Tracheotomy in the intensive care unit: guidelines from a French expert panel

Deployable machine learning-based decision support system for tracheostomy in acute burn patients

Background

Airway obstruction is a common emergency in acute burns with high mortality. Tracheostomy is the most effective method to keep patency of airway and start mechanical ventilation. However, the indication of tracheostomy is challenging and controversial. We aimed to develop and validate a deployable machine learning (ML)-based decision support system to predict the necessity of tracheostomy for acute burn patients.

Methods

We enrolled 1011 burn patients from Southwest Hospital (2018-20) for model development and feature selection. The final model was validated on an independent internal cross-temporal cohort (2021, n = 274) and an external cross-institutional cohort (Second Affiliated Hospital of Zhejiang University School of Medicine 2020-21, n = 376). To improve the model's deployment and interpretability, an ML-based nomogram, an online calculator, and an abbreviated scale were constructed and validated.

Results

The optimal model was the eXtreme Gradient Boosting classifier (XGB), which achieved an AUROC of 0.973 and AUPRC of 0.879 in training dataset, and AUROCs of greater than 0.95 in both cross-temporal and cross-institutional validation. Moreover, it kept stable discriminatory ability in validation subgroups stratified by sex, age, burn area, and inhalation injury (AUROC ranging 0.903-0.990). The analysis of calibration curve, decision curve, and score distribution proved the feasibility and reliability of the ML-based nomogram, abbreviated scale (BETS), and online calculator.

Conclusions

The developed system has strong predictive ability and generalizability in cross-temporal and cross-institutional evaluations. The nomogram, online calculator, and abbreviated scale based on ML show comparable prediction performance and can be deployed in broader application scenarios, especially in resource-limited clinical environments.

Epidemiology, timing, technique, and outcomes of tracheostomy in patients with trauma: a multi-centre retrospective study

BACKGROUND

Tracheostomy is performed in patients with trauma who need prolonged ventilation for respiratory failure or airway management. Although it has benefits, such as reduced sedation and easier care, it also has risks. This study explored the unclear timing, technique, and patient selection criteria for tracheostomy in patients with trauma.

METHODS

We included 220 adult patients with trauma who underwent tracheostomy after endotracheal intubation between January 2019 and December 2022. We compared clinical outcomes between patients who underwent early (within 10 days) and late (after 10 days) tracheostomy and between patients who underwent percutaneous dilatational tracheostomy (PDT) and surgical tracheostomy (ST). Factors associated with hospital and intensive care unit (ICU) length of stay (LOS), ICU-free days, duration of mechanical ventilation, and ventilator-free days (VFDs) were identified using multiple linear regression analysis.

RESULTS

The patients' mean age was 61.5 years; 75.9% were men. Most tracheostomies were performed after 10 days (n = 135, 61.4%), with PDT serving as the more common approach during this period. Contrastingly, early tracheostomies (n = 85, 38.6%) were predominantly performed using ST. Early tracheostomy was significantly associated with reduced hospital (P = 0.038) and ICU LOS (P = 0.047), decreased duration of mechanical ventilation (P = 0.001), and increased VFDs (P < 0.001). However, no significant association was found with ICU-free days (P = 0.072) or in-hospital mortality (P = 0.917).

CONCLUSION

Early tracheostomy was associated with reduced hospital and ICU LOS, decreased duration of mechanical ventilation, and increased VFDs.

Cryoablation for the Treatment of Post-Tracheostomy Tracheal Stenosis in Neurological Patients

INTRODUCTION

Post-tracheostomy tracheal stenosis is a clinically relevant late complication of tracheostomy. To date, there is no standardized treatment strategy for post-tracheostomy tracheal stenosis. Contact cryoablation is one of the applicable methods. The aim of the present study was to explore the efficacy and safety of contact cryoablation for the treatment of post-tracheostomy tracheal stenosis.

METHODS

A total of 63 consecutive patients were included in this unicentre, combined retrospective and prospective observational study in an intensive care unit of a German neurological specialist hospital from 30 April 2020 to 21 March 2024. Post-tracheostomy tracheal stenoses were confirmed by tracheoscopy. All eligible patients were primarily treated with contact cryoablation. Primary endpoint was the rate of successful removal of the tracheostomy tube (decannulation) until hospital discharge. Technical success was defined as the absence of an endoscopically relevant residual post-tracheostomy tracheal stenosis, and clinical success was defined as the absence of symptoms, e.g., dyspnoea and stridor, both at discretion of the endoscopist and treating physician.

RESULTS

A total of 78 interventions were performed (median: 1 per patient). Cryoablation was applied in 67% of patients at least once. A total of 70% of patients could be decannulated after treatment. Technical success and clinical success were achieved in 88% and 70% of patients, and in only 5% of patients surgical treatment was performed. No complications were observed.

CONCLUSION

Contact cryoablation appears to be an effective, complication-free, simple, and non-surgical treatment option for patients with post-tracheostomy tracheal stenosis. It could be an excellent option for every patient with suitable stenosis morphology. However, other endoscopic modalities must be available or complementarily used for non-suitable stenosis morphologies.

Device associated complications in the intensive care unit

Invasive devices are routinely used in the care of critically ill patients. Although they are often essential components of patient care, devices such as intravascular catheters, endotracheal tubes, and ventilators are a common source of complications in the intensive care unit. Critical care practitioners who use these devices need to use strategies for risk reduction and understand approaches to management when adverse events occur. This review discusses the identification, prevention, and management of complications of vascular, airway, and mechanical support devices commonly used in the intensive care unit.

Tracheostomy care of non-ventilated patients and COVID considerations: A scoping review of clinical practice guidelines and consensus statements

BACKGROUND

The purpose of this study is to examine and evaluate the existing clinical practice guidelines and consensus statements regarding tracheostomy care for non-mechanically ventilated patients.

