5 (1-7) and 7 (1-7), respectively. Increasing patient age was moderately associated with decreasing FOIS scores at all measured time points (τ = -0.33; 95% CI, -0.51 to -0.15 on POD 3; τ = -0.38; 95% CI, -0.55 to -0.21 on POD 5; τ = -0.33; 95% CI, -0.58 to -0.08 on POD 7; τ = -0.22; 95% CI, -0.42 to -0.01 on day of discharge; and τ = -0.31; 95% CI, -0.53 to -0.09 at 1-month follow-up visit). History of neurological disease, including traumatic brain injury and intraoperative hyoid release, was not associated with FOIS score at any of the measured time points (δ = 0.03; 95% CI, -0.31 to 0.36 on POD 3; δ = 0.11; 95% CI, -0.28 to 0.47 on POD 5, δ = 0.3; 95% CI, -0.25 to 0.70 on POD 7; δ = 0.15; 95% CI, -0.24 to 0.51 on the day of discharge, and δ = 0.27; 95% CI, -0.05 to 0.53 at follow-up). Resection length was also not correlated with FOIS score with τ ranging from -0.04 to -0.23. Conclusions and Relevance In this retrospective cohort study, most patients undergoing tracheal or cricotracheal resection experienced full resolution of dysphagia symptoms within the initial follow-up period. During preoperative patient selection and counseling, physicians should consider that older adult patients will experience greater severity of dysphagia throughout their postoperative course and delayed resolution of symptoms.
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Affiliation(s)
- Christopher G. Lui
- Department of Otolaryngology–Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Yael Bensoussan
- USF Health Voice Center, Department of Otolaryngology–Head & Neck Surgery, University of South Florida, Tampa
| | - Michelle Pei
- Department of Otolaryngology–Head and Neck Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - John Rodman
- Southern California Clinical and Translational Science Institute, University of Southern California, Los Angeles
| | - Karla O’Dell
- Caruso Department of Otolaryngology–Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles
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Ziaian B, Shahriarirad R, Fouladi D, Amirian A, Ranjbar K, Karoobi M, Ketabchi F, Mardani P, Fallahi MJ. The effect of suture techniques on the outcome of tracheal reconstruction: An observational study and review of literature. Surgeon 2023; 21:e89-e96. [PMID: 35504817 DOI: 10.1016/j.surge.2022.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 03/23/2022] [Accepted: 03/31/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND Tracheal resection and anastomosis surgery is a safe operation and is used to treat various benign and malignant diseases of the trachea. However, tracheal stenosis is among the main anastomotic complications following this procedure. Surgeons use both the continuous and the interrupted suture techniques for tracheal anastomosis, but contradicting results in each technique's complications have been reported in various studies. In this study, we aimed to compare the outcome of these two different suture techniques and a relevant literature review. METHODS Surgical records during a period of 15 years (2005-2019) were screened for tracheal reconstruction surgery in affiliated hospitals of Shiraz University of Medical Sciences, Shiraz, Iran. A total of 82 patients were evaluated based on surgical and suture features, along with their follow-up bronchoscopy for anastomotic complications. RESULTS Post-operational subclinical restenosis occurred in 8 (15.3%) out of 52 and 10 (33.3%) of 30 patients who underwent continuous and interrupted suturing techniques, respectively. Also, 6 (20%) patients in the interrupted group developed symptomatic restenosis, while in the continuous group, only one patient was clinically symptomatic. The patients with continuous suture technique had a shorter surgery time than patients whose interrupted technique was used (P < 0.001). CONCLUSIONS Based on our results, we conclude that restenosis is significantly reduced when the continuous technique is applied for tracheal anastomosis; However, the results are contradicting in relevant literature and due to the retrospective nature of our study, further human studies and clinical trials are warranted.
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Affiliation(s)
- Bizhan Ziaian
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Science, Shiraz, Iran; Department of Surgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Shahriarirad
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Science, Shiraz, Iran; Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Damoun Fouladi
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Science, Shiraz, Iran; Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Armin Amirian
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Science, Shiraz, Iran; Department of Surgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Keivan Ranjbar
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Science, Shiraz, Iran; Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammadreza Karoobi
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Science, Shiraz, Iran; Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Farzaneh Ketabchi
- Department of Physiology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Parviz Mardani
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Science, Shiraz, Iran; Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Javad Fallahi
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Science, Shiraz, Iran; Department of Internal Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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Burruss CP, Pappal RB, Witt MA, Harryman C, Ali SZ, Bush ML, Fritz MA. Healthcare disparities for the development of airway stenosis from the medical intensive care unit. Laryngoscope Investig Otolaryngol 2022; 7:1078-1086. [PMID: 36000059 PMCID: PMC9392386 DOI: 10.1002/lio2.865] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 06/27/2022] [Accepted: 06/29/2022] [Indexed: 11/09/2022] Open
Abstract
Objectives/hypothesis Study design Methods Results Conclusion Level of evidence
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Affiliation(s)
| | - Robin B. Pappal
- Department of Otolaryngology ‐ Head and Neck Surgery University of Kentucky Lexington Kentucky USA
| | - Michael A. Witt
- College of Medicine University of Kentucky Lexington Kentucky USA
| | | | - Syed Z. Ali
- Department of Anesthesiology University of Kentucky Lexington Kentucky USA
| | - Matthew L. Bush
- Department of Otolaryngology ‐ Head and Neck Surgery University of Kentucky Lexington Kentucky USA
| | - Mark A. Fritz
- Department of Otolaryngology ‐ Head and Neck Surgery University of Kentucky Lexington Kentucky USA
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Takaishi K, Kawahito S, Kitahata H. Management of a Patient With Tracheal Stenosis After Previous Tracheotomy. Anesth Prog 2021; 68:224-229. [PMID: 34911067 DOI: 10.2344/anpr-68-03-08] [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: 06/09/2021] [Accepted: 06/30/2021] [Indexed: 11/11/2022] Open
Abstract
Tracheal stenosis after tracheotomy can cause difficult airway management and respiratory complications. It is difficult to predict tracheal stenosis after tracheotomy based on a patient's symptoms as the symptoms of tracheal stenosis appear only after they become severe. In patients with a history of previous tracheotomy, it is important to consider the risk factors for tracheal stenosis. Detailed preoperative evaluation of patients with a history of previous tracheotomy is essential and should include 3-dimensional assessment of the airway. We report the preoperative assessment and perioperative management of an 83-year-old woman at high risk for tracheal stenosis due to a previous emergency tracheotomy who was scheduled to undergo general anesthesia for a right maxillectomy for squamous cell carcinoma. Preoperative anteroposterior chest radiograph revealed findings indicative of tracheal stenosis. Additional detailed examinations of the stenotic area were conducted with computed tomography imaging and bronchofiberscopy. General anesthesia with nasotracheal intubation was performed, and although there were no adverse intraoperative events, stridor after extubation was observed. Nebulized epinephrine was administered via an ultrasound nebulizer and effectively improved the patient's postoperative transient dyspnea.
