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Sissoko C, Walker V, Dion GR. Biomechanical Evaluation of Tracheal Needle Puncture Forces: Comparative Analysis of Annular Ligaments and Tracheal Cartilage. J Biomech Eng 2024; 146:011008. [PMID: 37851532 DOI: 10.1115/1.4063821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 10/13/2023] [Indexed: 10/20/2023]
Abstract
Percutaneous tracheotomies (PCT) are commonly performed minimally invasive procedures involving the creation of an airway opening through an incision or puncture of the tracheal wall. While the medical intervention is crucial for critical care and the management of acute respiratory failure, tracheostomy complications can lead to severe clinical symptoms due to the alterations of the airways biomechanical properties/structures. The causes and mechanisms underlaying the development of these post-tracheotomy complications remain largely unknown. In this study, we aimed to investigate the needle puncture process and its biomechanical characteristics by using a well establish porcine ex vivo trachea to simulate the forces involved in accessing airways during PCT at varying angular approaches. Given that many procedures involve inserting a needle into the trachea without direct visualization of the tracheal wall, concerns have been raised over the needle punctures through the cartilaginous rings as compared to the space between them may result in fractured cartilage and post-tracheostomy airway complications. We report a difference in puncture force between piercing the cartilage and the annular ligaments and observe that the angle of puncture does not significantly alter the puncture forces. The data collected in this study can guide the design of relevant biomechanical feedback system during airway access procedures and ultimately help refine and optimize PCT.
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Affiliation(s)
- Cheick Sissoko
- Department of Otolaryngology-Head & Neck Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0528, Cincinnati, OH 45267
| | - Victoria Walker
- University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0528, Cincinnati, OH 45267
| | - Gregory R Dion
- Department of Otolaryngology-Head & Neck Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0528, Cincinnati, OH 45267
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Boudreaux JC, Urban M, Thompson SL, Castleberry AW, Moulton MJ, Siddique A. Does Tracheostomy Improve Outcomes in Those Receiving Venovenous Extracorporeal Membrane Oxygenation? ASAIO J 2023; 69:e240-e247. [PMID: 37071756 PMCID: PMC10226464 DOI: 10.1097/mat.0000000000001934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023] Open
Abstract
Patients receiving venovenous extracorporeal membrane oxygenation (VV-ECMO) often require extended periods of ventilation. We examined the role of tracheostomy on outcomes of patients supported with VV-ECMO. We reviewed all patients at our institution who received VV-ECMO between 2013 and 2019. Patients who received a tracheostomy were compared with VV-ECMO-supported patients without tracheostomy. The primary outcome measure was survival to hospital discharge. Secondary outcome measures included length of intensive care unit (ICU) and hospital stay and adverse events related to the tracheostomy procedure. Multivariable analysis was performed to identify predictors of in-hospital mortality. We dichotomized patients receiving tracheostomy into an "early" and "late" group based on median days to tracheostomy following ECMO cannulation and separate analysis was performed. One hundred and fifty patients met inclusion criteria, 32 received a tracheostomy. Survival to discharge was comparable between the groups (53.1% vs. 57.5%, p = 0.658). Predictors of mortality on multivariable analysis included Respiratory ECMO Survival Prediction (RESP) score (odds ratio [OR] = 0.831, p = .015) and blood urea nitrogen (BUN) (OR = 1.026, p = 0.011). Tracheostomy performance was not predictive of mortality (OR = 0.837, p = 0.658). Bleeding requiring intervention occurred in 18.7% of patients following tracheostomy. Early tracheostomy (<7 days from the initiation of VV-ECMO) was associated with shorter ICU (25 vs. 36 days, p = 0.04) and hospital (33 vs. 47, p = 0.017) length of stay compared with late tracheostomy. We conclude that tracheostomy can be performed safely in patients receiving VV-ECMO. Mortality in these patients is predicted by severity of the underlying disease. Performance of tracheostomy does not impact survival. Early tracheostomy may decrease length of stay.
