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Jung DTU, Grubb L, Moser CH, Nazarian JTM, Patel N, Seldon LE, Moore KA, McGrath BA, Brenner MJ, Pandian V. Implementation of an evidence-based accidental tracheostomy dislodgement bundle in a community hospital critical care unit. J Clin Nurs 2022:10.1111/jocn.16535. [PMID: 36200145 PMCID: PMC9874912 DOI: 10.1111/jocn.16535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 07/13/2022] [Accepted: 08/23/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Tracheostomy dislodgment can lead to catastrophic neurological injury or death. A fresh tracheostomy amplifies the risk of such events, where an immature tract predisposes to false passage. Unfortunately, few resources exist to prepare healthcare professionals to manage this airway emergency. AIM To create and implement an accidental tracheostomy dislodgement (ATD) bundle to improve knowledge and comfort when responding to ATD. MATERIALS & METHODS A multidisciplinary team with expertise in tracheostomy developed a 3-part ATD bundle including (1) Tracheostomy Dislodgement Algorithm, (2) Head of Bed Tracheostomy Communication Tool and (3) Emergency Tracheostomy Kit. The team tested the bundle during the COVID-19 pandemic in a community hospital critical care unit with the engagement of nurses and Respiratory Care Practitioners. Baseline and post-implementation knowledge and comfort levels were measured using Dorton's Tracheotomy Education Self-Assessment Questionnaire, and adherence to protocol was assessed. Reporting follows the revised Standards for Quality Improvement Reporting Excellence (SQUIRE). RESULTS Twenty-four participants completed pre-test and post-test questionnaires. The median knowledge score on the Likert scale increased from 4.0 (IQR = 1.0) pre-test to 5.0 (IQR = 1.0) post-test. The median comfort level score increased from 38.0 (IQR = 7.0) pre-test to 40.0 (IQR = 5.0) post-test). In patient rooms, adherence was 100% for the Head of Bed Tracheostomy Communication Tool and Emergency Tracheostomy Kit. The adherence rate for using the Dislodgement Algorithm was 55% in ICU and 40% in SCU. DISCUSSION This study addresses the void of tracheostomy research conducted in local community hospitals. The improvement in knowledge and comfort in managing ATD is reassuring, given the knowledge gap among practitioners demonstrated in prior literature. The ATD bundle assessed in this study represents a streamlined approach for bedside clinicians - definitive management of ATD should adhere to comprehensive multidisciplinary guidelines. CONCLUSIONS ATD bundle implementation increased knowledge and comfort levels with managing ATD. Further studies must assess whether ATD bundles and other standardised approaches to airway emergencies reduce adverse events. Relevance to Clinical Practice A streamlined intervention bundle employed at the unit level can significantly improve knowledge and comfort in managing ATD, which may reduce morbidity and mortality in critically ill patients with tracheostomy.
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Affiliation(s)
- Dawn Ta Un Jung
- Division of Cardiac SurgeryJohns Hopkins HospitalBaltimoreMarylandUSA
| | - Lisa Grubb
- Johns Hopkins Medicine Howard County General HospitalColumbiaMarylandUSA,Johns Hopkins School of NursingBaltimoreMarylandUSA
| | | | | | - Neesha Patel
- Johns Hopkins Medicine Howard County General HospitalColumbiaMarylandUSA
| | - Lisa E. Seldon
- Johns Hopkins Medicine Howard County General HospitalColumbiaMarylandUSA
| | - Kristin A. Moore
- Johns Hopkins Medicine Howard County General HospitalColumbiaMarylandUSA
| | - Brendan A. McGrath
- University of Manchester, NHS Foundation Trust, National Tracheostomy Safety ProjectManchesterUK
| | - Michael J. Brenner
- Department of Otolaryngology – Head & Neck SurgeryUniversity of Michigan Medical SchoolAnn ArborMichiganUSA,Global Tracheostomy CollaborativeRaleighNorth CarolinaUSA
| | - Vinciya Pandian
- Department of Nursing FacultyJohns Hopkins UniversityBaltimoreMarylandUSA
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Alsunaid S, Holden VK, Kohli A, Diaz J, O'Meara LB. Wound care management: tracheostomy and gastrostomy. J Thorac Dis 2021; 13:5297-5313. [PMID: 34527367 PMCID: PMC8411156 DOI: 10.21037/jtd-2019-ipicu-13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/27/2020] [Indexed: 01/12/2023]
Abstract
Percutaneous dilatational tracheostomy (PDT) and percutaneous endoscopic gastrostomy (PEG) tube placements are routine procedures performed in the intensive care units (ICUs). They are performed to facilitate care and promote healing. They also help prevent complications from prolonged endotracheal intubation and malnutrition. In most cases, both are performed simultaneously. Physicians performing them require knowledge of local anatomy, tissue and vascular relationships, along with advance bronchoscopy and endoscopy skills. Although PDTs and PEGs are considered relatively low-risk procedures, operators need to have the knowledge and skill to recognize and prevent adverse outcomes. Current published literature on post-procedural care and stoma wound management was reviewed. Available recommendations for the routine care of tracheostomy and PEG tubes are included in this review. Signs and symptoms of early PDT- and PEG-related complications and their management are discussed in detail. These include hemorrhage, infection, accidental decannulation, tube obstruction, clogging, and dislodgement. Rare, life-threatening complications are also discussed. Multidisciplinary teams are needed for improved patient care, and members should be aware of all pertinent care aspects and potential complications related to PDT and PEG placement. Each institute is strongly encouraged to have detailed protocols to standardize care. This review provides a state-of-the-art guidance on the care of patients with tracheostomies and gastrostomies specifically in the ICU setting.