METHODS

A systematic search of databases, and professional organisations was conducted from inception to 19 March 2023. Two appraisers evaluated each guideline using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) and the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Text and Opinion Papers.

RESULTS

No specific clinical guidelines exist on airway management in non-mechanically ventilated patients. Of 6318 articles identified, we included 12 clinical practice guidelines, and 9 consensus statements, which were from China, the US, the UK, South Korea, Australia, France and Belgium. The AGREE II scores in six domains are (1) the scope and purpose, 70.30%; (2) stakeholder involvement, 37.61%; (3) rigor of development, 33.97%; (4) clarity of presentation, 68.16%; (5) applicability, 44.23% and (6) editorial independence, 40.06%. The overall quality of evidence was level B. The summarised recommendations for clinical practice encompass the following six areas: airway humidification, management of the trach cuff, management of inner cannula, tracheostoma care, tracheostomy suctioning and management and prevention of common post-operative complications.

CONCLUSIONS

The overall quality of the clinical guidelines on non-ventilated tracheostomy care was moderate, and further improvements are needed in domains of stakeholder involvement, applicability, clarity of presentation and editorial independence. Recommendations on non-ventilated tracheostomy care are often embedded in the guidelines on ventilated tracheostomy. Specific clinical guidelines are needed to provide a standardised approach to tracheostomy care for non-ventilated patients.

RELEVANCE TO CLINICAL PRACTICE

Patients with non-ventilated tracheostomy need specialised airway management. Improving patient outcomes requires standardised protocols, patient involvement, quality evaluation, and interdisciplinary approaches.

NO PATIENT OR PUBLIC CONTRIBUTION

The study reviewed clinical practice guidelines and consensus statements, therefore patient or public input was not needed.

Factors Associated With Tracheostomy in Ventilated Pediatric Trauma Patients. A National Trauma Database Study

PURPOSE

The purpose of the study was to find the factors that were associated with tracheostomy procedures in ventilated pediatric trauma patients.

METHODS

The Trauma Quality Improvement Program (TQIP) database of the calendar year 2017 through 2019 was accessed for the study. All patients <18 years old and who were on mechanical ventilation for more than 96 hours were included in the study. Multiple logistic regression analysis was performed to find the factors that were associated with a tracheostomy.

RESULTS

Out of 2653 patients, 1907 (71.88%) patients underwent tracheostomy. The patients who underwent tracheostomy had a lower median [IQR] of Glasgow Coma Scale (GCS) (3 [3-8] vs 5 [3-10], P < .001) and had a higher proportion of severe spine injury (On Abbreviated Injury Scale [AIS]≥3) (11.6% vs 8.8%, P = .044) when compared with patients who did not have tracheostomy. Lower GCS scores and severe spine injury were associated with higher odds of tracheostomy, with all P values <.05. Higher proportion of tracheostomy procedures were performed at level I pediatric trauma centers as compared to non-designated pediatric centers (odds ratio [95% CI]: 1.848 [1.524-2.242], P < .001).

CONCLUSION

A lower GCS score, severe spine injury and highest level trauma centers were associated with a tracheostomy.

Association of Designated Pediatric Trauma Center and Outcomes of Severely Injured Children Who Were Mechanically Ventilated and Underwent Tracheostomy: A Propensity-Matched Analysis

OBJECTIVES

The purpose of the study is to examine the outcomes of care delivered at the pediatric trauma center (PTC) in severely injured children who were intubated, mechanically ventilated, and underwent tracheostomy.

METHODS

The study data were obtained from the Trauma Quality Improvement Program database for the calendar years 2017 to 2019. All children aged ≤17 years who sustained severe injury, required intubation and mechanical ventilation for more than 96 hours, and underwent tracheostomy were included in the study. Patients' characteristics, injury severity, and outcomes were compared between the care provided at the PTCs (level I or level II) and nonpediatric trauma centers (NPTCs). The propensity score matching methodology was used to perform the analysis. All P values are 2-sided, and a P value of <0.0.5 is considered statistically significant.

RESULTS

Of 2164 patients who were qualified for the study, 1288 (59%) of the patients were treated at PTCs, and 876 (40.5%) of the patients were treated at NPTCs. Propensity matching created 876 pairs of patients. There were no significant differences found between the 2 groups on patients' characteristics except for age. Patients who were treated at PTCs had a median age of 14 (10-16) versus 15 (11-17) years ( P < 0.001) when compared with care provided at NPTCs. A longer hospital stay was found in the PTC group when compared with the NPTC group (24 [23, 25] vs 22 [21, 24], P = 0.008). Patients who were treated at PTC were found to have significantly less sepsis occurrence (0.9% vs 2.2%), and a higher proportion of patients were discharged home without needing additional support (26.2% vs 18.5%).

CONCLUSIONS

Care at the PTC was associated with a lower occurrence of sepsis complications. A higher number of patients were discharged home without additional services when the care was provided at PTC.

Impact of radiological surveillance for major blood vessels on complications of percutaneous dilatational tracheostomy: A retrospective cohort study

PURPOSE

Percutaneous dilatational tracheostomy (PDT) is the preferred method for managing long-term ventilator-dependent patients in ICUs. This study aimed to evaluate the association between preprocedural screening (ultrasound Doppler [USD] or computed tomography [CT]) for major neck blood vessels and complications in ICU patients undergoing PDT.

MATERIALS AND METHODS

This was a retrospective cohort study of patients who underwent PDT between 2012 and 2023 at a tertiary referral center. We performed a multivariable analysis and created a propensity-matched cohort. The primary outcome was bleeding within the first seven days after PDT. Secondary outcomes included early and late PDT complications and PTD-related mortality.