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Affiliation(s)
- Joel C. Boudreaux
- From the College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Marian Urban
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Shaun L. Thompson
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska
| | | | - Michael J. Moulton
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Aleem Siddique
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska
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Mussa CC, Gomaa D, Rowley DD, Schmidt U, Ginier E, Strickland SL. AARC Clinical Practice Guideline: Management of Adult Patients with Tracheostomy in the Acute Care Setting. Respir Care 2021; 66:156-169. [PMID: 32962998 PMCID: PMC9993821 DOI: 10.4187/respcare.08206] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Management of patients with a tracheostomy tube includes many components of care provided by clinicians from various health care disciplines. In recent years, clinicians worldwide have demonstrated a renewed interest in the management of patients with tracheostomy due to the recognition that more effective and efficient management of this patient population is necessary to decrease morbidity and mortality and to optimize the value of the procedure. Commensurate with the goal of enhancing the care of patients with tracheostomy, we conducted a systematic review to facilitate the development of recommendations relevant to the care of adult patients with tracheostomy in the acute care setting. From our systematic review, clinical practice guidelines were developed to address questions regarding the impact of tracheostomy bundles, tracheostomy teams, and protocol-directed care on time to decannulation, length of stay, tracheostomy-related cost, tracheostomy-related adverse events, and other tracheostomy-related outcomes in tracheostomized adult patients in the acute care setting. Using a modification of the RAND/UCLA Appropriateness Method, 3 recommendations were developed to assist clinicians with tracheostomy management of adult patients in the acute care setting: (1) evidence supports the use of tracheostomy bundles that have been evaluated and approved by a team of individuals experienced in tracheostomy management to decrease time to decannulation, tracheostomy-related adverse events, and other tracheostomy-related outcomes, namely, improved tolerance of oral diet; (2) evidence supports the addition of a multidisciplinary tracheostomy team to improve time to decannulation, length of stay, tracheostomy-related adverse events, and other tracheostomy-related outcomes, namely, increased speaking valve use; (3) evidence supports the use of a weaning/decannulation protocol to guide weaning and removal of the tracheostomy tube to improve time to decannulation.
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Affiliation(s)
| | - Dina Gomaa
- Department of Surgery, Division of Trauma/Critical Care, University of Cincinnati, Cincinnati, Ohio
| | - Daniel D Rowley
- Pulmonary Diagnostics & Respiratory Therapy Services, University of Virginia Medical Center, Charlottesville, Virginia
| | - Ulrich Schmidt
- Department of Anesthesiology, University of California San Diego, San Diego, California
| | - Emily Ginier
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, Michigan
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Jin YJ, Han SY, Park B, Park IS, Kim JH, Choi HG. Mortality and cause of death in patients with tracheostomy: Longitudinal follow-up study using a national sample cohort. Head Neck 2020; 43:145-152. [PMID: 32954559 DOI: 10.1002/hed.26471] [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: 02/04/2020] [Revised: 08/22/2020] [Accepted: 09/04/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The purpose of this study was to evaluate the long-term mortality and cause of death in patients with tracheostomy. METHODS Data from the Korean National Health Insurance Service-Health Screening Cohort were collected from 2002 to 2013. A total of 2394 tracheostomy participants and 9536 control participants were included in this study. The crude and adjusted hazard ratios (HRs) for tracheostomy-associated mortality were analyzed. Subgroup analysis according to age and cause of death was analyzed. RESULTS The tracheostomy group showed a significantly higher rate of death (69.1%) than the nontracheostomy group (13.3%). The adjusted HR for mortality was 13.5 in the tracheostomy group. The most common cause of death after tracheostomy was a circulatory disease, followed by neoplasm, respiratory disease, and trauma. CONCLUSIONS Patients with tracheostomy had a significantly increased long-term mortality rate compared with patients with nontracheostomy. The circulatory disease was the most common cause of death following tracheostomy.