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Affiliation(s)
- Kazumi Takaishi
- Associate Professor, Department of Dental Anesthesiology, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Shinji Kawahito
- Designated Professor, Department of Community Medicine and Human Resource Development, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Hiroshi Kitahata
- Professor, Department of Dental Anesthesiology, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
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Kambhampati S, Lavanya K. An Unusual Cause of Failed Tracheal Decannulation—A Case Report. Indian J Crit Care Med 2019; 23:378-379. [PMID: 31485109 PMCID: PMC6709837 DOI: 10.5005/jp-journals-10071-23223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Failure of decannulation may occur due to unexpected upper airway problems. However, the presence of a membrane in between the vocal cords is usually rare. We report a case of a 46-year-old female, who presented with focal seizures and progressed to status epilepticus. She was put on a mechanical ventilator because of hypoxic arrest. As she required prolonged ventilatory support, tracheostomy and gradual weaning from ventilator support to T-piece was done. Following stable hemodynamics, decannulation trial was attempted which failed. Subsequently, bronchoscopy was done to assess the upper airway. It revealed a thick membrane in between the vocal cords. Further examination with an indirect laryngoscope under general anesthesia confirmed the findings, and the membrance was excised. Decannulation was successful the very following day and the patient was discharged with stable hemodynamics.
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Affiliation(s)
- Sailaja Kambhampati
- Department of Pulmonary Medicine, Maxcure Hospital, Hyderabad, Telangana, India
- Sailaja Kambhampati, Department of Pulmonary Medicine, Maxcure Hospital, Hyderabad, Telangana, India, e-mail:
| | - K Lavanya
- Department of Pulmonology, Maxcure Hospital, Hyderabad, Telangana, India
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Khan A, Nath A, Mangla L, Paul M, Neyaz Z. Use of dedicated optical tracheal dilator for postintubation tracheal stenosis: First report from India. Lung India 2018; 35:417-420. [PMID: 30168462 PMCID: PMC6120308 DOI: 10.4103/lungindia.lungindia_372_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Postintubation tracheal stenosis is preventable yet commonly occurring clinical condition. Early in the disease, nonspecific symptoms may predominate but once the stenosis reaches a critical stage life-threatening respiratory compromise may ensue. Bronchoscopic interventions are an invaluable tool in the management both as a primary treatment and as an interim procedure before the surgery. Optical dilatational tracheoscopy is a safe and minimally invasive procedure in the treatment of benign tracheal stenosis. Involvement of multidisciplinary team early in the treatment planning gives the best possible results.
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Affiliation(s)
- Ajmal Khan
- Department of Pulmonary Medicine, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - Alok Nath
- Department of Pulmonary Medicine, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - Loveleen Mangla
- Department of Pulmonary Medicine, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - Mekhala Paul
- Department of Anesthesiology, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - Zafar Neyaz
- Department of Radiodiagnosis, SGPGIMS, Lucknow, Uttar Pradesh, India
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Abstract
The development of mechanical ventilators that can en sure adequate respiration for long periods of time has led to the problem of determining how to best integrate patients into the machine's airflow circuits. Tracheal tubes with inflatable cuffs efficiently connect the patient to the machine, but the tubes may be placed in one of two ways. Each option has relative advantages and disad vantages. Translaryngeal intubation (TLI) can be per formed safety and quickly and is the preferred first step in airway management. However, when TLI is needed for prolonged periods, it may damage the larynx. Tra cheostomy, on the otherhand, has potential operative and tracheal complications, but presents little risk to the larynx and may be better tolerated by the patient requir ing long-term intubation. This review provides a histor ical background of these two methods and analyzes their respective advantages and complications. Guide lines for the optimal use of TLI and tracheostomy, par ticularly in adult patients requiring long-term intuba tion, are developed by comparing the risks and benefits of these two methods.
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Affiliation(s)
- Gene L. Colice
- VAM & ROC Medicine (111), White River Junction, Vermont 05001
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8
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Abstract
The placement of a tracheostomy has become a routine procedure for intensive care unit patients who are mechanical ventilator dependent for a period of time, usually exceeding 1 or 2 weeks. It is vital for the intensivist to be familiar with all aspects of tracheostomies care including the timing of converting a patient to a tracheostomy, types of procedure, risks and benefits, and issues of daily care including oral feedings, speech, and decannulation. In this article we provide a comprehensive review for the intensivist regarding tracheostomies in the intensive care setting. We specifically review indications, timing, surgical options including percutaneous dilation tracheostomy, complications, decannulation, oral feeding, speaking devises, stomal stents, and routine tracheostomy care.
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Affiliation(s)
- A. Alan Conlan
- From the Division of Cardiothoracic Surgery, University of Massachusetts Medical School, Worcester, MA
| | - Scott E. Kopec
- From the Division of Pulmonary, Allergy, and Critical Care, University of Massachusetts Medical School, Worcester, MA
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Prasad KT, Dhooria S, Sehgal IS, Aggarwal AN, Agarwal R. Complete subglottic tracheal stenosis managed with rigid bronchoscopy and T-tube placement. Lung India 2016; 33:661-663. [PMID: 27890997 PMCID: PMC5112825 DOI: 10.4103/0970-2113.192879] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Surgery is the preferred treatment modality for benign tracheal stenosis. Interventional bronchoscopy is used as a bridge to surgery or in instances when surgery is not feasible or has failed. Stenosis in the subglottic trachea is particularly a treatment challenge, in view of its proximity to the vocal cords. Herein, we describe a patient with complete tracheal stenosis in the subglottic region, which developed after prolonged intubation and mechanical ventilation. The patient developed recurrent stenosis despite multiple surgical and endoscopic procedures. We were able to manage the patient successfully with rigid bronchoscopy and Montgomery T-tube placement.
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Affiliation(s)
- Kuruswamy Thurai Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Howle AA, Baguley IJ, Brown L. Management of Dysphagia Following Traumatic Brain Injury. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2014. [DOI: 10.1007/s40141-014-0064-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Jiang N, Del Signore AG, Iloreta AM, Malkin BD. Evaluation of a teaching tool to increase the accuracy of pilot balloon palpation for measuring tracheostomy tube cuff pressure. Laryngoscope 2013; 123:1884-8. [DOI: 10.1002/lary.24062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Revised: 01/18/2013] [Accepted: 01/30/2013] [Indexed: 11/08/2022]
Affiliation(s)
- Nancy Jiang
- Department of Otolaryngology-Head and Neck Surgery; Mount Sinai School of Medicine; New York; New York; U.S.A
| | - Anthony G. Del Signore
- Department of Otolaryngology-Head and Neck Surgery; Mount Sinai School of Medicine; New York; New York; U.S.A
| | - Alfred M. Iloreta
- Department of Otolaryngology-Head and Neck Surgery; Mount Sinai School of Medicine; New York; New York; U.S.A
| | - Benjamin D. Malkin
- Department of Otolaryngology-Head and Neck Surgery; Mount Sinai School of Medicine; New York; New York; U.S.A
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Mahafza T, Batarseh S, Bsoul N, Massad E, Qudaisat I, Al-Layla AE. Early vs. late tracheostomy for the ICU patients: Experience in a referral hospital. Saudi J Anaesth 2012; 6:152-4. [PMID: 22754442 PMCID: PMC3385258 DOI: 10.4103/1658-354x.97029] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The aim of this study is to present our experience with elective surgical tracheostomy for intensive care unit (ICU) patients who needed prolonged translaryngeal intubation in order to evaluate the proper timing and advantages of early vs. late tracheostomy and to stress upon the risks associated with delayed tracheostomy. METHODS Medical records of all patients, who underwent elective tracheostomy for prolonged intubation from September 2006 to August 2010 at Jordan University hospital, were reviewed. RESULTS A total of 106 patients (74 males) were included; their age ranged from 2 months to 90 yr with mean age of 46.5 yr. The mean time at which tracheostomy was done after initial tracheal intubation was 23 days (range 3-7 weeks). Trauma was the most frequent cause of ICU admission 38 (35.8%), followed by post-surgery causes 14 (13.2%). An early tracheostomy showed less complication vs late procedure. The length of stay in the ICU for patients who had an early tracheostomy was 26 days while this period for patients who had late tracheostomy was 47 days. Mortality rate among patients who had early tracheostomy was 17.1% while for late tracheostomy patients, it was 36.1%. CONCLUSION Proper assessment and early tracheostomy is recommended for patients who require prolonged tracheal intubation in the ICU.