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Affiliation(s)
- Sammar Alsunaid
- Division of Pulmonary & Critical Care Medicine, Section of Interventional Pulmonology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Van K Holden
- Division of Pulmonary & Critical Care Medicine, Section of Interventional Pulmonology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Akshay Kohli
- Department of Internal Medicine, Medstar Washington Hospital Center, Georgetown University, Washington, DC, USA
| | - Jose Diaz
- Division of Acute Care Emergency Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Lindsay B O'Meara
- Division of Acute Care Emergency Surgery, University of Maryland Medical Center, Baltimore, MD, USA
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Tara A, Kumaraswami S, Berzofsky C. From Tracheal Stenosis to Tracheostomy Displacement: A Case Report on a Seemingly Never-Ending Difficult Airway. A A Pract 2020; 14:e01185. [PMID: 32224697 DOI: 10.1213/xaa.0000000000001185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report a case of undiagnosed tracheal stenosis that culminated in acute respiratory failure in an inpatient unit. After failed intubation attempts, the placement of a supraglottic airway resulted in successful ventilation and was followed by a tracheostomy in the operating room. Postoperatively, the tracheostomy tube became accidentally dislodged necessitating emergency measures with eventual reinsertion of a longer tracheostomy tube. We present this case to highlight life-saving airway strategies that may be considered in such emergency situations and propose 2 simple algorithms to guide anesthesiologists in managing similar airway emergencies.
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Affiliation(s)
| | | | - Craig Berzofsky
- Otolaryngology, New York Medical College, Westchester Medical Center, Valhalla, New York
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Doherty C, Neal R, English C, Cooke J, Atkinson D, Bates L, Moore J, Monks S, Bowler M, Bruce IA, Bateman N, Wyatt M, Russell J, Perkins R, McGrath BA. Multidisciplinary guidelines for the management of paediatric tracheostomy emergencies. Anaesthesia 2018; 73:1400-1417. [PMID: 30062783 DOI: 10.1111/anae.14307] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2018] [Indexed: 01/09/2023]
Abstract
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.
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Affiliation(s)
- C Doherty
- Department of Paediatric Anaesthesia, Manchester University NHS Foundation Trust, Manchester, UK
| | - R Neal
- Paediatric Intensive Care Medicine, Paediatrics, Birmingham Children's Hospital, Birmingham, UK
| | - C English
- Department of Paediatric ENT, Manchester University NHS Foundation Trust, Manchester, UK
| | - J Cooke
- Department of Paediatric Otolaryngology, Great Ormond Street Hospital, London, UK
| | - D Atkinson
- Department of Anaesthesia and Intensive Care Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - L Bates
- Department of Anaesthesia and Intensive Care Medicine, Royal Bolton Hospital, Bolton, UK
| | - J Moore
- Department of Anaesthesia and Intensive Care Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - S Monks
- Department of Anaesthesia, East Lancashire Hospitals NHS Trust, Burnley, UK
| | - M Bowler
- Department of Paediatric Anaesthesia, Manchester University NHS Foundation Trust, Manchester, UK
| | - I A Bruce
- Department of Paediatric Otolaryngology, Royal Manchester Children's Hospital, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - N Bateman
- Department of Paediatric Otolaryngology, Royal Manchester Children's Hospital, Manchester, UK
| | - M Wyatt
- Department of Paediatric Otolaryngology, Great Ormond Street Hospital, London, UK
| | - J Russell
- Department of Paediatric ENT, Our Lady's Children's Hospital, Dublin, Ireland
| | - R Perkins
- Department of Paediatric Anaesthesia, Manchester University NHS Foundation Trust, Manchester, UK
| | - B A McGrath
- Department of Anaesthesia and Intensive Care Medicine, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Yap D, Goddard S, Ng M, Al-Hussaini A, Owens D. An animal tissue simulation assessing three directional displacement forces on five common tracheostomy securing techniques. Ann R Coll Surg Engl 2018; 100:459-463. [PMID: 29692192 PMCID: PMC6111910 DOI: 10.1308/rcsann.2018.0069] [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] [Accepted: 10/16/2017] [Indexed: 11/22/2022] Open
Abstract