RESULTS

A total of 1766 consecutive critically ill patients hospitalized at a tertiary academic hospital were evaluated for PDT. Of these, 881 (49.9 %) underwent only physical examination before PDT, while 885 (50.1 %) underwent additional imaging (CT/USD). A higher proportion of patients in the imaging group were referred to open surgery due to suspected major blood vessels interfering with the procedure (6.2 % vs. 3.0 %, p = 0.001). Among the 1685 patients who underwent PDT, there was no significant difference in the rate of early bleeding between the physical examination group and the imaging group (4.6 % vs. 6.3 %, p = 0.12). Similarly, the overall early complication rates (5.5 % vs. 7.6 %, p = 0.08), late complication rates (1.6 % vs. 2.2 %, p = 0.42), and PDT-related mortality rates (0.7 % vs. 0.6 %, p = 0.73) did not exhibit significant differences between the two groups. In a propensity score-matched cohort, results remained consistent.

CONCLUSIONS

Physical examination can effectively identify major neck blood vessels without increasing the risk of bleeding during and after PDT.

Tracheostomy in otorhinolaryngology education and training programs: A Japanese nationwide survey

OBJECTIVE

Surgical airway management is one of the most effective techniques for safe airway management. Within the training programs relating to knowledge and skills required by otorhinolaryngologists, tracheostomy and postoperative management are important items that must be fully understood by airway surgeons. We performed a nationwide survey to identify problems within tracheostomy and postoperative management in Japan in order to establish practical and safe guidelines for surgical airway management.

METHODS

We conducted a questionnaire survey of the current status of tracheostomy and postoperative management at core institution of otorhinolaryngology training programs in Japan.

RESULTS

Responses were obtained from all 101 core training institutions in Japan. Tracheostomy was performed in the operating room at 61.4% of institutions and in the ICU at 26.7%. 89.1% of them performed surgical tracheostomy (ST) in all cases. Even in the remaining 10.9%, percutaneous dilatational tracheostomy (PDT) was performed in less than 10% of cases. The primary surgeon was an otorhinolaryngology resident at 89.1% of institutions. The method of securing the tube immediately after surgery was by securing it with an attached cord at 48.5% of institutions, by suturing to the skin at 25.7%, and using a Velcro band at 24.8%. The first tube change after tracheostomy was performed on the seventh postoperative day at 81.2% of institutions. 87.1% had more than one person performing the first tube change. The tracheostomy postoperative complications within the past year were as follows: tracheostomal granulation: 89.1%; subcutaneous and/or mediastinal emphysema: 62.4%; tube stenosis: 55.4%; accidental tube removal: 50.5%; incorrect tube insertion or misplacement: 15.8%; hemorrhage from tracheal foramen requiring hemostasis in the operating room: 14.9%; pneumothorax: 4.0%; tracheo-innominate arterial fistula: 2.0%; and tracheoesophageal fistula: 1.0%. The method for educating otorhinolaryngology residents about tracheostomy was on-the-job training at 98.0% of institutions.

CONCLUSIONS

For airway management in otorhinolaryngology training programs, after learning the basics of ST, PDT should also be well understood. Furthermore, in order to create safe educational programs for intraoperative and postoperative management, it is necessary to train otorhinolaryngologists with accurate knowledge and skills, and to strengthen collaboration with multiple professions in their leadership roles as airway surgeons.

Tracheostomy in Critically Ill COVID-19 Patients on Extracorporeal Membrane Oxygenation: A Single-Center Experience

OBJECTIVES

Novel coronavirus-19 (COVID-19) has led to over 6 million fatalities globally. An estimated 75% of COVID-19 patients who require critical care admission develop acute respiratory distress syndrome (ARDS) needing invasive mechanical ventilation (IMV) and/or extracorporeal membrane oxygenation (ECMO). Due to prolonged ventilation requirements, these patients often also require tracheostomy. We performed a review of clinical outcomes in COVID-19 patients on ECMO at a high-volume tertiary care center in Hamilton, Ontario, Canada.

METHODOLOGY

We performed a retrospective case series, including 24 adult patients diagnosed with COVID-19 who required IMV, veno-venous (ECMO), and tracheostomy. All patients were included from April to December 2021. We extracted demographic and clinical variables pertaining to the tracheostomy procedure and ECMO therapy. We performed descriptive statistical analyses. This study was approved by the Hamilton Integrated Research Ethics Board (14217-C).

RESULTS

We included 24 consecutive patients with COVID-19 who required tracheostomy while undergoing ECMO therapy. The mean age was 49.4 years [standard deviation (SD): 7.33], the majority of patients were male (75%), with mean body mass index of 32 (SD: 8.81). Overall mortality rate was 33.3%. Percutaneous tracheostomy was performed most frequently (83.3%) and, similar to open tracheostomy, was associated with a low rate of perioperative bleeding complications. Within surviving patients, the mean time to IMV weaning and decannulation was 60.2 (SD: 24.6) and 49.4 days (SD: 21.8), respectively.

CONCLUSION

Percutaneous tracheostomy appears to be safe in COVID-19 patients on ECMO and holding anticoagulation 24 hours prior to and after tracheostomy may limit bleeding events in these patients.

Impact of Early Tracheostomy on Clinical Outcomes in Trauma Patients Admitted to the Intensive Care Unit: A Retrospective Causal Analysis

OBJECTIVES

To assess the indications, timing, and clinical outcomes that result from the early tracheostomy (ET) administration, by causal inference models.

DESIGN

A retrospective observational study.

SETTING

Multiinstitutional intensive care unit in the United States PARTICIPANTS: The study comprised 626 trauma patients.

INTERVENTIONS

An ET versus late tracheostomy (LT).