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Affiliation(s)
- Tareq Mahafza
- Department of Otolaryngology, University of Jordan, and Jordan University Hospital, Jordan
| | - Sana Batarseh
- Department of Otolaryngology, University of Jordan, and Jordan University Hospital, Jordan
| | - Nader Bsoul
- Department of General Surgery, University of Jordan, and Jordan University Hospital, Jordan
| | - Ehab Massad
- Department of General Surgery, University of Jordan, and Jordan University Hospital, Jordan
| | - Ibraheem Qudaisat
- Department of Anesthesia & Intensive Care, University of Jordan, and Jordan University Hospital, Jordan
| | - Abd Elmon’em Al-Layla
- Department of Otolaryngology, University of Jordan, and Jordan University Hospital, Jordan
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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: 24] [Impact Index Per Article: 1.8] [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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Zias N, Chroneou A, Tabba MK, Gonzalez AV, Gray AW, Lamb CR, Riker DR, Beamis JF. Post tracheostomy and post intubation tracheal stenosis: report of 31 cases and review of the literature. BMC Pulm Med 2008; 8:18. [PMID: 18803874 PMCID: PMC2556644 DOI: 10.1186/1471-2466-8-18] [Citation(s) in RCA: 128] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2008] [Accepted: 09/21/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Severe post tracheostomy (PT) and post intubation (PI) tracheal stenosis is an uncommon clinical entity that often requires interventional bronchoscopy before surgery is considered. We present our experience with severe PI and PT stenosis in regards to patient characteristics, possible risk factors, and therapy. METHODS We conducted a retrospective chart review of 31 patients with PI and PT stenosis treated at Lahey Clinic over the past 8 years. Demographic characteristics, body mass index, co-morbidities, stenosis type and site, procedures performed and local treatments applied were recorded. RESULTS The most common profile of a patient with tracheal stenosis in our series was a female (75%), obese (66%) patient with a history of diabetes mellitus (35.4%), hypertension (51.6%), and cardiovascular disease (45.1%), who was a current smoker (38.7%). Eleven patients (PI group) had only oro-tracheal intubation (5.2 days of intubation) and developed web-like stenosis at the cuff site. Twenty patients (PT group) had undergone tracheostomy (54.5 days of intubation) and in 17 (85%) of them the stenosis appeared around the tracheal stoma. There was an average of 2.4 procedures performed per patient. Rigid bronchoscopy with Nd:YAG laser and dilatation (mechanical or balloon) were the preferred methods used. Only 1(3.2%) patient was sent to surgery for re-stenosis after multiple interventional bronchoscopy treatments. CONCLUSION We have identified putative risk factors for the development of PI and PT stenosis. Differences in lesions characteristics and stenosis site were noted in our two patient groups. All patients underwent interventional bronchoscopy procedures as the first-line, and frequently the only treatment approach.
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Affiliation(s)
- Nikolaos Zias
- Department of Pulmonary and Critical Care Medicine, Lahey Clinic Medical Center, Tufts University School of Medicine, Burlington, Massachusetts, USA.
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15
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Tracheostomy. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50017-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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17
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Marel M, Pekarek Z, Spasova I, Pafko P, Schutzner J, Betka J, Pospisil R. Management of Benign Stenoses of the Large Airways in the University Hospital in Prague, Czech Republic, in 1998–2003. Respiration 2005; 72:622-8. [PMID: 16355003 DOI: 10.1159/000089578] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2004] [Accepted: 09/07/2005] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Clinically significant benign stenoses of the large airways develop in about 1% of patients after intubation. The management of benign stenoses is not unified around the world, nor are there any accepted methods for their screening. OBJECTIVES The purpose of this study is to describe and compare results of interventional bronchoscopy and surgical therapy of benign stenoses as well as to propose an algorithm for the management of this airways disorder. METHODS Prospective study on 80 consecutive patients with benign stenoses of the large airways admitted to the Pulmonary Department of the University Hospital of Prague-Motol. RESULTS Sixty-two patients developed stenoses after endotracheal intubation or tracheostomy, in 18 patients the stenosis was caused by other diseases or pathological situations. Thirty-eight patients were sent for surgical resection of the stenotic part of the airways. 2 surgically treated patients developed recurrence of the stenosis and had to be reoperated on. Narrowing of the trachea at the site of end-to-end anastomosis developed in 6 other patients and was cured by interventional bronchoscopy. The remaining 42 patients were treated by interventional bronchoscopy (Nd-YAG laser, electrocautery, stent) which was curative in 35 patients. Sixty-five patients were alive at the time of evaluation, 15 patients died. Five of them died between 3 and 14 (median 4) months after surgery from a disease other than airway stenosis. Ten nonresected patients also died, with 1 exception, due to a disease other than airway stenosis; the median survival was 9 months. CONCLUSIONS We recommend to assess the patient for surgery after the initial diagnosis and therapeutic bronchoscopy with dilatation of the stenosis. If the patient is not a suitable candidate for resection, interventional bronchoscopy is an appropriate alternative for the management of benign stenoses of the large airways.
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Affiliation(s)
- Miloslav Marel
- Pulmonary Department of the 1st Medical Faculty, Charles University, Katerinska 19, Prague 2, 120-00 Czech Republic.