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Affiliation(s)
- Young Ju Jin
- Department of Otorhinolaryngology-Head & Neck Surgery, Wonkwang University Hospital, Wonkwang University College of Medicine, Iksan, South Korea
| | - Seung Yoon Han
- Department of Otorhinolaryngology-Head & Neck Surgery, Wonkwang University Hospital, Wonkwang University College of Medicine, Iksan, South Korea
| | - Bumjung Park
- Department of Otorhinolaryngology-Head & Neck Surgery, Hallym University College of Medicine, Anyang, South Korea
| | - Il-Seok Park
- Department of Otorhinolaryngology-Head & Neck Surgery, Hallym University College of Medicine, Seoul, South Korea
| | - Jin-Hwan Kim
- Department of Otorhinolaryngology-Head & Neck Surgery, Hallym University College of Medicine, Dongtan, South Korea
| | - Hyo Geun Choi
- Department of Otorhinolaryngology-Head & Neck Surgery, Hallym University College of Medicine, Anyang, South Korea.,Hallym Data Science Laboratory, Hallym University College of Medicine, Anyang, South Korea
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Tokarz E, Szymanowski AR, Loree JT, Muscarella J. Gaps in Training: Misunderstandings of Airway Management in Medical Students and Internal Medicine Residents. Otolaryngol Head Neck Surg 2020; 164:938-943. [DOI: 10.1177/0194599820949528] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Objectives (1) Evaluate baseline airway knowledge of medical students (MSs) and internal medicine (IM) residents. (2) Improve MS and IM resident understanding of airway anatomy, general tracheostomy and laryngectomy care, and management of airway emergencies. Methods A before-and-after survey study was carried out over a single academic year. MS and IM resident knowledge was evaluated before and after an educational, grand rounds–style lecture reviewing airway anatomy, tracheostomy tube components, tracheostomy and laryngectomy care, and clinical vignettes. The primary outcome measure was change in pre- and postlecture survey scores. Results Prelecture surveys were completed by 90 participants, and 83 completed a postlecture assessment. Postlecture scores were statistically improved for all questions on the assessment ( P < .001). Level of training did not confer an improved pre- or postlecture survey score. Discussion While the majority of participants in our study had previously cared for patients with a tracheostomy or laryngectomy, less than half were able to correctly address basic airway emergencies. Senior IM residents were no more proficient than MSs in addressing airway emergencies. The lack of formal airway training places patients at risk with routine care and in emergencies, demonstrating the need for formal airway education for early medical trainees. Implications for Practice Our data demonstrate a serious gap in MS and IM resident knowledge with respect to emergent airway care in patients with tracheostomies and laryngectomies. An interdepartmental collaborative curriculum offers a realistic and potentially life-saving solution for medical trainees.
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Affiliation(s)
- Ellen Tokarz
- Department of Otolaryngology–Head and Neck Surgery, State University of New York at Buffalo, Buffalo, New York, USA
| | - Adam R. Szymanowski
- Department of Otolaryngology–Head and Neck Surgery, State University of New York at Buffalo, Buffalo, New York, USA
| | - John T. Loree
- State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Joseph Muscarella
- Department of Otolaryngology–Head and Neck Surgery, State University of New York at Buffalo, Buffalo, New York, USA
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Rodrigues LADB, Lago AF, Menegueti MG, Farias VA, Auxiliadora-Martins M, Ferez MA, Martinez EZ, Basile-Filho A. The use of distributed random forest model to quantify risk predictors for tracheostomy requirements in septic patients: A retrospective cohort study. Medicine (Baltimore) 2020; 99:e20757. [PMID: 32664069 PMCID: PMC7360240 DOI: 10.1097/md.0000000000020757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The search for early clinical risk factors in the intensive care setting may improve the outcome of critically ill patients. The objective of this retrospective study is to identify and quantify early predictors for patients who would require tracheostomy. Five hundred and forty four septic patients were divided in 2 groups: non-tracheostomized (NT) (n = 484) and tracheostomized (T) (n = 60). The patients consisted of 241 males (49.8%) in NT and 27 (45%) in T group, respectively (P = .4971). The median and interquartile range difference of age of NT group was of 72 years [59-82] and T of 75 [55.0-83.5] (P = .4687). The SAPS 3 for the group NTxT was 70 [55-85] and 85.5 [77-91] (P = .0001), the SOFA of 9 [6-13] and 12 [10-14] (P = .0002). The comparison of logistic regression analysis for predictors of non-tracheostomy and tracheostomy groups showed an adjusted odds ratio (OR) for SAPS 3 range between 74 and 87 of 18.14 (95%CI = 3.36-97.84) and between 88 and 116 of 27.77 (95%CI = 4.43-174.24) (P < .05). For SOFA, the adjusted OR between 10 and 13 was 12.23 (95%CI = 2.46-60.81) and between 14 and 20 was 8.45 (95%CI = 1.58-45.29) (P < .05). The need for blood transfusions and dialysis presented an OR of 2.74 (95%CI = 1.23-6.08) and 3.33 (95%CI = 1.43-7.73) (P < .05), respectively. Our data shows that SAPS 3 ≥ 74, SOFA ≥ 11, blood transfusions and the need for dialysis were independently associated and could be considered major predictors for tracheostomy requirements in septic patients.