MEASUREMENTS AND MAIN RESULTS

Trauma patients with tracheostomy were identified from 2 public databases named Medical Information Mart for the Intensive Care-IV and eICU Collaborative Research Database. Tracheostomy was defined as early (≤7 days) or late (>7 days) from intensive care unit admission. A marginal structural Cox model (MSCM) with inverse probability weighting was employed. For comparison, the authors also used time-dependent propensity-score matching (PSM) to account for differences in the probability of receiving an ET or LT. A total of 626 eligible patients were enrolled in the study, of whom 321 (51%) received a ET. The MSCM and time-dependent PSM indicated that the ET group was associated with reduced ventilation-associated pneumonia (VAP) and a shorter mechanical ventilation (MV) duration than the LT group. Yet, mortality did not show any difference between the two groups.

CONCLUSIONS

The authors' study observed that ET was not associated with reduced mortality in trauma patients, but it was associated with reduced VAP risk and MV duration. The results warrant further validation in randomized controlled trials.

Open Versus Percutaneous Tracheostomy in Patients With Liver Cirrhosis: Analysis of a Nationwide Database

BACKGROUND

Evidence for the appropriate type of tracheostomy in patients with liver cirrhosis is lacking. A retrospective analysis of the National Inpatient Sample (NIS) was performed.

METHODS

Adult patients with liver cirrhosis undergoing tracheostomy while on mechanical ventilation for respiratory failure were abstracted from the NIS database between 2016 and 2018 and analyzed. Patients were divided according to the type of tracheostomy performed into open tracheostomy (OT) and percutaneous tracheostomy (PT) and analyzed for tracheostomy complications and clinical outcomes. Subgroup analyses were performed for patients with compensated cirrhosis (CC) and decompensated cirrhosis (DC).

RESULTS

A total of 44745 cases were analyzed. The OT group had a higher rate of overall tracheostomy-related complications (TC) (5.1% vs 3.5%; P < .001), hemorrhage from the tracheostomy site (HC) (2.7% vs 1.8%; P = .008) and other complications (OC) (2.7% vs 1.8%, P = .003). Multivariate analyses showed that OT was a risk factor for TC (Adjusted odds ratio (AOR) 1.50, P < .001), HC (AOR 1.46, P = .009), and OC (AOR 1.55, P = .003). Similarly, in subgroup analyses, OT cases, compared to PT, were associated with increased TC (5.0% vs 3.4%, P < .001), HC (2.7% vs 1.7%, P = .002) and OC (2.6% vs 1.8%, P = .020) in DC patients.

DISCUSSION

OT is associated with a significantly higher rate of complications. OT was also associated with more complications in DC patients, suggesting that a percutaneous approach may be the best option in cirrhotic patients when feasible.

Bronchoscopy Findings during Percutaneous Dilation Tracheostomy: A Single Tertiary Medical Center Experience

Percutaneous dilation tracheostomy (PDT) is a common procedure in intensive care units. Bronchoscopy has been recommended to guide PDT to decrease complication rates, but no study has analyzed bronchoscopy outcomes during PDT. In this retrospective study, we analyzed bronchoscopy findings and clinical outcomes during PDT. We collected data on all patients who underwent PDT between May 2018 and February 2021. All PDT operations were guided by bronchoscopy, and we assessed the airway to the third order of the bronchi. Forty-one patients who underwent PDT were included in this study. The average duration of PDT was 102.8 ± 34.6 s, and the average duration of bronchoscopy was 49.8 ± 43.8 s. No complications related to bronchoscopy and no significant changes in gas exchange or ventilator parameters were noted after the procedure. Fifteen patients (36.6%) exhibited abnormal bronchoscopy findings, including two patients (13.3%) with intra-airway mass lesions and obvious airway obstruction. None of the patients with intra-airway masses could be liberated from mechanical ventilation. This study observed a non-negligibly high incidence of unexpected endotracheal or endobronchial masses in patients with chronic respiratory failure during PDT, and a high rate of weaning failure was noted in these patients. The completion of bronchoscopy during PDT may provide additional clinical benefits.

SPECIAL CONSIDERATIONS IN PEDIATRIC TRACHEOSTOMY - A NARRATIVE REVIEW

Surgical tracheostomy is a life-saving procedure performed for emergent or expectant airway compromise. Morbidity in the pediatric population is higher than in adults due to smaller operating field, immaturity of tissues, anatomic specificities of the child's neck, or the presence of craniofacial dysmorphism. The procedure varies among surgeons regarding the position of the skin incision (vertical or horizontal), resection of the subcutaneous adipose tissue and isthmus of the thyroid gland, use of tracheal flaps, and use of maturation or stay sutures. Both early and late complications can be life-threatening, and include accidental decannulation, stomal plugging, bleeding, and difficult ventilating. Consistent tracheostomal care is crucial in avoiding complications. Primary caregivers must be included and educated about proper stomal care. Decannulation failures are common. Prerequisites for safe decannulation include non-dependence on mechanical ventilation and no recent aspiration events, positive endoscopic airway assessment, and successful daytime capping. The role of polysomnography in decannulation protocols is debated. Although seldom performed, tracheostomy is the procedure of choice in a selected group of pediatric patients. The risks and benefits of the procedure must be weighed for each patient. The education of medical personnel and caregivers is key to reducing serious complications.

Utility of the modified Volume-Viscosity Swallow Test for bedside screening of dysphagia in critically ill patients

BACKGROUND AND AIM

Aspiration and dysphagia are frequent in critically ill patients, and evidence of the validity of bedside screening tests is lacking. This study evaluated the modified Volume-Viscosity Swallow Test (mV-VST) as a screening tool for aspiration and dysphagia in intensive care unit patients.

