A novel method for replacement of the dislodged tracheostomy tube: the nasogastric tube "guidewire" technique

Multidisciplinary guidelines for the management of paediatric tracheostomy emergencies

Temporary and permanent tracheostomies are required in children to manage actual or anticipated long-term ventilatory support, to aid secretion management or to manage fixed upper airway obstruction. Tracheostomies may be required from the first few moments of life, with the majority performed in children < 4 years of age. Although similarities with adult tracheostomies are apparent, there are key differences when managing the routine and emergency care of children with tracheostomies. The National Tracheostomy Safety Project identified the need for structured guidelines to aid multidisciplinary clinical decision making during paediatric tracheostomy emergencies. These guidelines describe the development of a bespoke emergency management algorithm and supporting resources. Our aim is to reduce the frequency, nature and severity of paediatric tracheostomy emergencies through preparation and education of staff, parents, carers and patients.

Tracheostomy in the ICU

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.

The usefulness of the stay suture technique in tracheostomy

OBJECTIVE

Tracheostomy tube displacement may occur at any time in the course of patient management. Although an infrequent occurrence, such displacement is potentially serious. The purpose of this study was to evaluate the advantages and complications of the stay suture technique in tracheostomy.

STUDY DESIGN

Prospective cohort study.

METHODS

The SST involves the placement of sutures between the anterior tracheal wall and the skin in order to hasten the formation of a mature stoma. The study patients were divided into two groups. One group underwent tracheostomy with the SST (n =104), and the other group was treated with a conventional tracheostomy (n = 101). The postoperative complications for each group were then reviewed.

RESULTS

The most common indication for tracheostomy was prolonged endotracheal intubation (79.3%), and the most common complication in each group was postoperative stoma infection. Unexpected decannulation occurred in three patients from the conventional tracheostomy group, causing death of the patients. However, the SST group did not show any occurrence of unexpected decannulation.

CONCLUSIONS

Unexpected decannulation was a fatal complication. Because this complication was not observed in any patients who underwent the SST, our study recommends use of this method as a countermeasure for unexpected decannulation.

LEVEL OF EVIDENCE

4.

Safer tracheostomy: a proposal for the routine use of an airway exchange catheter during tracheostomy

In the United States, more than 100,000 tracheostomies are performed annually. Many patients undergoing tracheostomy are critically ill, making them higher risk surgical candidates. Fortunately, the loss of airway during the procedure is rare, but when it occurs, the outcome can be catastrophic. In this report, we describe a technique to minimize the risk of airway loss by using an airway exchange catheter as an airway conduit during endotracheal tube removal. We present 2 clinical cases in which this technique was used successfully and made an important contribution to patient safety.

Sternoclavicular osteomyelitis: a new complication of misplaced tracheostomy tube

We report a patient who presented with erythema and swelling over the chest and neck several days after the placement of a tracheostomy tube. Sternoclavicular osteomyelitis and anterior mediastinal abscess occurred, as complications of inadvertent pretracheal tracheostomy tube placement, which were treated with right sternoclavicular resection and mediastinal drainage.

Difficult tracheostomy tube placement in an obese patient with a short neck -A case report-

We report a difficult case of tracheostomy in a 34-year-old obese woman with a short neck. The tracheostomy tube placement repeatedly failed because of anatomical changes due to obesity and a short neck, tracheal mucosal swelling due to prolonged intubation, and unexpected false passage; however, it was successfully performed using an endotracheal tube exchanger as a guidewire.

Light at a tunnel's end: The lightwand as a rapid tracheal location aid when encountering false passage during tracheostomy

False passage and loss of airway during tracheostomy are not uncommon, especially in patients with short and thick necks. Distorted neck anatomy following either repeated insertion attempts or due to underlying malignancy may make it very difficult to locate the trachea even while attempting open/surgical tracheostomy, despite good exposure of the neck in such situations. The lightwand is not an ideal device for tracheal intubation in such patients. However, it can be useful in these patients while performing open tracheostomy. Passing the lightwand through the orotracheal tube can aid in rapid identification of the trachea in such situations and may help reduce the occurrence of complications subsequent to repeated false passage. We report a series of four such cases where use of lightwand aided in rapidly locating the trachea during tracheostomy complicated by distorted anatomy.