Introduction Several methods of securing a tracheostomy tube have been described in the literature including using ties or tapes around the neck and suturing the plastic flange to the neck in various ways. However, there are no wet lab-based studies to objectively determine the force required to displace the tracheostomy tube using different securing techniques. Ours is the first animal tissue simulation study published in the literature. Methods A simulated tracheostomy stoma was created on a sheep neck model. A tracheostomy tube was inserted into the stoma and secured using various methods. Tension tests were conducted to significantly displace the tube from the stoma. Each technique was repeated six times on different sheep necks. All results were analysed using SPSS®. Results Repeat measurements indicated that the largest displacement forces come from an oblique direction while the lowest force values were found at the lateral angle. Averages of displacement showed that medially placed sutures required the largest forces in comparison with other securing methods. Wilcoxon signed-rank testing indicated that medial and continuous suture security resists displacement at forces that otherwise displace flange and interrupted sutures. Conclusions This study has shown that any type of securing suture requires a greater displacement force than the strap of the tracheostomy tube holder alone. Medially placed sutures require a greater displacement force than those placed laterally. Displacement in the lateral direction requires the least force in comparison with movement at perpendicular or oblique angles.
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Affiliation(s)
- D Yap
- Aneurin Bevan University Health Board, UK
| | - S Goddard
- Welsh Institute for Minimal Access Therapy, UK
| | - M Ng
- Cardiff and Vale University Health Board, UK
| | | | - D Owens
- Cardiff and Vale University Health Board, UK
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Fan Y, Cai J, Yan C. Technical Improvements of Difficult Tracheotomy. Indian J Surg 2016; 77:985-9. [PMID: 27011495 DOI: 10.1007/s12262-014-1101-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 05/08/2014] [Indexed: 11/30/2022] Open
Abstract
The aim of this study was to explore the application value of technical improvements of difficult tracheotomy. Percutaneous dilatational tracheotomy kit combined with traditional surgical tracheotomy was performed on seven patients with various types of difficult tracheotomy surgery from Jan. 2011 to Mar. 2013 in our hospital. The indicators, such as difficulty degree and intraoperative peripheral oxygen saturation changes of each patient, were assessed and analyzed. The average operating time was 20 min (from the beginning of skin incision to the implantation of the tracheal tube), and the time from cutting out tracheal cartilage rings to completely implanting tracheal tube was with 2 min; the intraoperative oxygen saturation degrees were all above 92 %. There were no serious complications, such as intraoperative hemorrhea, asphyxia, cardiac arrest, or others, and no complications, such as postoperative bleeding, pneumothorax, cervical spinal cord injury, tracheal stenosis, tracheoesophageal fistula, or others, appeared. The technical improvements used in difficult tracheotomy could reduce the risk of surgery, difficulties of the surgical operation and postoperative complications and make the operation much more easy and more suitable for the clinical application.
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Affiliation(s)
- Yongzhong Fan
- Department of Neurosurgery, Danyang People's Hospital, Danyang, 212300 Jiangsu Province China
| | - Jundan Cai
- Intensive Care Unit, Danyang People's Hospital, Danyang, 212300 Jiangsu Province China
| | - Chaojun Yan
- Department of Neurosurgery, Danyang People's Hospital, Danyang, 212300 Jiangsu Province China
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Long B, Koyfman A. Resuscitating the tracheostomy patient in the ED. Am J Emerg Med 2016; 34:1148-55. [PMID: 27073134 DOI: 10.1016/j.ajem.2016.03.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 03/18/2016] [Accepted: 03/19/2016] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Emergency physicians must be masters of the airway. The patient with tracheostomy can present with complications, and because of anatomy, airway and resuscitation measures can present several unique challenges. Understanding tracheostomy basics, features, and complications will assist in the emergency medicine management of these patients. OBJECTIVE OF REVIEW The aim of this review is to provide an overview of the basics and features of the tracheostomy, along with an approach to managing tracheostomy complications. DISCUSSION This review provides background on the reasons for tracheostomy placement, basics of tracheostomy, and tracheostomy tube features. Emergency physicians will be faced with complications from these airway devices, including tracheostomy obstruction, decannulation or tube dislodgement, stenosis, tracheoinnominate fistula, and tracheoesophageal fistula. Critical patients should be evaluated in the resuscitation bay, and consultation with ENT should be completed while the patient is in the department. This review provides several algorithms for management of complications. Understanding these complications and an approach to airway management during cardiac arrest resuscitation is essential to optimizing patient care. CONCLUSION Tracheostomy patients can present unique challenges for emergency physicians. Knowledge of the basics and features of tracheostomy tubes can assist physicians in managing life-threatening complications including tube obstruction, decannulation, bleeding, stenosis, and fistula.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, Houston, TX 78234.