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Affiliation(s)
| | | | | | | | | | | | | | - Anibal Basile-Filho
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, SP, Brazil
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Blecha S, Brandl M, Zeman F, Dodoo-Schittko F, Brandstetter S, Karagiannidis C, Bein T, Apfelbacher C. 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. Ann Intensive Care 2020; 10:52. [PMID: 32377963 PMCID: PMC7203349 DOI: 10.1186/s13613-020-00671-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 04/28/2020] [Indexed: 12/19/2022] Open
Abstract
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)
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Affiliation(s)
- Sebastian Blecha
- Department of Anaesthesiology, University Medical Centre Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany.
| | - Magdalena Brandl
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
| | - Florian Zeman
- Centre of Clinical Studies, University Medical Centre Regensburg, Regensburg, Germany
| | - Frank Dodoo-Schittko
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
| | - Susanne Brandstetter
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany.,University Children's Hospital Regensburg (KUNO), University of Regensburg, Regensburg, Germany
| | - Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Cologne, Germany
| | - Thomas Bein
- Department of Anaesthesiology, University Medical Centre Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Christian Apfelbacher
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany.,Institute of Social Medicine and Health Economics, Otto von Guericke University Magdeburg, Magdeburg, Germany
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Fokin AA, Wycech J, Chin Shue K, Stalder R, Crawford M, Lozada J, Puente I. Early Versus Late Tracheostomy in Trauma Patients With Rib Fractures. J Surg Res 2019; 245:72-80. [PMID: 31401250 DOI: 10.1016/j.jss.2019.07.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 06/19/2019] [Accepted: 07/11/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Patients with blunt chest trauma with multiple rib fractures (RF) may require tracheostomy. The goal was to compare early (≤7 d) versus late (>7 d) tracheostomy patients and to analyze clinical outcomes, to determine which timing is more beneficial. METHODS This retrospective review included 124 patients with RF admitted to trauma ICU at two level 1 trauma centers who underwent tracheostomy. Analyzed variables included age, gender, injury severity score, Glasgow Coma Scale, number of ribs fractured, total fractures of the ribs, prevalence of bilateral RF, flail chest, maxillofacial injuries, cervical vertebrae trauma, traumatic brain injuries (TBI), coinjuries, epidural analgesia, surgical stabilization of RF, failure to extubate, hospital LOS, intensive care unit LOS (ICULOS), duration of mechanical ventilation, mortality, and timing and type of tracheostomy. RESULTS Mean number of RF in all tracheostomized patients with blunt chest trauma was 5.2 and 85% of patients had pulmonary co-injuries. Mean tracheostomy timing was 9.9 d. Early tracheostomy (ET) was correlated with statistically significant reduction in ICULOS and duration of mechanical ventilation. The dominant cause of mortality in all groups was TBI and it was more pronounced in the ET patients. Most deaths were encountered between 3 and 5 wk after admission. ET was more often performed in the operating room with an open technique, whereas late tracheostomy was more often implemented with percutaneous technique at bedside. CONCLUSIONS ET could be beneficial in chest trauma patients with multiple RF as it reduces ICULOS and ventilation requirements. Mortality benefits are not correlated with tracheostomy timing.
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Affiliation(s)
- Alexander A Fokin
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida.
| | - Joanna Wycech
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida; Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, Florida
| | - Kyle Chin Shue
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida; Department of Surgery, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida
| | - Ryan Stalder
- Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, Florida; Wake Forest University, Winston-Salem, North Carolina
| | - Maggie Crawford
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida
| | - Jose Lozada
- Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, Florida
| | - Ivan Puente
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida; Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, Florida; Department of Surgery, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida; Department of Surgery, Florida International University, Herbert Wertheim College of Medicine, Miami, Florida
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Abstract
Tracheostomy remains one of the most commonly performed surgical procedures in the setting of acute respiratory failure. Tracheostomy literature focuses on 2 aspects of this procedure: when (timing) and how (technique). Recent trials have failed to demonstrate an effect of tracheostomy timing on most clinically important endpoints. Nonetheless, relative to continued translaryngeal intubation, studies suggest that tracheostomy use is associated with less need for sedation and enhanced patient comfort. Evidence likewise suggests that percutaneous dilational tracheostomy is advantageous with respect to cost and complication profile and should be considered the preferred approach in appropriately selected patients.
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Affiliation(s)
- Bradley D Freeman
- Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Box 8109, St Louis, MO 63110, USA.
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