Tracheotomy-Related Deaths

Is There an Over-Indication for Elective Tracheostomy in Patients With Oral Cavity Cancer?

OBJECTIVES

Temporary tracheostomies (TT) are often used in oral oncologic surgery to secure the postoperative airway. Our primary objective was to determine if there was an over-indication for elective tracheostomy in our population. If so, our secondary objective was to ascertain which patients could have possibly avoided TT.

MATERIALS AND METHODS

We performed a retrospective study of patients with oral and oropharyngeal squamous cell carcinoma in which resection with curative intent and TT were performed. Variables collected included demographics, comorbidities, and complications. Additionally, we retrospectively applied the Cameron and TRACHY tracheostomy scoring systems to evaluate overall tracheostomy recommendations.

RESULTS

A total of 116 elective tracheostomies were performed between January 2019 and December 2020. According to the Cameron and TRACHY scoring systems, recommendations for tracheostomy coincided in only 54.3% and 45.7%, respectively. Tumor anatomy and type of reconstruction were associated with less time until decannulation. Additionally, in patients without TT recommendation determined by both scores with tumor anatomy and location, as well as T and N stages were also associated with less time until decannulation.

CONCLUSION

There appears to be an over-indication for elective tracheostomy in our patients with oral cavity and oropharyngeal cancer. The patients that could have potentially avoided elective TT were those with lateral anatomy, without flap or with fasciocutaneous flap, location in the mandibular alveolus or anterior tongue, as well as N0/N1 and T1/T2 patients.

Is Continued Perioperative Antithrombotic Therapy Safe When Performing Open Tracheostomy?

OBJECTIVES

To date, there are no specific guidelines on antithrombotic therapy (ATT) management, which includes both anticoagulation and antiplatelet medications, for open tracheostomy. The objective of this study was to evaluate whether the use of perioperative antithrombotic medication during open tracheostomy influences the incidence of perioperative or postoperative complications.

METHODS

A retrospective review was conducted of all patients who underwent open tracheostomies at a tertiary care medical center from January 2015 to December 2019. Charts were reviewed for demographics, comorbidities, indication for tracheostomy, ATT use, operative details, and complications.

RESULTS

A total of 217 tracheostomies were evaluated for this study, of which 148 (68.2%) were not on ATT and 69 (31.8%) were on ATT during surgery. No significant difference was observed based on ATT status in perioperative bleeding (P = .983), postoperative bleeding (P = .24), or median days to decannulation (P = .5986). ATT patients were 2.67 times more likely to experience 30-day mortality than those non-ATT patients (P = .035). There was only one death due to hemorrhage in the ATT group. This was unrelated to the tracheostomy. This compares to 2 hemorrhage-related deaths in those not on ATT.

CONCLUSION

There was no significant difference in perioperative or postoperative bleeding based on ATT use. Patients on ATT were significantly more likely to experience 30-day mortality, however only one death was due to hemorrhage in the ATT group and was unrelated to tracheostomy. Therefore, continued perioperative ATT use appears to be safe when performing open tracheostomy.

LEVEL OF EVIDENCE

4.

Effectiveness of interprofessional tracheostomy teams: A systematic review

AIM(S)

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

DESIGN

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

METHODS

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

DATA SOURCES

MEDLINE, CINAHL and EMBASE.

RESULTS

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

CONCLUSION

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

IMPLICATIONS FOR PATIENT CARE

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

IMPACT

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

REPORTING METHOD

PRISMA and Synthesis Without Meta-analysis (SWiM).

PATIENT/PUBLIC CONTRIBUTION

None.

Successful endoscopic hemostatic treatment for endotracheal bleeding

A 42-year-old male patient experienced hemorrhagic shock after endotracheal intubation. Emergency gastroscopy showed no upper gastrointestinal bleeding, but active tracheal bleeding. After sedation, the tracheal bleeding was successfully stopped with gastroscopy. Post-intubation airway bleeding is a rare but fatal adverse event, and finding the exact bleeding site and quickly stopping the bleeding is the key to successful treatment.