Safe reliable atraumatic replacement of misplaced paediatric tracheostomy tubes

OBJECTIVE

Displacement of tracheostomy tubes, especially soon after insertion has a high morbidity and mortality rate. We present a safe atraumatic reliable method of tracheostomy tube replacement.

SETTING

Tertiary paediatric centre.

MATERIALS AND METHODS

The method involves using a suction catheter placed in the trachea. Its position can be confirmed by suctioning tracheal secretions. The catheter can be used to employ the Seldinger technique for replacement of the tracheostomy tube and can be used to jet ventilate the patient if there is failure to site a tube. This buys time while a surgical airway is placed. We also outline the minimum contents of the emergency box, which should be carried at all times by the carers of a child with a tracheostomy.

CONCLUSIONS

Use of a suction catheter is a safe reliable atraumatic way of replacing a tracheostomy tube.

Assessment of healthcare professionals' knowledge of managing emergency complications in patients with a tracheostomy

BACKGROUND

Ear, nose, and throat (ENT) surgeons perform the majority of surgical tracheostomies. Intensive care anaesthetists are increasingly performing bedside percutaneous tracheostomy. The objectives of this study were to characterize emergency complications of tracheostomy and to ascertain healthcare professionals' knowledge of life-saving strategies for the patient with a tracheostomy.

METHODS

Seventy staff members in two large teaching hospitals completed an interview questionnaire, comprising a simple clinical scenario and unambiguous questions regarding the emergency management of patients with a tracheostomy.

RESULTS

There were significant gaps in knowledge among healthcare professionals regarding the management of specific tracheostomy-related emergencies.

CONCLUSIONS

Knowledge of tracheostomy-related emergencies appears to be insufficient among non-ENT healthcare professionals. This needs to be addressed in order to maximize patient safety.

Repositioning a displaced tracheostomy tube with an Aintree intubation catheter mounted on a fibre-optic bronchoscope

Although tracheostomy tube displacement is uncommon, the management is often difficult and the associated mortality is high. It is important to ensure that the airway is secure and then either replace or reposition the tracheostomy tube. This case report describes the use of an Aintree intubation catheter (C-CAE-19.0-56-AIC, William Cook Europe, Denmark) mounted on an intubating fibre-optic bronchoscope (11302BD1, Karl Storz Endoskope, Germany) to reposition a partially displaced tracheostomy tube.