METHODS

An observational, prospective longitudinal cohort single-center study included patients older than 18 years old, on mechanical ventilation for at least 48 h, conscious and cooperative. Patients had been admitted in intensive care between March 2016 and August 2019 at a university hospital in Spain. Data from the mV-VST and the flexible endoscopic evaluation of swallowing (FEES) test in extubated and tracheostomized patients were collected; the ROC curve was obtained for each group, and the sensitivity (Se), specificity (Sp), positive (pPV) and negative (nPV) predictive values of mV-VST were calculated and compared with the FEES results. We calculated percentages and 95% confidence intervals (CI) for qualitative variables and means or medians for quantitative variables according to the Shapiro-Wilk test. A univariate analysis identified dysphagia risk factors in each group.

RESULTS

The study included 87 patients: 44 extubated and 43 tracheostomized with similar age, body mass index, Sequential Organ Failure Assessment, Charlson comorbidity index, type and reason for admission. Aspiration with FEES was significantly higher in extubated patients than in tracheostomized patients, 43.2% vs. 23.2%, respectively, p = 0.04. With the mV-VST, aspiration was detected in 54.5% of extubated patients and in 39.5% of tracheostomized patients. In the extubated group, the Se of mV-VST to detect aspiration was 89.5%, Sp was 72%, and nPV was 90%. In the tracheostomized group, Se was 100%, Sp was 78.8%, and nPV was 100%. The ROC curve showed that mV-VST similarly identifies aspiration in extubated and tracheostomized patients.

CONCLUSIONS

Dysphagia and aspiration are frequent amongst patients in intensive care after mechanical ventilation. The mV-VST is a valid screening tool to detect aspiration and dysphagia in extubated and tracheostomized patients.

Updates in percutaneous tracheostomy and gastrostomy: should we strive for combined placement during one procedure?

PURPOSE OF REVIEW

Percutaneous tracheostomy and gastrostomy are minimally invasive procedures among the most common performed in intensive care units. Practices across centres vary considerably, and questions remain about the optimal timing, performance and postoperative care related to these procedures.

RECENT FINDINGS

The COVID-19 pandemic has triggered a reevaluation of the practice of percutaneous tracheostomy and gastrostomy in the ICU. Combined percutaneous tracheostomy and gastrostomy at the bedside has potential benefits, including improved nutrition, decreased exposure to anaesthetics, decreased patient transport and decreased hospital costs. Percutaneous ultrasound gastrostomy is a novel technique that eliminates the need for an endoscope that may allow intensivists to perform gastrostomy at the bedside.

SUMMARY

Multidisciplinary care is essential to the follow up of critically ill patients receiving tracheostomy and gastrostomy. Combined tracheostomy and gastrostomy has numerous potential benefits to patients and hospital systems. Interventional pulmonologists are uniquely qualified to perform both procedures and serve on a tracheostomy and gastrostomy team.

Bleeding Hazard of Percutaneous Tracheostomy in COVID-19 Patients Supported With Venovenous Extracorporeal Membrane Oxygenation: A Case Series

OBJECTIVES

Tracheostomy usually is performed to aid weaning from mechanical ventilation and facilitate rehabilitation and secretion clearance. Little is known about the safety of percutaneous tracheostomy in patients with severe COVID-19 supported on venovenous extracorporeal membrane oxygenation (VV-ECMO). This study aimed to investigate the bleeding risk of bedside percutaneous tracheostomy in patients with COVID-19 infection supported with VV-ECMO.

DESIGN

A Retrospective review of electronic data for routine care of patients on ECMO.

SETTING

Tertiary, university-affiliated national ECMO center.

PARTICIPANTS

Patients with COVID-19 who underwent percutaneous tracheostomy while on VV-ECMO support.

INTERVENTIONS

No intervention was conducted during this study.

MEASUREMENTS AND MAIN RESULTS

Electronic medical records of 16 confirmed patients with COVID-19 who underwent percutaneous tracheostomy while on VV-ECMO support, including patient demographics, severity of illness, clinical variables, procedural complications, and outcomes, were compared with 16 non-COVID-19 patients. The SPSS statistical software was used for statistical analysis. The demographic data were compared using the chi-square test, and normality assumption was tested using the Shapiro-Wilk test. The indications for tracheostomy in all the patients were prolonged mechanical ventilation and sedation management. None of the patients suffered a life-threatening procedural complication within 48 hours. Moderate-to-severe bleeding was similar in both groups. There was no difference in 30- and 90-days mortality between both groups. As per routine screening results, none of the staff involved contracted COVID-19 infection.

CONCLUSIONS

In this case series, percutaneous tracheostomy during VV-ECMO in patients with COVID-19 appeared to be safe and did not pose additional risks to patients or healthcare workers.

A U-shaped association of tracheostomy timing with all-cause mortality in mechanically ventilated patients admitted to the intensive care unit: A retrospective cohort study

Objectives

To evaluate the association of tracheostomy timing with all-cause mortality in patients with mechanical ventilation (MV).

Method

It's a retrospective cohort study. Adult patients undergoing invasive MV who received tracheostomy during the same hospitalization based on the Medical Information Mart for Intensive Care-III (MIMIC-III) database, were selected. The primary outcome was the relationship between tracheostomy timing and 90-day all-cause mortality. A restricted cubic spline was used to analyze the potential non-linear correlation between tracheostomy timing and 90-day all-cause mortality. The secondary outcomes included free days of MV, incidence of ventilator-associated pneumonia (VAP), free days of analgesia/sedation in the intensive care unit (ICU), length of stay (LOS) in the ICU, LOS in hospital, in-ICU mortality, and 30-day all-cause mortality.