Risk of death at home or on hospital readmission after discharge with pediatric tracheostomy

OBJECTIVE

To evaluate outcomes of patients discharged home following tracheostomy, including the timing and place of death for non-survivors.

STUDY DESIGN

We retrospectively reviewed medical records of infants undergoing tracheostomy between 2006 and 2017, within the first year of life for congenital or acquired neonatal conditions.

RESULTS

Of the 224 patients discharged after tracheostomy, 127 (57%) required home mechanical ventilation (MV). Overall, 40 (18%) patients died (65% were on MV); 38% of the deaths occurred at home and 63% at a subsequent hospitalization. Having tube feeding was identified as significantly associated with increased mortality on multivariate analysis. Having a tracheostomy for upper airway obstruction was the only variable significantly associated with increased risk of death at home on multivariate analysis.

CONCLUSIONS

Having tube feeding was associated with increased risk of death overall and having the tracheostomy for obstructive airway conditions was associated with death occurring at home.

A safer and more practical tracheotomy in invasive mechanical ventilated patients with COVID-19: A quality improvement study

IMPORTANCE

The number of infections and deaths caused by the global epidemic of severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) invasion is steadily increasing daily. In the early stages of outbreak, approximately 15%-20% of patients with coronavirus disease 2019 (COVID-19) inevitably developed severe and critically ill forms of the disease, especially elderly patients and those with several or serious comorbidities. These more severe forms of disease mainly manifest as dyspnea, reduced blood oxygen saturation, severe pneumonia, acute respiratory distress syndrome (ARDS), thus requiring prolonged advanced respiratory support, including high-flow nasal cannula (HFNC), non-invasive mechanical ventilation (NIMV), and invasive mechanical ventilation (IMV).

OBJECTIVE

This study aimed to propose a safer and more practical tracheotomy in invasive mechanical ventilated patients with COVID-19.

DESIGN

This is a single center quality improvement study.

PARTICIPANTS

Tracheotomy is a necessary and important step in airway management for COVID-19 patients with prolonged endotracheal intubation, IMV, failed extubation, and ventilator dependence. Standardized third-level protection measures and bulky personal protective equipment (PPE) may hugely impede the implementation of tracheotomy, especially when determining the optimal pre-surgical positioning for COVID-19 patients with ambiguous surface position, obesity, short neck or limited neck extension, due to vision impairment, reduced tactile sensation and motility associated with PPE. Consequently, the aim of this study was to propose a safer and more practical tracheotomy, namely percutaneous dilated tracheotomy (PDT) with delayed endotracheal intubation withdrawal under the guidance of bedside ultrasonography without the conventional use of flexible fiberoptic bronchoscopy (FFB), which can accurately determine the optimal pre-surgical positioning, as well as avoid intraoperative damage of the posterior tracheal wall and prevent the occurrence of tracheoesophageal fistula (TEF).

Mortality Risk Factors in Patients Admitted with the Primary Diagnosis of Tracheostomy Complications: An Analysis of 8026 Patients