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Rodriguez JL, Steinberg SM, Luchetti FA, Gibbons KJ, Taheri PA, Flint LM. Early tracheostomy for primary airway management in the surgical critical care setting. Br J Surg 2005. [DOI: 10.1002/bjs.1800771228] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Abstract
During a 12-month period, 264 patients with multiple injuries who required mechanical ventilation were admitted to the surgical intensive care unit. One hundred twenty patients (46%) were disengaged from the ventilator, and 38 patients (14%) died. Of the remaining 106 patients (40%) 51 patients (group I) were to receive tracheostomy within 1 to 7 days, and 55 patients (group II) underwent late (8 or more days after admission) tracheostomy. Multiple variables in four categories (admission, operative, ventilatory, and outcome) were analyzed prospectively to define the impact that early tracheostomy had on duration of mechanical ventilation, intensive care stay, and hospital stay. Morbidity and mortality rates of the procedures were assessed. Early tracheostomy, in a homogeneous group of critically ill patients, is associated with a significant decrease in duration of mechanical ventilation, as well as shorter intensive care unit and hospital stays, compared with translaryngeal endotracheal intubation. There were no deaths attributable to tracheostomy, and overall morbidity of the procedures was 4%. We conclude that early tracheostomy has an overall risk equivalent to that of endotracheal intubation. Furthermore, early tracheostomy shortens days on the ventilator and intensive care unit and hospital days and should be considered for patients in the intensive care unit at risk for more than 7 days of intubation. (Surgery 1990;108:655–9.)
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Affiliation(s)
- Jorge L Rodriguez
- Department of Surgery, State University of New York at Buffalo, Buffalo, N.Y
- University of Michigan, Ann Arbor, Mich
- Tulane University, New Orleans, La
| | - Steven M Steinberg
- Department of Surgery, State University of New York at Buffalo, Buffalo, N.Y
- University of Michigan, Ann Arbor, Mich
- Tulane University, New Orleans, La
| | - Frederick A Luchetti
- Department of Surgery, State University of New York at Buffalo, Buffalo, N.Y
- University of Michigan, Ann Arbor, Mich
- Tulane University, New Orleans, La
| | - Kevin J Gibbons
- Department of Surgery, State University of New York at Buffalo, Buffalo, N.Y
- University of Michigan, Ann Arbor, Mich
- Tulane University, New Orleans, La
| | - Paul A Taheri
- Department of Surgery, State University of New York at Buffalo, Buffalo, N.Y
- University of Michigan, Ann Arbor, Mich
- Tulane University, New Orleans, La
| | - Lewis M Flint
- Department of Surgery, State University of New York at Buffalo, Buffalo, N.Y
- University of Michigan, Ann Arbor, Mich
- Tulane University, New Orleans, La
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Hsu CL, Chen KY, Chang CH, Jerng JS, Yu CJ, Yang PC. Timing of tracheostomy as a determinant of weaning success in critically ill patients: a retrospective study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2004; 9:R46-52. [PMID: 15693966 PMCID: PMC1065112 DOI: 10.1186/cc3018] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2004] [Revised: 09/24/2004] [Accepted: 11/16/2004] [Indexed: 12/26/2022]
Abstract
Introduction Tracheostomy is frequently performed in critically ill patients for prolonged intubation. However, the optimal timing of tracheostomy, and its impact on weaning from mechanical ventilation and outcomes in critically ill patients who require mechanical ventilation remain controversial. Methods The medical records of patients who underwent tracheostomy in the medical intensive care unit (ICU) of a tertiary medical centre from July 1998 to June 2001 were reviewed. Clinical characteristics, length of stay in the ICU, rates of post-tracheostomy pneumonia, weaning from mechanical ventilation and mortality rates were analyzed. Results A total of 163 patients (93 men and 70 women) were included; their mean age was 70 years. Patients were classified into two groups: successful weaning (n = 78) and failure to wean (n = 85). Shorter intubation periods (P = 0.02), length of ICU stay (P = 0.001) and post-tracheostomy ICU stay (P = 0.005) were noted in patients in the successful weaning group. Patients who underwent tracheostomy more than 3 weeks after intubation had higher ICU mortality rates and rates of weaning failure. The length of intubation correlated with the length of ICU stay in the successful weaning group (r = 0.70; P < 0.001). Multivariate analysis revealed that tracheostomy after 3 weeks of intubation, poor oxygenation before tracheostomy (arterial oxygen tension/fractional inspired oxygen ratio <250) and occurrence of nosocomial pneumonia after tracheostomy were independent predictors of weaning failure. Conclusion The study suggests that tracheostomy after 21 days of intubation is associated with a higher rate of failure to wean from mechanical ventilation, longer ICU stay and higher ICU mortality.
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Affiliation(s)
- Chia-Lin Hsu
- Division of Pulmonary Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Kuan-Yu Chen
- Division of Pulmonary Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Hsuin Chang
- Division of General Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jih-Shuin Jerng
- Division of Pulmonary Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chong-Jen Yu
- Assistant Professor, Division of Pulmonary Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Pan-Chyr Yang
- Professor, Division of Pulmonary Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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François B, Clavel M, Desachy A, Puyraud S, Roustan J, Vignon P. Complications of tracheostomy performed in the ICU: subthyroid tracheostomy vs surgical cricothyroidotomy. Chest 2003; 123:151-8. [PMID: 12527616 DOI: 10.1378/chest.123.1.151] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The morbidity of surgical tracheostomy performed in critically ill patients is not well-known. Accordingly, the aim of this prospective study was to determine the incidence and severity of complications associated with subthyroid tracheostomy and cricothyroidotomy when performed in the ICU. METHODS Over a 2-year period, individual consecutive patients who were undergoing an elective tracheostomy were studied. Attending physicians elected the timing and technique of the tracheostomy. All procedures were performed at the bedside. A complete laryngeal examination was performed before ICU discharge, prior to decannulation, and 6 months after the tracheostomy. RESULTS A tracheostomy (subthyroid, 86 patients; cricothyroidotomy, 32 patients) was performed in 118 of 1,574 patients (mean [+/- SD] age, 54 +/- 18 years; 79 men, 39 women; mean APACHE [acute physiology and chronic health evaluation] II score, 19 +/- 2). No deaths could be attributed to the tracheostomy procedure, and 40 complications occurred in 36 patients (30%), with a similar incidence in both groups (subthyroid group, 30 of 86 patients; cricothyroidotomy, 10 of 32 patients; p = 0.9). The severity and timing of complications were comparable between groups. CONCLUSIONS In the present series, the incidence and severity of complications associated with conventional subthyroid tracheostomy and surgical cricothyroidotomy performed in the ICU were similar. The bedside cricothyroidotomy, which is technically easier to perform, represents a valuable alternative to conventional tracheostomy in the management of critically ill patients.
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Affiliation(s)
- Bruno François
- Intensive Care Unit, Dupuytren Teaching Hospital, Limoges, France.
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Chopra H, Khurana AS, Malhotra U, Mathur N, Sidhu US. Incidence and types of post extubation complications following endotracheal intubation and tracheostomy. Indian J Otolaryngol Head Neck Surg 2000; 52:364-5. [PMID: 23119725 PMCID: PMC3451378 DOI: 10.1007/bf02991479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
This study was undertaken to study early and late post extubation complications following endotracheal intubation and tracheostomy. A total 60 patients who were admitted in Dayanand Medical College and Hospital were studied prospectively. They were divided into 3 groups and were screened with various modalities like fiberoptic laryngoscopy. Bronchoscope, X-Ray Soft Tissue Neck and CT Scan, Complications like glottic edema, vocal tears, vocal granuhmas and tracheal stenosis were seen and were accordingly managed.