Results

A total of 1,209 patients were included in this study, of these, 163 (13.5%) patients underwent tracheostomy within 4 days after intubation, while 647 (53.5%) patients underwent tracheostomy more than 11 days after intubation. The tracheotomy timing showed a U-shaped relationship with all-cause mortality, patients who underwent tracheostomy between 5 and 10 days had the lowest 90-day mortality rate compared with patients who underwent tracheostomy within 4 days and after 11 days [84 (21.1%) vs. 40 (24.5%) and 206 (31.8%), P < 0.001].

Conclusion

The tracheotomy timing showed a U-shaped relationship with all-cause mortality, and the risk of mortality was lowest on day 8, but a causal relationship has not been demonstrated.

Tracheostomy outcomes in critically ill patients with COVID-19: a systematic review, meta-analysis, and meta-regression

BACKGROUND

We performed a systematic review of mechanically ventilated patients with COVID-19, which analysed the effect of tracheostomy timing and technique (surgical vs percutaneous) on mortality. Secondary outcomes included intensive care unit (ICU) and hospital length of stay (LOS), decannulation from tracheostomy, duration of mechanical ventilation, and complications.

METHODS

Four databases were screened between January 1, 2020 and January 10, 2022 (PubMed, Embase, Scopus, and Cochrane). Papers were selected according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Population or Problem, Intervention or exposure, Comparison, and Outcome (PICO) guidelines. Meta-analysis and meta-regression for main outcomes were performed.

RESULTS

The search yielded 9024 potentially relevant studies, of which 47 (n=5268 patients) were included. High levels of between-study heterogeneity were observed across study outcomes. The pooled mean tracheostomy timing was 16.5 days (95% confidence interval [CI]: 14.7-18.4; I2=99.6%). Pooled mortality was 22.1% (95% CI: 18.7-25.5; I2=89.0%). Meta-regression did not show significant associations between mortality and tracheostomy timing, mechanical ventilation duration, time to decannulation, and tracheostomy technique. Pooled mean estimates for ICU and hospital LOS were 29.6 (95% CI: 24.0-35.2; I2=98.6%) and 38.8 (95% CI: 32.1-45.6; I2=95.7%) days, both associated with mechanical ventilation duration (coefficient 0.8 [95% CI: 0.2-1.4], P=0.02 and 0.9 [95% CI: 0.4-1.4], P=0.01, respectively) but not tracheostomy timing. Data were insufficient to assess tracheostomy technique on LOS. Duration of mechanical ventilation was 23.4 days (95% CI: 19.2-27.7; I2=99.3%), not associated with tracheostomy timing. Data were insufficient to assess the effect of tracheostomy technique on mechanical ventilation duration. Time to decannulation was 23.8 days (95% CI: 19.7-27.8; I2=98.7%), not influenced by tracheostomy timing or technique. The most common complications were stoma infection, ulcers or necrosis, and bleeding.

CONCLUSIONS

In patients with COVID-19 requiring tracheostomy, the timing and technique of tracheostomy did not clearly impact on patient outcomes.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO CRD42021272220.

Debunk the Myth: Percutaneous Tracheostomy in Cervical Spine Injury

How to cite this article: Govil D, Pachisia AV. Debunk the Myth: Percutaneous Tracheostomy in Cervical Spine Injury. Indian J Crit Care Med 2022;26(10):1067-1068.

Prediction of factors influencing the timing and prognosis of early tracheostomy in patients with multiple rib fractures: A propensity score matching analysis

Objective

To investigate the factors affecting the timing and prognosis of early tracheostomy in multiple rib fracture patients.

Methods

A retrospective case-control study was used to analyze the clinical data of 222 patients with multiple rib fractures who underwent tracheotomy in the Affiliated Hospital of Yangzhou University from February 2015 to October 2021. According to the time from tracheal intubation to tracheostomy after admission, the patients were divided into two groups: the early tracheostomy group (within 7 days after tracheal intubation, ET) and late tracheostomy group (after the 7th day, LT). Propensity score matching (PSM) was used to eliminate the differences in baseline characteristics Logistic regression was used to predict the independent risk factors for early tracheostomy. Kaplan–Meier and Cox survival analyses were used to analyze the influencing factors of the 28-day survival.

Results

According to the propensity score matching analysis, a total of 174 patients were finally included in the study. Among them, there were 87 patients in the ET group and 87 patients in the LT group. After propensity score matching, Number of total rib fractures (NTRF) (P < 0.001), Acute respiratory distress syndrome (ARDS) (P < 0.001) and Volume of pulmonary contusion(VPC) (P < 0.000) in the ET group were higher than those in the LT group. Univariate analysis showed that the patients who underwent ET had a higher survival rate than those who underwent LT (P = 0.021). Pearson's analysis showed that there was a significant correlation between NTRF and VPC (r = 0.369, P = 0.001). A receiver operating characteristic(ROC)curve analysis showed that the areas under the curves were 0.832 and 0.804. The best cutoff-value values of the VPC and NTRF were 23.9 and 8.5, respectively. The Cox survival analysis showed that the timing of tracheostomy (HR = 2.51 95% CI, 1.12–5.57, P = 0.004) and age (HR = 1.53 95% CI, 1.00–2.05, P = 0.042) of the patients had a significant impact on the 28-day survival of patients with multiple rib fractures. In addition, The Kaplan–Meier survival analysis showed that the 28-day survival of patients in the ET group was significantly better than that of the LT group, P = 0.01.

Conclusions

NTRF, ADRS and VPC are independent risk factors for the timing and prognosis of early tracheotomy. A VPC ≥ 23.9% and/or an NTRF ≥ 8.5 could be used as predictors of ET in patients with multiple rib fractures. Predicting the timing of early tracheostomy also need prediction models in the future.