Background: Tracheostomy is a procedure commonly conducted in patients undergoing emergency admission and requires prolonged mechanical ventilation. In the present study, the aim was to determine the prevalence and risk factors of mortality among emergently admitted patients with tracheostomy complications, during the years 2005−2014. Methods: This was a retrospective cohort study. Demographics and clinical data were obtained from the National Inpatient Sample, 2005−2014, to evaluate elderly (65+ years) and non-elderly adult patients (18−64 years) with tracheostomy complications (ICD-9 code, 519) who underwent emergency admission. A multivariable logistic regression model with backward elimination was used to identify the association between predictors and in-hospital mortality. Results: A total of 4711 non-elderly and 3315 elderly patients were included. Females included 44.5% of the non-elderly patients and 47.6% of the elderly patients. In total, 181 (3.8%) non-elderly patients died, of which 48.1% were female, and 163 (4.9%) elderly patients died, of which 48.5% were female. The mean (SD) age of the non-elderly patients was 50 years and for elderly patients was 74 years. The mean age at the time of death of non-elderly patients was 53 years and for elderly patients was 75 years. The odds ratio (95% confidence interval, p-value) of some of the pertinent risk factors for mortality showed by the final regression model were older age (OR = 1.007, 95% CI: 1.001−1.013, p < 0.02), longer hospital length of stay (OR = 1.008, 95% CI: 1.001−1.016, p < 0.18), cardiac disease (OR = 3.21, 95% CI: 2.48−4.15, p < 0.001), and liver disease (OR = 2.61, 95% CI: 1.73−3.93, p < 0.001). Conclusion: Age, hospital length of stay, and several comorbidities have been shown to be significant risk factors in in-hospital mortality in patients admitted emergently with the primary diagnosis of tracheostomy complications. Each year of age increased the risk of mortality by 0.7% and each additional day in the hospital increased it by 0.8%.

Clinical Proof of Concept for Stabilization of Tracheostomy Tubes Using Novel DYNAtraq Device

Introduction

Tracheostomy is one of the most common surgical strategies in intensive care units (ICU) and provides relevant clinical benefit for multiple indications. However, the complications associated with its use range from 5 to 40% according to different series. The risk of these complications could be reduced if fixation strategies and alignment of the tracheostomy tube with respect to the tracheal axis are improved.

Aim

To build a functional device of technological innovation in respiratory medicine for the fixation and alignment of tracheostomy cannula (acronym DYNAtraq) and to evaluate its feasibility and safety in a pilot study in mechanically ventilated patients.

Methods

Study carried out in four phases: (1) design engineering and functional prototyping of the device; (2) study of cytotoxicity and tolerance to the force of traction and push; (3) pilot study of feasibility and safety of its use in tracheostomized and mechanically ventilated patients; and (4) health workers satisfaction study.

Results

The design of the innovative DYNAtraq device included, on the one hand, a connector with very little additional dead space to be inserted between the cannula and the ventilation tubes, and, on the other hand, a shaft with two supports for adhesion to the skin of the thorax with very high tolerance (several kilograms) to pull and push. In patients, the device corrected the malpositioned tracheostomy tubes for the latero-lateral (p < 0.001) and cephalo-caudal angles (p < 0.001). Its effect was maintained throughout the follow-up time (p < 0.001). The use of DYNAtraq did not induce serious adverse events and showed a 70% protective effect for complications (RR = 0.3, p < 0.001) in patients.

Conclusion

DYNAtraq is a new device for respiratory medicine that allows the stabilization, alignment and fixation of tracheostomy tubes in mechanically ventilated patients. Its use provides additional benefits to traditional forms of support as it corrects misalignment and increases tolerance to habitual or forced movements. DYNAtraq is a safe element and can reduce the complications of tracheostomy tubes.

The Feasibility of Percutaneous Dilatational Tracheostomy in Immunosuppressed ICU Patients with or without Thrombocytopenia

Background

Percutaneous dilatational tracheostomy (PDT) has become the preferred method in several intensive care units (ICUs), but data on PDT performed in immunosuppressed and thrombocytopenic patients are scarce. This study aimed to analyze the feasibility of PDT in immunosuppressed and thrombocytopenic patients compared to conventional open surgical tracheostomy (OST).

Methods

We retrospectively analyzed the charts of patients who underwent PDT or OST between May 2017 and November 2020. Our outcomes were stoma site infections and bleeding complications.