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, TX 75390.
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Surgically modified airways: What every anesthesiologist should know. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2015. [DOI: 10.1016/j.tacc.2015.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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9
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Morris LL, Whitmer A, McIntosh E. Tracheostomy care and complications in the intensive care unit. Crit Care Nurse 2013; 33:18-30. [PMID: 24085825 DOI: 10.4037/ccn2013518] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Tracheotomy is a common procedure in intensive care units, and nurses must provide proper care to tracheostomy patients to prevent complications. One of the most important considerations is effective mobilization of secretions, and a suction catheter is the most important tool for that purpose. Each bedside should be equipped with a functional suctioning system, an oxygen source, a manual resuscitation bag, and a complete tracheostomy kit, which should accompany patients wherever they go in the hospital. Complications include infection, tracheomalacia, skin breakdown, and tracheoesophageal fistula. Tracheostomy emergencies include hemorrhage, tube dislodgement and loss of airway, and tube obstruction; such emergencies are managed more effectively when all necessary supplies are readily available at the bedside. This article describes how to provide proper care in the intensive care unit, strategies for preventing complications, and management of tracheostomy emergencies.
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Schaetzel S, Juern J, Kiehl K, Xiang Q, Weigelt J. The effect of suturing on force for dislodgement of tracheostomy tubes. J Trauma Acute Care Surg 2013; 75:492-5. [DOI: 10.1097/ta.0b013e3182a075a6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Difficult tracheostomy tube insertion rescued by an angiographic catheter. J Anesth 2013; 27:787-8. [PMID: 23604818 DOI: 10.1007/s00540-013-1614-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Accepted: 04/10/2013] [Indexed: 10/26/2022]
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12
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McGrath BA, Bates L, Atkinson D, Moore JA. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia 2012; 67:1025-41. [DOI: 10.1111/j.1365-2044.2012.07217.x] [Citation(s) in RCA: 135] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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Use of the Trachlight in securing the airway due to accidental dislodgement of a tracheostomy tube. J Clin Anesth 2012; 24:433-4. [PMID: 22626678 DOI: 10.1016/j.jclinane.2011.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Revised: 08/03/2011] [Accepted: 08/16/2011] [Indexed: 10/28/2022]
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14
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Letters for J R Army Med Corps 2011; vol 157. J ROY ARMY MED CORPS 2011. [DOI: 10.1136/jramc-157-03-17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Truong A, Truong DT. Late tracheostomy tube decannulation by progression of a laryngeal tumour: an approach for airway control. Can J Anaesth 2011; 58:771-2. [PMID: 21618073 DOI: 10.1007/s12630-011-9526-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Accepted: 05/16/2011] [Indexed: 11/25/2022] Open
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Misra S, Rao M. Tracheostomy stomal ventilation is not tracheal ventilation. Acta Anaesthesiol Scand 2009; 53:546; author reply 547. [PMID: 19317868 DOI: 10.1111/j.1399-6576.2008.01897.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Walton JJ, Nesbitt ID, Cressey DM, Cosgrove JF, Kilner AJ. Use of a plastic Yankauer sucker for the reinsertion of a displaced percutaneous dilational tracheostomy tube. Anaesthesia 2008; 63:102-3. [PMID: 18086088 DOI: 10.1111/j.1365-2044.2007.05389.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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How I do it: securing tracheostomy tubes. Eur Arch Otorhinolaryngol 2007; 265:607-8. [DOI: 10.1007/s00405-007-0508-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2007] [Accepted: 10/11/2007] [Indexed: 10/22/2022]
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Bhuvanagiri A, Thirugnanam M, Rehman K, Grew NR. Repositioning a displaced tracheostomy tube. Br J Anaesth 2007; 98:276. [PMID: 17251222 DOI: 10.1093/bja/ael356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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