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Affiliation(s)
- H Chopra
- Dept. of Chest, Dayanand Medical & Hospital, Ludhiana, ; 908/4C, Tagore Nagar, Near Deaf & Dumb School, Ludhiana
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Abstract
Percutaneous tracheostomy is now established in intensive care practice. However, discussion continues on many aspects of the procedure. This update reviews recent studies of bedside percutaneous tracheostomy, which suggest that the commonly used techniques are safe in terms of short and long-term complications. The introduction of percutaneous tracheostomy into an intensive care unit has training implications, particularly for surgeons. The timing of percutaneous tracheostomy in critically ill patients, and the use of the technique in children remain controversial.
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Affiliation(s)
- M Mercer
- The Intensive Care Unit, Frenchay Hospital, Bristol, BS16 1LE, UK
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Morgan AS, Mackay LE. Causes and complications associated with swallowing disorders in traumatic brain injury. J Head Trauma Rehabil 1999; 14:454-61. [PMID: 10653941 DOI: 10.1097/00001199-199910000-00006] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A major complication commonly seen in persons with severe brain injury is swallowing dysfunction. The neuropathology leading to impaired swallowing is discussed. In addition, Other risk factors associated with dysfunctional swallowing, such as tracheostomy and the need for prolonged ventilatory support, are discussed. Within the intensive care environment, the consequences of impaired swallowing leading to aspiration-a major cause of pneumonia-are discussed.
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Affiliation(s)
- A S Morgan
- Department of Surgery, Saint Francis Hospital and Medical Center, Hartford, Connecticut 06105, USA
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Dulguerov P, Gysin C, Perneger TV, Chevrolet JC. Percutaneous or surgical tracheostomy: a meta-analysis. Crit Care Med 1999; 27:1617-25. [PMID: 10470774 DOI: 10.1097/00003246-199908000-00041] [Citation(s) in RCA: 243] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare percutaneous with surgical tracheostomy using a meta-analysis of studies published from 1960 to 1996. DATA SOURCES Publications obtained through a MEDLINE database search with a Boolean combination (tracheostomy or tracheotomy) and complications, with constraints for human studies and English language. STUDY SELECTION Publications addressing all peri- and postoperative complications. Studies limited to specific tracheostomy complications or containing insufficient details were excluded. Two authors independently selected the publications. DATA EXTRACTION A list of relevant surgical variables and complications was compiled. Complications were divided into peri- and postoperative groups and further subclassified into severe, intermediate, and minor groups. Because most studies of percutaneous tracheostomy were published after 1985, surgical tracheostomy studies were divided into two periods: 1960 to 1984 and 1985 to 1996. The articles were analyzed independently by three investigators, and rare discrepancies were resolved through discussion and data reexamination. DATA SYNTHESIS Earlier surgical tracheostomy studies (n = 17; patients, 4185) have the highest rates of both peri- (8.5%) and postoperative (33%) complications. Comparison of recent surgical (n = 21; patients, 3512) and percutaneous (n = 27; patients, 1817) tracheostomy trials shows that perioperative complications are more frequent with the percutaneous technique (10% vs. 3%), whereas postoperative complications occur more often with surgical tracheotomy (10% vs. 7%). The bulk of the differences is in minor complications, except perioperative death (0.44% vs. 0.03%) and serious cardiorespiratory events (0.33% vs. 0.06%), which were higher with the percutaneous technique. Heterogeneity analysis of complication rates shows higher heterogeneity in older and surgical trials. CONCLUSIONS Percutaneous tracheostomy is associated with a higher prevalence of perioperative complications and, especially, perioperative deaths and cardiorespiratory arrests. Postoperative complication rates are higher with surgical tracheostomy.
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Affiliation(s)
- P Dulguerov
- Department of Otolaryngology-Head and Neck Surgery, University of Geneva Hospital, Switzerland.
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Abstract
Although life-saving, mechanical ventilation may be associated with many complications, including consequences of positive intrathoracic pressure, the many aspects of volutrauma, and adverse effects of intubation and tracheostomy. Optimal ventilatory care requires implementing mechanical ventilation with attention to minimizing adverse hemodynamic effects, averting volutrauma, and effecting freedom from mechanical ventilation as quickly as possible so as to minimize the risk of airway complications.
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Affiliation(s)
- S Sandur
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation, Ohio, USA
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Trottier SJ, Hazard PB, Sakabu SA, Levine JH, Troop BR, Thompson JA, McNary R. Posterior tracheal wall perforation during percutaneous dilational tracheostomy: an investigation into its mechanism and prevention. Chest 1999; 115:1383-9. [PMID: 10334157 DOI: 10.1378/chest.115.5.1383] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVES Part 1: To describe the complication of posterior tracheal wall injury and perforation associated with the percutaneous dilational tracheostomy (PDT). Part 2: To determine the mechanism of posterior tracheal wall injury during PDT. DESIGN Prospective observational study. SUBJECTS Part 1: Medical-surgical ICU patients requiring tracheostomy. Part 2: Swine and cadaver models. INTERVENTIONS Part 1: Consecutive medical-surgical ICU patients undergoing tracheostomy tube insertion via the percutaneous dilation technique with bronchoscopic guidance were enrolled in the study. Demographic data and complications were recorded. Part 2: Tracheostomy tubes were inserted via the percutaneous dilational technique in the swine model with concomitant bronchoscopic video recording from the proximal and distal airways. Tracheostomy tubes were inserted via the percutaneous dilational technique in the cadaver model followed by anatomic inspection of the airway. RESULTS Part 1: Seven (29%) of 24 medical-surgical ICU patients sustained complications associated with PDT. Three patients (12.5%) sustained posterior tracheal wall perforations followed by the development of tension pneumothoraces. Part 2: The swine model demonstrated that posterior tracheal wall perforation may occur during PDT when the guiding catheter is withdrawn into the dilating catheters. Five-centimeter posterior tracheal wall mucosal lacerations occurred when the guidewire and the guiding catheter were not properly stabilized during PDT. CONCLUSION Percutaneous dilational tracheostomy was associated with a 29% complication rate in this observational study. Of concern was the high rate (12.5%) of posterior tracheal wall perforation. The swine and cadaver models suggest that posterior tracheal wall injury or perforation may occur if the guidewire and guiding catheter are not properly stabilized. To avoid posterior tracheal wall injury, the guidewire and guiding catheter should be firmly stabilized during PDT.
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Affiliation(s)
- S J Trottier
- Department of Critical Care Medicine, St. John's Mercy Medical Center, St. Louis University, MO 63141, USA.