Results

63 patients underwent PDT, and 21 patients underwent OST. Distribution of gender ratio, age, SAPS II, time of ventilation before tracheostomy, and preexisting hematooncological diseases was comparable between the two groups. After allogeneic stem cell transplantation (alloSCT), patients were more likely to undergo PDT than OST (p=0.033). The PDT cohort suffered from mucositis more frequently (p=0.043). There were no significant differences in leucocyte or platelet count on the tracheostomy day. Patients with coagulation disorders and patients under immunosuppression were distributed equally among both groups. Stoma site infection was documented in five cases in PDT and eight cases in the OST group. Moderate infections were remarkably increased in the OST group. Smears were positive in six cases in the PDT group; none of these patients had local infection signs. In the OST group, smears were positive in four cases; all had signs of a stroma site infection. Postprocedural bleedings occurred in eight cases (9.5%) and were observed significantly more often in the OST group (p=0.001), leading to emergency surgery in one case of the OST group.

Conclusion

PDT is a feasible and safe procedure in a predominantly immunosuppressed and thrombocytopenic patient cohort without an increased risk for stoma site infections or bleeding complications.

Managing complications of percutaneous tracheostomy and gastrostomy

Percutaneous tracheostomy and gastrostomy are some of the most commonly performed procedures at bedside in the intensive care unit. While they are generally considered safe, they can be associated with numerous short and long-term complications, many of which can occur long after their placement and cause significant morbidity. Performers of these procedures should possess a comprehensive understanding of procedural indications and contraindications, and know how to recognize and manage complications that may arise. In this review, we highlight complications of percutaneous tracheostomy and describe strategies for their prevention and management, with a special focus on post-tracheostomy tracheal stenosis. Other complications reviewed include bleeding, pneumothorax and subcutaneous emphysema, posterior wall injury, tube displacement, tracheomalacia, tracheoinominate artery fistula, tracheo-esophageal fistula, and stomal cellulitis. Gastrostomy complications and their management are also discussed including bleeding, internal organ injury, necrotizing fasciitis, aspiration pneumonia, buried bumper syndrome, tumor seeding, wound infection, tube displacement, peristomal leakage, and gastric outlet obstruction. In light of the potentially serious outcomes associated with complications of percutaneous tracheostomy and gastrostomy, the emphasis should be placed on risk-reduction strategies to minimize morbidity and mortality. We therefore present detailed pragmatic and comprehensive checklists to serve as a reference for clinicians involved in performing these procedures.

Liposomal Inhalation after Tracheostomy-A Randomized Controlled Trial

BACKGROUND

Tracheostomy is a common procedure in critical care. The aim of this study was to evaluate the application of a liposomal inhalation compared to standard physiologic saline (SPS) inhalation on basis of objective and subjective parameters of airway inflammation.

METHODS

We evaluated in this two-armed, double-blinded and randomized control group study the effect of liposomal compared with SPS inhalation in newly tracheotomized patients. The primary endpoint was defined as trend of tracheobronchial IL-6 secretion at day 1 compared to day 10. Further objective and subjective parameter were evaluated.

RESULTS

Fifty patients were randomized in each arm. Tracheal IL-6 levels decreased significantly only after liposomal inhalation. Both inhalative agents seem to have an effect on the respiratory impairment after tracheostomy. Subjective patient impairment was reduced significantly from day 1 to day 10 after tracheostomy with liposomal inhalation.

CONCLUSIONS

Liposomal inhalation demonstrated an advantage over SPS inhalation in newly tracheotomized patients.

An Overview of Outcomes Associated With Early Versus Late Tracheostomy From a National Standpoint

Tracheostomy is a procedure that is commonly used in critically ill patients who require prolonged mechanical ventilation due to acute respiratory failure or airway problems. The best tracheostomy timing (early vs. late) and techniques (percutaneous dilatational, other new percutaneous procedures, open surgery) have been hotly debated. This research aimed to evaluate the outcome of early versus late tracheostomy in terms of in-hospital mortality, patient length of stay in the hospital, and cost after a detailed analysis and review using National Inpatient Survey (NIS) data. This study indicates that early tracheostomy greatly reduces in-hospital mortality, the need to transfer to skilled nursing facilities as well as direct variables, length of stay, and potentially overall hospital cost in the ICU.