Early prediction of hospital outcomes in patients tracheostomized for complex mechanical ventilation weaning

Background

Tracheostomy is often performed in the intensive care unit (ICU) when mechanical ventilation (MV) weaning is prolonged to facilitate daily care. Tracheostomized patients require important healthcare resources and have poor long-term prognosis after the ICU. However, data lacks regarding prediction of outcomes at hospital discharge. We looked for patients’ characteristics, ventilation parameters, sedation and analgesia use (pre-tracheostomy) that are associated with favorable and poor outcomes (post-tracheostomy) using univariate and multivariate logistic regressions.

Results

Eighty tracheostomized patients were included (28.8% women, 60 [52–71] years). Twenty-three (28.8%) patients were intubated for neurological reasons. Time from intubation to tracheostomy was 14.7 [10–20] days. Thirty patients (37.5%) had poor outcome (19 patients deceased and 11 still tracheostomized at hospital discharge). All patients discharged with tracheostomy (n = 11) were initially intubated for a neurological reason. In univariate logistic regressions, older age and higher body-mass index (BMI) were associated with poor outcome (OR 1.18 [1.07–1.32] and 1.04 [1.01–1.08], p < 0.001 and p = 0.025). No MV parameters were associated with poor outcome. In the multiple logistic regression model higher BMI and older age were also associated with poor outcome (OR 1.21 [1.09–1.36] and 1.04 [1.00–1.09], p < 0.001 and p = 0.046).

Conclusions

Hospital mortality of patients tracheostomized because of complex MV weaning was high. Patients intubated for neurological reasons were frequently discharged from the acute care hospital with tracheostomy in place. Both in univariate and multivariate logistic regressions, only BMI and older age were associated with poor outcome after tracheostomy for patients undergoing prolonged MV weaning.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-022-01047-z.

Prevention of Severe Respiratory Tract Infection and Prognosis in Neurosurgical Patients with Severe Tracheotomy Based on 5E Rehabilitation Nursing Model

Background

Continuous nursing based on 5E rehabilitation mode can improve the physiology and psychology of patients to some extent. The purpose of this study was to explore the effect of continuous nursing of 5E rehabilitation mode on the prevention and prognosis of severe respiratory tract infection in patients with severe tracheotomy in neurosurgery.

Objective

To explore the effect of 5E rehabilitation nursing model on the prevention of severe respiratory tract infection and prognosis in patients with severe tracheotomy in neurosurgery.

Methods

The starting and ending time of this study is from February 2019 to July 2021. In this paper, 60 patients with severe tracheotomy were divided into the control group and research group according to random number table method. The former group received routine nursing, and the latter group received rehabilitation nursing model based on 5E. The patients' satisfaction, oxygenation index, partial pressure of carbon dioxide, partial pressure of oxygen, SAS, SDS score, incidence of severe respiratory tract infection, and quality of life scores were compared.

Results

The nursing satisfaction of the research group was higher than that of the control group (P < 0.05). 24 hours after weaning, the oxygenation index and partial pressure of oxygen in the research group were higher than those in the control group, while the partial pressure of carbon dioxide in the research group was lower than that in the control group (P < 0.05). After nursing, the scores of self-rating anxiety scale and self-rating depression scale in the research group were lower than those in the control group, and the difference was statistically significant (P < 0.05). The incidence of severe respiratory tract infection in the research group was significantly lower than that in the control group (P < 0.05). After nursing, the scores of physiological function, psychological function, social function, and health self-cognition in the research group were lower than those in the control group (P < 0.05).

Conclusion

The nursing program of neurosurgical patients with severe tracheotomy based on 5E rehabilitation model can effectively enhance patients' nursing satisfaction, activities of daily living, anxiety, and depression and promote the prognosis.

Association between tracheostomy timing and outcomes for older critically ill COVID-19 patients: prospective observational study in European intensive care units

BACKGROUND

Tracheostomy is performed in patients expected to require prolonged mechanical ventilation, but to date optimal timing of tracheostomy has not been established. The evidence concerning tracheostomy in COVID-19 patients is particularly scarce. We aimed to describe the relationship between early tracheostomy (≤10 days since intubation) and outcomes for patients with COVID-19.

METHODS

This was a prospective cohort study performed in 152 centres across 16 European countries from February to December 2020. We included patients aged ≥70 yr with confirmed COVID-19 infection admitted to an intensive care unit, requiring invasive mechanical ventilation. Multivariable analyses were performed to evaluate the association between early tracheostomy and clinical outcomes including 3-month mortality, intensive care length of stay, and duration of mechanical ventilation.

RESULTS

The final analysis included 1740 patients with a mean age of 74 yr. Tracheostomy was performed in 461 (26.5%) patients. The tracheostomy rate varied across countries, from 8.3% to 52.9%. Early tracheostomy was performed in 135 (29.3%) patients. There was no difference in 3-month mortality between early and late tracheostomy in either our primary analysis (hazard ratio [HR]=0.96; 95% confidence interval [CI], 0.70-1.33) or a secondary landmark analysis (HR=0.78; 95% CI, 0.57-1.06).

CONCLUSIONS

There is a wide variation across Europe in the timing of tracheostomy for critically ill patients with COVID-19. However, we found no evidence that early tracheostomy is associated with any effect on survival amongst older critically ill patients with COVID-19.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT04321265.

Tracheostomy in COVID-19 acute respiratory distress syndrome patients and follow-up: A parisian bicentric retrospective cohort

BACKGROUND

Tracheostomy has been proposed as an option to help organize the healthcare system to face the unprecedented number of patients hospitalized for a COVID-19-related acute respiratory distress syndrome (ARDS) in intensive care units (ICU). It is, however, considered a particularly high-risk procedure for contamination. This paper aims to provide our experience in performing tracheostomies on COVID-19 critically ill patients during the pandemic and its long-term local complications.