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Leonard RC, Lewis RH, Singh B, van Heerden PV. Late outcome from percutaneous tracheostomy using the Portex kit. Chest 1999; 115:1070-5. [PMID: 10208210 DOI: 10.1378/chest.115.4.1070] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE To assess late outcome following percutaneous tracheostomy using the Portex kit (Hythe, Kent, UK). DESIGN Prospective observational cohort study. SETTING Teaching hospital. PATIENTS Forty-nine consecutive patients who underwent percutaneous tracheostomy in the ICU using the Portex kit and who survived 6 months after the procedure. INTERVENTIONS Questionnaires regarding six symptoms were sent to all 49 surviving patients; the 39 respondents were invited to attend for review. Thirteen patients underwent pulmonary function testing, of whom 10 also underwent fiberoptic laryngotracheoscopy under local anesthesia. RESULTS The most common symptom was a minor change in voice. One patient had required treatment for symptomatic tracheal stenosis by the time of review; one was referred for revision of a tethered scar. Pulmonary function testing was easily performed by all patients and revealed no evidence of upper airway obstruction. Tracheoscopy likewise showed no evidence of tracheal stenosis. CONCLUSIONS One of 49 patients had developed tracheal stenosis. None of the patients attending for detailed review showed any sign of late complications other than one tethered scar.
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Affiliation(s)
- R C Leonard
- Department of Intensive Care, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.
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Emshoff R, Bertram S, Kreczy A. Topographic variations in anatomical structures of the anterior neck of children: an ultrasonographic study. ORAL SURGERY, ORAL MEDICINE, ORAL PATHOLOGY, ORAL RADIOLOGY, AND ENDODONTICS 1999; 87:429-36. [PMID: 10225624 DOI: 10.1016/s1079-2104(99)70241-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Tracheostomies in children are frequently used for temporary airway support during surgical procedures. In pediatric patients with congenital craniofacial malformations, preoperative assessment of the delicate anatomy of the airway is necessary. The purpose of this study was to assess the ultrasonographic anatomy of the anterior neck with regard to the performance of tracheostomy. STUDY DESIGN Ultrasonographic investigation was done in 50 pediatric patients (age range, 6 to 15 years) to analyze the relationships among the anatomical structures that are of practical interest with respect to tracheostomy. RESULTS The data reveal that information concerning variations in anatomical structures lying in the immediate vicinity of the tracheostomy site was readily obtainable with the techniques used. CONCLUSIONS In pediatric patients requiring tracheostomy for surgical treatment of severe congenital craniofacial malformations, preoperative ultrasonography may be used to diagnose individual anatomical variations at the tracheostomy site.
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Affiliation(s)
- R Emshoff
- Department of Oral and Maxillo-Facial Surgery, University of Innsbruck, Austria
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30
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Stoeckli SJ, Breitbach T, Schmid S. A clinical and histologic comparison of percutaneous dilational versus conventional surgical tracheostomy. Laryngoscope 1997; 107:1643-6. [PMID: 9396679 DOI: 10.1097/00005537-199712000-00012] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
To directly compare percutaneous dilational tracheostomy (PDT) with conventional surgical tracheostomy, a prospective study was performed in 83 patients requiring tracheostomy for prolonged mechanical ventilation in the intensive care unit or after surgery for a large tumor in the upper respirodigestive tract. Median follow-up was 355 days after PDT and 338 days after conventional tracheostomy. The overall morbidity rate was significantly lower with PDT than with conventional tracheostomy (6.4% vs 36.1%; P < 0.001). Compared with conventional tracheostomy, PDT was also associated with a significantly lower incidence of postoperative bleeding (2.1% vs 13.9%; P < 0.05) and postoperative wound infection (0% vs 22.2%; P < 0.001). There were no clinical signs of laryngotracheal stenosis in either group. In conclusion, PDT is a simple, fast, safe bedside procedure that is associated with significantly lower morbidity than standard surgical tracheostomy.
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Affiliation(s)
- S J Stoeckli
- Clinic of Otorhinolaryngology, Head and Neck Surgery, University Hospital of Zurich, Switzerland
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31
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Sugerman HJ, Wolfe L, Pasquale MD, Rogers FB, O'Malley KF, Knudson M, DiNardo L, Gordon M, Schaffer S. Multicenter, randomized, prospective trial of early tracheostomy. THE JOURNAL OF TRAUMA 1997; 43:741-7. [PMID: 9390483 DOI: 10.1097/00005373-199711000-00002] [Citation(s) in RCA: 196] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Determine the effect of early (days 3-5) or late (days 10-14) tracheostomy on intensive care unit length of stay (ICU LOS), frequency of pneumonia, and mortality, and evidence of short-term or long-term pharyngeal, laryngeal, or tracheal injury in head trauma, non-head trauma, and critically ill nontrauma patients. STUDY DESIGN Randomized, prospective. SETTING Five Level I trauma centers. METHODS Data were obtained prospectively and included Acute Physiology and Chronic Health Evaluation III score (AIII), Glasgow Coma Scale score, Emergency Room Trauma Score, Injury Severity Score, Acute Injury Score, type of endotracheal tube or tracheostomy, level of positive end-expiratory pressure, and peak inspiratory pressure. Patients were to undergo laryngoscopy for detection of injury according to the Lindholm criteria at the time of endotracheal tube or tracheostomy removal and be reevaluated at 3 to 5 months after discharge. RESULTS One hundred fifty-seven patients were entered, 127 to early randomization (3-5 days) and 28 to late randomization (10-14 days); however, only 112 patients with early and 14 with late randomization had completed data forms for the primary study goals. An additional 22 patients from the early entry groups were rerandomized late. Early randomization data: the AIII score was higher (p < 0.05) in the head trauma tracheostomy (65 +/- 4) than in the nontracheostomy group (51 +/- 4) and in the nontrauma tracheostomy (92 +/- 6) than in the nontracheostomy group (68 +/- 7), but was equivalent in the non-head trauma group. Glasgow Coma Scale score, Emergency Room Trauma Score, Injury Severity Score, Acute Injury Score, positive end-expiratory pressure, and peak inspiratory pressure were not significantly different in any of the groups. There were no significant differences in ICU LOS, frequency of pneumonia, or death in any of the groups after either early or late tracheostomy compared with continued endotracheal intubation. Only 83 patients underwent postextubation laryngoscopy. There were no significant differences between the groups; however, there were trends to more vocal cord ulceration and subglottic inflammation in the continued intubation group. No patient was seen in this study with late vocal cord or laryngeal stenosis; there were no tracheal-innominate artery fistulae. Seven of the patients with abnormal findings at extubation had normal 3- to 5-month postextubation laryngoscopy. CONCLUSION Physician bias limited patient entry into the study. Although there were higher AIII scores in the head trauma early tracheostomy patients, there were no differences in the primary end points of ICU LOS, pneumonia, or death in any of the groups studied. Long-term endoscopic follow-up was poor, but no known late tracheal stenosis was seen.