A cartilage conserving concept of a surgical tracheostomy-introduction and analysis of safety and complications of the Visor-tracheostomy-a retrospective monocentric comparative study over 8 years

INTRODUCTION

For decades, surgical tracheostomy using a Bjoerk-flap has been the standard procedure to create a reliable epithelialized tracheostomy in head and neck tumour surgery. This technique is being used as the gold standard approach in every surgical subspecialty. Preparation of the Bjoerk-flap requires splitting one or two tracheal rings, causing potential tracheal instability and tissue trauma. As a surgical alternative, the Visor-tracheostomy allows creating an epithelialized tracheostomy without splitting tracheal rings. This work aimed to prove the safety of the Visor-tracheostomy method, due to peri- and early postoperative complications.

METHODS

We present a step-by-step approach of this "new tracheostomy method". Monocentric, retrospective data within 8 years were evaluated. Complications such as wound infection, tracheostoma bleeding, tracheostoma dehiscence, and via falsa in a total of 453 tracheostomies (161 Bjoerk-flap and 292 Visor-tracheostomies) were compared and the results were analysed descriptively.

RESULTS

Our data did not reveal a statistically significant difference in risk for a complication between the two methods (Visor-tracheostomy vs. Bjoerk-flap; p = 0.60; OR = 1.26, 95%-CI 0.60-2.82). This supports the hypothesis that applying the new cartilage conserving Visor-tracheostomy does not result in a reduction of safety for the patient.

CONCLUSION

We contend, that the Visor-tracheostomy has the potential to supersede other surgical tracheostomy techniques in some indications.

LEVEL OF EVIDENCE

III (Comparative retrospective monocentric study).

Absence of calvarial fracture could predict the need for tracheostomy in traumatic brain injury

Aim

Tracheostomy is a common procedure for intubated patients with traumatic brain injury (TBI) in the intensive care unit (ICU) but optimal timing and the predictors of tracheostomy are still unclear. The aim of our study was to explore whether the traumatic variables of head injury predict the need for tracheostomy in intubated TBI patients.

Methods

A single‐center, retrospective observational study including a series of TBI patients admitted to Fukui Prefectural Hospital from April 1, 2004 to March 31, 2020 was carried out. Our primary outcome was tracheostomy. Patients with TBI who were intubated and admitted into the ICU within 24 h after injury were enrolled. Exclusion criteria were age less than 18 years, pregnancy, mortality within 24 h, post‐cardiac arrest syndrome, and patients for whom life‐sustaining interventions were withheld. Radiologic images were also reviewed and the morphology of the head injury was categorized.

Results

Seventy‐six patients were included. Forty‐six patients (60.5%) underwent tracheostomy and 30 patients (39.5%) were successfully extubated. Calvarial fracture (odds ratio [OR] 0.34; 95% confidence interval [CI], 0.13–0.88; P = 0.03), Injury Severity Score (OR 1.07; 95% CI, 1.00–1.15; P = 0.04), and Glasgow Comas Scale score (OR 0.84; 95% CI, 0.73–0.96) were statistically significant in the univariable analysis. Multivariate logistic regression identified calvarial fracture as an independent predictor for tracheostomy. The model involving calvarial fracture, Injury Severity Score ≥16, and Glasgow Coma Scale score ≤8 showed the area under the receiver operating characteristic curve for the model was 0.737 (95% CI, 0.629–0.846).

Conclusions

The absence of calvarial fracture could predict the necessity for tracheostomy in intubated TBI patients when combined with other factors. Further prospective randomized trials are necessary to confirm the findings.

Tracheostomy complications in otorhinolaryngology are rare despite the critical airway

Purpose

To identify complications of surgical tracheostomies in otorhinolaryngologic patients and adjust our processes to be properly prepared in the future.