Liberation from prolonged mechanical ventilation

After weaning from PMV, patients are usually far from ready to resume normal activities. A prolonged recovery period after catastrophic illness is the rule, with multidisciplinary rehabilitation and discharge planning efforts. Following such efforts, reports of success of restorative care are institutional and population specific. That all PMV patients are not "chronically critically ill" introduces selection factors that make comparisons between institutions even more difficult. Half of the authors' patients were able to go home in past years [14], although more recently, with patients admitted more debilitated and more ill, the percent returning home has gradually declined to the low 20% range. Bagley et al [11] report discharge to home in 31% of patients weaned. Gracey et al [6,133], treating younger, postsurgical patients, have reported the highest discharge to home rate, 57%; over 70% were eventually discharged to home after first being transferred to a rehabilitation unit. On the other hand, the few reports of survival 1 or more years after discharge are in the 50% range at best (Table 2). Carson and colleagues [9] report a 23% 1-year survival in 133 PMV patients. Their premorbid functional status and age analysis showed younger and more independent patients having a better mortality (56%), and older and more dependent patients having a 95% mortality at 1 year. Nasraway et al [25] report a 1-year mortality of 50.5% in 97 patients transferred from five ICUs to multiple ECFs. Most of these patients would probably meet criteria for PMV, with median time mechanically ventilated 33 days, and 71 ventilator dependent at the time of ICU discharge. A report from 25 Vencor Hospitals [134] not included in Table 2 because weaning outcome was not reported, examines mortality and cost in patients > 65 years of age primarily referred for failure to wean from mechanical ventilation (91% of the cohort of 1619 patients.) There was a 58% in-hospital mortality by day 102 (28 days in the acute care hospital before referral, 74 days in the LTAC afterward), and a 67% mortality in postdischarge follow-up to day 180. Results of functional status studies and quality-of-life (QQL) measures, some using validated instruments, are now being reported in small series of PMV patients. These will merit consideration as important as weaning outcome, disposition, and survival data, as they accumulate to round out the treatment results in this population. Using a proprietary instrument, Carson et al [9] found 42% of 1-year survivors, that is, 8% of study patients, functionally independent at 1 year after discharge. Nasraway [25], using a single-question QQL assessment, and a validated functionality measurement, found 11.5% of his original cohort at home, breathing independently, with a "fair or better" QOL and good physical functionality. In a preliminary report from Dr. Criner's VRU, objective physical improvement was demonstrated in rehabilitation after PMV, using a functional independence measure scale [89]. A full report from the same unit, using a Sickness Impact Profile score makes it clear that PMV had no independent adverse effect on QOL several years later [135]. The 46 patients (25 of whom, with mean age 59 years, responded to the follow-up questionnaire), followed for 24 months after the catastrophic episode, scored their QOL based on their underlying chronic diseases, if any. The older patients, status postsurgical illness, predominantly cardiac surgery, rated their QOL better than younger patients with acute or chronic diseases. Similar findings have been reported in a recent ICU study, reporting QOL after prolonged intensive care [136]. Those who work to liberate PMV patients from mechanical ventilation, a satisfying end in many ways, have demonstrated that this post-ICU critical care activity is usually safe, and successful, although only in observational studies. Will multicenter studies in PMV patients liberated from mechanical ventilation yield facility benchmark, weaning outcome, and survival data that warrant continuation of these activities on a cost-per-outcome basis? That remains to be seen. Assessing and interpreting QOL and functionality findings in these patients, many with underlying chronic diseases resulting in long convalescence and rehabilitation, is a particularly important challenge. The authors are participating in a multicenter study that will yield some of these data; no doubt others will also address these questions. In the mean time, "No one in our society is willing to put Grandma out on an iceberg because she's no longer contributing. Someone needs to take care of these people" [137].

Loss of the airway during tracheostomy: rescue oxygenation and re-establishment of the airway

PURPOSE

To describe loss of the airway during tracheostomy and suggest a method for re-establishment of the airway and providing rescue oxygenation.

CLINICAL FEATURES

A 22-yr-old female diagnosed with encephalomyelopathy was admitted to the intensive care unit with a progressively deteriorating level of consciousness and respiratory failure requiring intubation and ventilation. Several weeks later, an elective tracheostomy was performed under anesthesia. The surgeon made an anterior tracheal wall incision and inserted a cuffed #6 Shiley tracheostomy tube. No end-tidal CO(2) was detected and the patient could not be ventilated. After another failed attempt at insertion of a second tracheostomy tube, the diagnosis was made of a false passage within the trachea. The Shiley tracheostomy tube was removed and a #6 regular endotracheal tube was introduced in the trachea through the tracheostomy incision. The patient now could be ventilated with difficulty and low readings of end-tidal CO(2) were noted. Despite all efforts to further ventilate the patient, the arterial oxygen saturation never recovered, resulting in cardiac arrest.

CONCLUSION

To restore a lost airway during tracheostomy, we recommend that a jet ventilation airway exchange catheter (JVAE) be inserted in the endotracheal tube through a bronchoscope port attachment prior to surgical entry into the trachea. The JVAE will also ensure continued ability to oxygenate the patient.

The tracheostomy tube change: a review of techniques

Tracheostomy tube changing is a routine procedure. However, occasional problems can arise and result in fatalities. This article reviews the various measures and techniques used to optimize the safeguarding of the airway during a tracheostomy tube change, including the 'railroad' technique. The management of accidental decannulations is also reviewed.