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Affiliation(s)
- H J Sugerman
- Department of Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond 23298-0519, USA
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Koh WY, Lew TW, Chin NM, Wong MF. Tracheostomy in a neuro-intensive care setting: indications and timing. Anaesth Intensive Care 1997; 25:365-8. [PMID: 9288378 DOI: 10.1177/0310057x9702500407] [Citation(s) in RCA: 104] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
A retrospective review was made of 49 survivors who were mechanically ventilated for more than 48 hours in the neurosurgical ICU. Thirty-two patients (Gp I) were successfully extubated, 9 patients (Gp II) underwent tracheostomy after one or more failed extubations, and 8 patients (Gp III) underwent elective tracheostomy. Glasgow Coma Scale (GCS) scores at extubation were 11.3 +/- 2.8 (mean (SD) for Gp I vs 7.8 +/- 2.7 for Gp II (P = n.s.) and at elective tracheostomy (Gp III) was 5.4 +/- 2.3. Incidence of ventilator-associated pneumonia were 35% in Gp I vs 100% of patients in Gp II and III (P < 0.05). Reasons for reintubation in 7 of 9 patients (Gp II) were upper airway obstruction and tenacious tracheal secretions while 14 of 17 patients were weaned off the ventilator within 48 hours of tracheostomy. The length of stay in ICU was 16.8 +/- 7.1 days in Gp II vs 11.7 +/- 2.9 days in Gp III (P < 0.05). In our study, elective tracheostomy for selected patients with poor GCS scores and nosocomial pneumonia has resulted in shortened ICU length of stay and rapid weaning from ventilatory support.
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Affiliation(s)
- W Y Koh
- Department of Anaesthesia and Intensive Care, Tan Tock Seng Hospital, Singapore
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Abstract
Transportation of the intensive care unit (ICU) patient to the operating room for tracheotomy has been implicated as an unnecessary source of complications and has been cited as a relative indication for percutaneous tracheotomy. However, there is very little evidence in the literature to support this claim. We evaluated 100 consecutive patients who were transported from the ICU to the operating room for tracheotomy. There were no complications related to patient transportation. A total of five complications occurred, all unrelated to patient transportation. Two patients receiving pressure control ventilation developed a pneumothorax on postoperative days 7 and 8, respectively. There were three minor complications directly related to the tracheotomy: peristomal cellulitis, tracheitis, and hemorrhage of less than 25 cc on postoperative day 1. The minor complications were treated appropriately and resolved without any adverse sequelae. We provide a detailed review of 100 consecutive ICU patient tracheotomy cases and compare this with 109 tracheotomies in non-ICU patients. Transportation of the ICU patient does not appear to increase the risk of complications during tracheotomy and should not be cited as a cause of complications in the percutaneous tracheotomy literature. The results with standard surgical tracheotomy in the controlled setting of the operating room should serve as the standard by which other procedures are judged.
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Affiliation(s)
- D E Henrich
- Department of Surgery, University of North Carolina, Chapel Hill, USA
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Rumbak MJ, Graves AE, Scott MP, Sporn GK, Walsh FW, Anderson WM, Goldman AL. Tracheostomy tube occlusion protocol predicts significant tracheal obstruction to air flow in patients requiring prolonged mechanical ventilation. Crit Care Med 1997; 25:413-7. [PMID: 9118655 DOI: 10.1097/00003246-199703000-00007] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE This study was undertaken to test the hypothesis that a tracheal tube occlusion protocol predicts clinically important obstruction to air flow in patients requiring prolonged mechanical ventilation, making routine bronchoscopy unnecessary. DESIGN A prospective evaluation of 75 patients who were clinically ready to be decannulated. All patients underwent the tracheal tube occlusion protocol followed by bronchoscopy. SETTING Three hospitals affiliated with a college of medicine. PATIENTS Over a 24-month period, 52 males and 23 females were enrolled in the study. Mean age was 55 yrs (range 25 to 85). Mean endotracheal/tracheostomy time was 2.4/8.9 wks (range 1 to 4/5 to 14). All patients were mechanically ventilated for at least 4 wks and were successfully weaned from the mechanical ventilator for at least 48 hrs. During spontaneous breathing, these data were observed: minute ventilation of < 10 L/min; resting respiratory rate of < 18 breaths/min; and arterial oxygen saturation of > 90% on 40% oxygen tracheal collar mask. The tracheal tube occlusion protocol consisted of deflating the cuff on the fenestrated tracheal tube and occluding the tube. INTERVENTIONS Patients who developed respiratory distress when the tracheal tube was occluded were deemed to have failed the protocol. At bronchoscopy, the patients were asked to cough and hyperventilate in an attempt to forcibly reduce the cross-sectional area of the trachea. A sustained, subjectively assessed decrease of > or = 50% of the effective cross-sectional area of the trachea was considered to be an indication for intervention. MEASUREMENTS AND MAIN RESULTS Sixty-three (84%) of 75 patients tolerated the tracheal tube occlusion protocol. Twelve (16%) of 75 patients developed signs of respiratory distress and showed decreased oxygen saturation values necessitating uncapping of the tracheal tube. All patients had some degree of tracheal injury. However, those patients who failed to tolerate the tracheal tube occlusion protocol had clinically important tracheal obstruction to air flow. CONCLUSION A tracheal tube occlusion protocol can predict clinically important obstruction to air flow after prolonged mechanical ventilation.
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Affiliation(s)
- M J Rumbak
- Department of Internal Medicine, University of South Florida College of Medicine, Tampa General Hospital, USA
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Guntupalli KK, Bandi V, Sirgi C, Pope C, Rios A, Eschenbacher W. Usefulness of flow volume loops in emergency center and ICU settings. Chest 1997; 111:481-8. [PMID: 9042000 DOI: 10.1378/chest.111.2.481] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- K K Guntupalli
- Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
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Abstract
Airway management of critically ill patients has been enhanced by the recent introduction of several new types of artificial airways and laryngoscopes. New drugs for sedation and neuromuscular blockade have been developed to facilitate care of the intubated patient. Guidelines for management of the difficult airway have been introduced. Several new prospective studies have improved our understanding of complications of intubation and how to avoid these sometimes tragic events. A consensus is evolving that TLI and tracheotomy each have clear advantages and disadvantages in prolonged airway maintenance and that multiple factors, not simply the duration of TLI, must be considered in the optimal timing of tracheotomy for each patient. Complex medicolegal and ethical issues directly impact intubation, perhaps more so than any other practice in critical care medicine. Physicians who care for critically ill patients should be familiar with these recent developments and concepts in airway management.
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Affiliation(s)
- S A Blosser
- Department of Surgery, Pennsylvania State University College of Medicine, Hershey, USA
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Richard I, Giraud M, Perrouin-Verbe B, Hiance D, Mauduyt de la Greve I, Mathé JF. Laryngotracheal stenosis after intubation or tracheostomy in patients with neurological disease. Arch Phys Med Rehabil 1996; 77:493-6. [PMID: 8629927 DOI: 10.1016/s0003-9993(96)90039-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE This retrospective study evaluated the incidence of airway complications in neurological patients following translaryngeal intubation, tracheostomy, or both. DESIGN The medical records of 315 consecutive patients (200 with traumatic brain injuries, 31 traumatic tetraplegics, and 84 with other neurological disorders) were reviewed. The type of artificial airway, duration of intubation, and use of nocturnal ventilation were recorded. Eighty-six percent of the patients underwent some combination of tracheal tomograms, flow-volume loop analysis, and fiberoptic tracheolaryngoscopy. Stenosis was classified as severe if it required surgery, if it required maintaining the tracheostomy, or was lethal. It was classified as benign if it was successfully treated by medical or local means. RESULTS Fifty-five percent of the patients were intubated translaryngeally only (mean = 17 days). Three percent underwent tracheostomy only, and 42% underwent tracheostomy after intubation for a mean of 13 days. The overall incidence of airway stenosis was 20%, 1/4 of which was severe. Fifteen percent of these patients died as a result of tracheal complications. The incidence of stenosis was higher following tracheostomy than following intubation only (29% vs 13%, p < .01). The incidence of severe stenosis in intubated-only patients was low (1%) compared with that following tracheostomy (10%, p < .01). No significant relationship was found between the length of intubation or the timing of tracheostomy. CONCLUSION Fewer complications are associated with transtracheal intubation than with tracheostomy. The data suggest that longer periods of intubation be used when attempting ventilator weaning before restoring to tracheostomy if weaning fails.