Methods

We reviewed retrospectively all surgical tracheostomies (n = 255) performed by otolaryngologist-head and neck surgeons at Helsinki University Hospital between Jan 2014 and Feb 2017. Patient demographics, surgical details, surgical and medical complications, and tracheostomy-related mortality were recorded from the hospital charts. Risk factors for complications were assessed.

Results

Altogether, 55 (22%) complications were identified in 39 (15%) patients, with pneumonia, accidental decannulation, and bleeding being the most common. No patient or surgery-related factor reached significance in overall complication risk factor analysis. Medical complications were more common after elective tracheostomies compared to emergency procedures (10.6% vs. 3.5%, p < 0.05). Majority of complications (78%) were classified as mild or moderate according to Clavien–Dindo. Only 2 (0.8%) tracheostomy-related deaths were recorded.

Conclusion

In otorhinolaryngologists service, severe complications and tracheostomy-related deaths are very rare. Reducing their prevalence even further with careful planning is possible.

Safety of percutaneous dilatational tracheotomy (PDT) with the rigid tracheotomy endoscope (TED): a 6-month follow-up multicenter investigation

Background

The rigid tracheotomy endoscope (TED) was recently introduced to improve the fiberoptic technique during percutaneous dilatational tracheotomy (PDT) in critically ill patients. The aim was to evaluate the long-term complications of PDT using TED equipment in a prospective multicenter investigation.

Methods

One hundred eighty adult patients underwent PDT using TED in four German hospitals. Patients who were alive or their guardians were contacted via telephone and interviewed using a structured questionnaire 6 months following the tracheostomy procedure. Patients with airway complaints were invited for outpatient clinical ENT examination. The incidence of adverse events related to PDT was registered.

Results

Of 180 patients who received tracheostomy, 137 (76.1%) were alive at the time of follow-up. None of the 43 lethal events was related to the PDT. Fifty-three (38.7%) patients were available for follow-up examination, whereas 14 (10.2%) were able to visit ENT physicians. Two (3.8%) out of 53 patients developed tracheocutaneous fistula with required surgical closure of tracheostoma. Dyspnea (7.5%), hoarseness (5.7%), stridor and swallowing difficulties (both with 3.8%) were the most common complaints. Tracheal stenosis was confirmed in 1 patient (1.88% [95% CI: 0.33; 9.93]).

Conclusion

The use of TED for PDT in the clinical setting is safe regarding adverse events at 6-month follow-up. The incidence of tracheal stenosis after PDT with TED is comparable with that of flexible bronchoscopy; however, its role for PDT at the intensive care unit should be clarified in further investigations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01264-2.

Qualitative indications for tracheostomy and chronic mechanical ventilation in patients with severe bronchopulmonary dysplasia

BACKGROUND

The decision to pursue chronic mechanical ventilation involves a complex mix of clinical and social considerations. Understanding the medical indications to pursue tracheostomy would reduce the ambiguity for both providers and families and facilitate focus on appropriate clinical goals.

OBJECTIVE

To describe potential indications to pursue tracheostomy and chronic mechanical ventilation in infants with severe BPD (sBPD).

STUDY DESIGN

We surveyed centers participating in the Children's Hospitals Neonatal Consortium to describe their approach to proceed with tracheostomy in infants with sBPD. We requested a single representative response per institution. Question types were fixed form and free text responses.

RESULTS

The response rate was high (31/34, 91%). Tracheostomy was strongly considered when: airway malacia was present, PCO₂ ≥ 76-85 mmHg, FiO₂ ≥ 0.60, PEEP ≥ 9-11 cm H₂O, respiratory rate ≥ 61-70 breaths/min, PMA ≥ 44 weeks, and weight <10th %ile at 44 weeks PMA.

CONCLUSIONS

Understanding the range of indications utilized by high level NICUs around the country to pursue a tracheostomy in an infant with sBPD is one step toward standardizing consensus indications for tracheostomy in the future.

Ultrasound guided percutaneous dilatation tracheotomy (US-PDT) to prevent potentially life-threatening complications: A case report

•

Percutaneous dilatation tracheotomy enables non-surgeons to perform tracheotomies at patients bedside.

•

Bleeding is a common complication of percutaneous dilatation tracheotomies.

•

Performing a pre-operative neck ultrasound can help identifying aberrant vessels and reduce the risk of periprocedural bleeding.

Introduction

Percutaneous dilatation tracheotomy (PDT) is a relatively recent technique that enables non surgeons to perform tracheotomies at bedside reducing operation rooms schedules. It is burdened by a moderate risk of postoperative bleeding.

Presentation of case

The patient was a 57 years old with a temporal intraparenchymal hematoma, submitted to percutaneous dilatation tracheotomy. Despite the favorable anatomical features, a pre-procedural US was performed, identifying a pulsating vessel with an arterial pattern, 2 cm above the hollow. The procedure was then considered at high risk, an operation room was required for the technique and an on-call surgeon was alerted.

The procedure was ended safely and any bleeding was avoided because the technique was practiced with the best precautions.

Discussion

PDT strength is the possibility for non surgeons to perform tracheotomies in selected patients at bedside, reducing operation rooms congestion. Such technique though is a “blind” technique, and postoperative bleedings can occur and represent a feared complication. Conversely, the surgical tracheotomy permits a better control of hemorrhages, but needs the involvement of a surgeon and availability of an operation room. Performing a PDT guided by a neck ultrasound is useful to identify eventual aberrant vessel whose course could complicate the tracheotomy, it is part of PDT guidelines of some States.

Conclusion

US-PDT could help reducing procedure related complications selecting those high risk patients still in need of operating room and surgical assistance. US-PDT feasibility combined to its easy availability and low costs encourage its introduction into everyday practice.

Tracheostomy in patients with acute respiratory distress syndrome is not related to quality of life, symptoms of psychiatric disorders or return-to-work: the prospective DACAPO cohort study

Background

Acute respiratory distress syndrome (ARDS) is a life-threatening condition that often requires prolonged mechanical ventilation. Tracheostomy is a common procedure with some risks, on the other hand with potential advantages over orotracheal intubation in critically ill patients. This study investigated the association of tracheostomy with health-related quality of life (HRQoL), symptoms of psychiatric disorders and return-to-work of ARDS survivors.

Methods

Data were collected in the context of the prospective observational German-wide DACAPO study. Clinical and demographic patient data and treatment characteristics were obtained from the participating intensive care units (ICU). HRQoL and return-to-work were assessed using patient-reported questionnaires 3, 6 and 12 months after ICU discharge. HRQoL was measured with the Physical and Mental Component Scale of the Short-Form 12 Questionnaire (PCS-12, MCS-12). The prevalence of psychiatric symptoms (depression and post-traumatic stress disorder [PTSD]) was assessed using the Patient Health Questionnaire-9 and the Post-Traumatic Stress Syndrome-14. Physician-diagnosed anxiety and obsessive–compulsive disorder were recorded by patient self-report in the follow-up questionnaires. The associations of tracheostomy with HRQoL, psychiatric symptoms and return-to-work after 12 months were investigated by means of multivariable linear and logistic regression models.

Results

Primary 877 ARDS patients (mean ± standard deviation: 54 ± 16 years, 68% male) survived and were discharged from ICU. Out of these patients, 478 (54.5%) were tracheotomised during ICU treatment. After 12 months, patient-reported outcomes could be analysed of 388 (44.2%) respondents, 205 with tracheostomy and 183 without. One year after ICU discharge, tracheostomy showed no significant association with physical or mental health-related quality of life (PCS-12: − 0.73 [− 3.96, 2.51]; MCS-12: − 0.71 [− 4.92, 3.49]), symptoms of psychiatric disorders (depression: 0.10 [− 1.43, 1.64]; PTSD: 3.31 [− 1.81, 8.43]; anxiety: 1.26 [0.41, 3.86]; obsessive–compulsive disorder: 0.59 [0.05, 6.68]) or return-to-work (0.71 [0.31, 1.64]) in the multivariable analysis (OR [95%-CI]).