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Affiliation(s)
- I Richard
- Service de Rééducation Fonctionnelle, Centre Hospitalier Régional Universitaire de Nantes, France
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Affiliation(s)
- T S Lee
- Department of Anesthesiology, Harbor-UCLA Medical Center, Torrance 90509-2910, USA
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Law JH, Barnhart K, Rowlett W, de la Rocha O, Lowenberg S. Increased frequency of obstructive airway abnormalities with long-term tracheostomy. Chest 1993; 104:136-8. [PMID: 8325056 DOI: 10.1378/chest.104.1.136] [Citation(s) in RCA: 80] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Eighty-one patients with long-term tracheostomy tubes (mean duration, 4.9 months) were examined via fiberoptic bronchoscopy prior to decannulation. Obstructive airway lesions were observed in 54 patients (67 percent). All tracheal lesions were anatomically located proximal to the stoma. No cuff lesions were observed. The two most commonly observed lesions were tracheal granuloma (60 percent) and tracheomalacia (29 percent). Less frequently observed lesions were tracheostenosis (14 percent) and vocal cord and laryngeal dysfunction (8 percent). As a result of the high frequency of tracheal abnormalities, especially that for tracheal granuloma which has not been previously reported (to our knowledge), we recommend that all decannulation candidates undergo anatomic examination of the airways.
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Affiliation(s)
- J H Law
- Department of Respiratory Services and Speech Pathology, Tustin Rehabilitation Hospital, Calif
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Abstract
Thirty-four intensive care patients who received elective tracheostomies were studied to determine the incidence and nature of complications associated with tracheostomies. Indication for tracheostomy was long-term ventilation. Adverse consequences occurred in 47% of the patients. The most frequent problem was pneumonia. There were no intraoperative complications. Two deaths occurred due to delayed haemorrhage. Some complications of tracheostomy were influenced by the preceding period of endotracheal intubation. In patients requiring prolonged mechanical ventilation, tracheostomy carries a considerable risk. Optimal airway care only will reduce the incidence of complications.
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Affiliation(s)
- R H Gunawardana
- Department of Anaesthesiology, Faculty of Medicine, University of Peradeniya, Sri Lanka
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Heffner JE, Zamora CA. Clinical predictors of prolonged translaryngeal intubation in patients with the adult respiratory distress syndrome. Chest 1990; 97:447-52. [PMID: 2404704 DOI: 10.1378/chest.97.2.447] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
This study was designed to determine if clinical features apparent after seven days of mechanical ventilation predict long-term intubation beyond 14 days and subsequent need for tracheotomy in patients with ARDS. Twenty-four patients were entered into the study. Group 1 patients were successfully extubated in less than or equal to 14 days after onset of ARDS and group 2 patients remained intubated greater than 14 days. On day 7 of ARDS, group 1 had a higher PaO2/PAO2 ratio, a lower PEEP requirement, less severe chest radiographic abnormalities and a greater likelihood of an improved radiograph from the baseline study. None of group 1 and 11 group 2 patients eventually underwent tracheotomy. Clinical features apparent after seven days of mechanical ventilation in patients with ARDS suggest the likelihood of prolonged intubation beyond 14 days and eventual tracheotomy. Recognition of these features may allow more timely conversion of endotracheal intubation to tracheotomy.
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Affiliation(s)
- J E Heffner
- Department of Medicine, Medical Unviersity of South Carolina, Charleston 29425
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Carrey Z, Gottfried SB, Levy RD. Ventilatory muscle support in respiratory failure with nasal positive pressure ventilation. Chest 1990; 97:150-8. [PMID: 2403893 DOI: 10.1378/chest.97.1.150] [Citation(s) in RCA: 197] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Long-term intermittent mechanical ventilation results in improvements in ventilatory performance and clinical status between ventilation sessions in patients with chronic respiratory failure. The application of intermittent positive pressure ventilation through a nasal mask (NPPV) is a simple, noninvasive method for the provision of chronic intermittent ventilatory support. We investigated the effects of NPPV on inspiratory muscle activity in three normal subjects and nine patients with acute or chronic ventilatory failure due to restrictive (four subjects) or obstructive (five subjects) respiratory disorders. NPPV resulted in reductions of phasic diaphragm electromyogram amplitude to 6.7 +/- 0.7 percent (mean +/- SEM) of values obtained during spontaneous breathing in the normal subjects, 6.4 +/- 3.2 percent in the restrictive group, and 8.3 +/- 5.1 percent in the obstructive group. Simultaneous decreases in activity of accessory respiratory muscles were observed. The reductions in inspiratory muscle activity were confirmed by the finding of positive intrathoracic pressure swings on inspiration in all subjects. With NPPV, oxygen saturation and PCO2 remained stable or improved as compared with values obtained during spontaneous breathing. These results indicate that NPPV can noninvasively provide ventilatory support while reducing inspiratory muscle energy expenditure in acute and chronic respiratory failure of diverse etiology. Long-term assisted ventilation with NPPV may be useful in improving ventilatory performance by resting the inspiratory muscles.
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Affiliation(s)
- Z Carrey
- Department of Medicine, Royal Victoria, McGill University, Montreal, Quebec, Canada
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Scher N, Dobleman TJ, Panje WR. Endotracheal intubation as an alternative to tracheostomy after intraoral or oropharyngeal surgery. Head Neck 1989; 11:500-4. [PMID: 2584005 DOI: 10.1002/hed.2880110605] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Patients who undergo oral or oropharyngeal surgery usually require a tracheostomy for postoperative airway maintenance. However, the development in recent years of soft endotracheal tubes now provides the alternative of short-term endotracheal intubation, with minimal sequelae. Our favorable experience with the use of short-term intubation in children with epiglottitis prompted us to apply the technique to adults. Over a 2-year period at the University of Chicago Medical Center, we successfully used postoperative endotracheal intubation for 19 adult and pediatric patients who underwent major intraoral procedures, thus avoiding the possible complications, discomfort, and anxiety associated with tracheostomy. The patients were given intravenous steroids and antibiotics concomitantly, so that tissue edema and inflammation were minimized. No complications related to intubation and no postextubation airway compromise were noted in any of the patients.
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Affiliation(s)
- N Scher
- Department of Otolaryngology--Head and Neck Surgery, Pritzker School of Medicine, University of Chicago, Illinois 60637
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Affiliation(s)
- M J Bishop
- University of Washington School of Medicine, Seattle
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Affiliation(s)
- J E Heffner
- Medical University of South Carolina, Charleston 29425
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