Conclusions

Up to 1 year after ICU discharge, neither HRQoL nor symptoms of psychiatric disorders nor return-to-work was affected by tracheostomy.

Trial registration NCT02637011 (ClinicalTrials.gov, Registered 15 December 2015, retrospectively registered)

Tracheostomy: Experience at Tertiary Hospital

An attempt was made to find indications of tracheostomy procedure and its complications in the modern era of medicine with refined surgical techniques at a tertiary hospital. A retrospective study of 240 patients, who had undergone tracheostomy, was done during the period from January 2013 to April 2017 at Govt. Medical College Hospital. Various details of all participants such as age and sex of patients, detailed history of the current disease, and detailed information about tracheostomy and complications were recorded. In the present study, the most common indication for tracheostomy was prolonged ventilation due to Organophosphorus poisoning and Snake bite. The complication rate for tracheostomy procedure was 11.5%. The most common complication was tubal occlusion (7.5%) followed by Granulations around stoma (2.5%), Tracheal stenosis (1.25%), tracheoesophageal fistula (0.4%). No death was occurred during the tracheostomy procedure. The morbidity and mortality due to tracheostomy are reduced definitely. Tracheostomy Complications can be prevented by refined surgical techniques, use of high volume low pressure cuffed tracheostomy tubes and attentive post-operative nursing care. Yet complications of tracheomalacia and tracheal stenosis call for further improvement.

Protocol based evaluation for feasibility of extubation compared to clinical scoring systems after major oral cancer surgery safely reduces the need for tracheostomy: a retrospective cohort study

Background

Despite risks, complications and negative impact to quality of life, tracheostomy is widely used to bypass upper airway obstruction after major oral cancer surgery (MOCS). Decision to tracheostomy is frequently based on clinical scoring systems which mainly have not been validated by different cohorts. Delayed extubation in the Intensive Care Unit (ICU) may be a suitable alternative in selected cases. We hypothesize that delayed routine ICU extubation after MOCS instead of scoring system based tracheostomy is safe, feasible and leads to lower tracheostomy rates.

Methods

We retrospectively analyzed our clinical protocol which provides routine extubation of patients after MOCS in the ICU. The primary outcome measure was a composite of early reintubation within 24 h or secondary tracheostomy. Secondary outcome measures included airway obstruction related morbidity and mortality. Predictor variables included tumor localisation, surgical procedure and reconstruction method, length of operation and pre-existing morbidity. Furthermore we assessed the ability of four clinical scoring systems to identify patients requiring secondary tracheostomy. Statistical processing includes basic descriptive statistics, Chi-squared test and multivariate logistic regression analysis.

Results

Two hundred thirty four cases were enclosed to this retrospective study. Fourteen patients (6%) required secondary tracheostomy, Ten patients (4%) required reintubation within 24 h after extubation. No airway obstruction associated mortality, morbidity and cannot intubate cannot ventilate situation was observed. Seventy five percent of the patients were extubated within 17 h after ICU admission. All evaluated scores showed a poor positive predictive value (0.08 to 0.18) with a sensitivity ranged from 0.13 to 0.63 and specificity ranged from 0.5 to 0.93.

Conclusions

Our data demonstrate that common clinical scoring systems fail to prevent tracheostomy in patients after MOCS. Application of scoring systems may lead to a higher number of unnecessary tracheostomies. Delayed routine extubation in the ICU after MOCS seems an appropriate and safe approach to avoid tracheostomy and the related morbidity.

Electronic supplementary material

The online version of this article (10.1186/s12871-018-0506-8) contains supplementary material, which is available to authorized users.