METHODS

We performed a retrospective analysis of prospectively collected data of patients tracheostomized for a COVID-19-related ARDS in two university hospitals in the Paris region between January 27th (date of first COVID-19 admission) and May 18th, 2020 (date of last tracheostomy performed). We focused on tracheostomy technique (percutaneous versus surgical), timing (early versus late) and late complications.

RESULTS

Forty-eight tracheostomies were performed with an equal division between surgical and percutaneous techniques. There was no difference in patients' characteristics between surgical and percutaneous groups. Tracheostomy was performed after a median of 17 [12-22] days of mechanical ventilation (MV), with 10 patients in the "early" group (≤ day 10) and 38 patients in the "late" group (> day 10). Survivors required MV for a median of 32 [22-41] days and were ultimately decannulated with a median of 21 [15-34] days spent on cannula. Patients in the early group had shorter ICU and hospital stays (respectively 15 [12-19] versus 35 [25-47] days; p = 0.002, and 21 [16-28] versus 54 [35-72] days; p = 0.002) and spent less time on MV (respectively 17 [14-20] and 35 [27-43] days; p<0.001). Interestingly, patients in the percutaneous group had shorter hospital and rehabilitation center stays (respectively 44 [34-81] versus 92 [61-118] days; p = 0.012, and 24 [11-38] versus 45 [22-71] days; p = 0.045). Of the 30 (67%) patients examined by a head and neck surgeon, 17 (57%) had complications with unilateral laryngeal palsy (n = 5) being the most prevalent.

CONCLUSIONS

Tracheostomy seems to be a safe procedure that could help ICU organization by delegating work to a separate team and favoring patient turnover by allowing faster transfer to step-down units. Following guidelines alone was found sufficient to prevent the risk of aerosolization and contamination of healthcare professionals.

Fiber-optic Bronchoscope-guided vs Mini-surgical Technique of Percutaneous Dilatational Tracheostomy in Intensive Care Units

Background

Percutaneous dilatational tracheostomy (PCDT) using fiber-optic bronchoscope (FOB) is a widely practiced technique, but its availability and cost remain a concern in nations with limited resources. Mini-surgical technique of PCDT incorporating minimal blunt dissection has shown improved results even without the use of FOB. The study is primarily intended to compare these two techniques and establish a safer cost-effective alternative to FOB-guided PCDTs.

Patients and methods

This randomized comparative study [registered (CTRI/2018/04/013191)] was conducted on 120 mechanically ventilated patients. In 60 patients, mini-surgical PCDT (group-M) was performed with 2 cm longitudinal skin incision and blunt dissection till pretracheal fascia without FOB guidance using Portex-Ultraperc^™ sets. In remaining 60 patients, PCDT was performed under FOB vision with similar skin incision (without blunt dissection) using Portex-Ultraperc^™ sets (group-F). Two techniques were compared with regard to procedural time and percentage of complications occurred during or after the procedure.

Results

Procedure time [group-M: 6.30 ± 1.28 minutes; group-F: 14.43 ± 1.84 minutes (p <0.001)] and mean blood loss [group-M: 5.33 ± 1.69 mL; group-F: 6.87 ± 3.11 mL (p = 0.001)] was significantly less in group-M. Higher incidence of desaturation [group-M: 16.7%; group-F: 35% (p = 0.022)] was noted in group-F, whereas arrhythmias [group-M: 21.7%; group-F: 6.7% (p = 0.018)] were higher in group-M. There was no statistical difference in incidence of pneumothorax and subcutaneous emphysema. There was no incidence of posterior tracheal wall perforation in any of the patients.

Conclusion

Mini-surgical technique is a faster alternative of FOB-guided PCDT with comparable incidence of complications. It can safely be used in intensive care units (ICUs) where FOB is not available.

Clinical trial registration number

CTRI/2018/05/014307.

Name of registry

Clinical Trials Registry of India (CTRI), URL-http://ctri.nic.in.

How to cite this article

Kumar A, Kohli A, Kachru N, Bhadoria P, Wadhawan S, Kumar D. Fiber-optic Bronchoscope-guided vs Mini-surgical Technique of Percutaneous Dilatational Tracheostomy in Intensive Care Units. Indian J Crit Care Med 2021;25(11):1269-1274.

Continuous humidification enhances postoperative recovery in laryngeal cancer patients undergoing tracheotomy

OBJECTIVE

To investigate the effects of perioperative continuous humidification on patients with laryngeal cancer undergoing tracheotomy.

METHODS

Eighty patients with laryngeal cancer underwent tracheotomy in our hospital were selected as the subjects and divided into the observation group and the control group according to random table method. Patients in the control group were given routine tracheotomy care, including regular open endotracheal suction, tracheotomy nursing, oral care, dietary intervention, etc., while those in the observation group were given continuous airway humidification on the basis of the control group. The differences in sputum pH, viscosity, comfort, cough frequency, and respiratory ventilation were compared between the two groups at three postoperative time points. The incidence of complications such as pulmonary infection, bloody sputum and sputum crust, and the improvement of clinical symptoms were compared between the two groups.

RESULTS

The sputum pH of patients in the observation group was higher than that in the control group at the 4th and 7th postoperative days (P<0.001). The observation group showed significantly lower percentage of grade 3 viscous sputum and higher comfort scores than the control group at the 7th postoperative day (P=0.020, P<0.001). The observation group showed lower cough frequency and higher airway patency than the control group at the 4th and 7th postoperative days (P<0.001, P<0.001, P<0.001, P=0.007).

CONCLUSION

Perioperative continuous airway humidification in patients with laryngeal cancer undergoing tracheotomy could reduce sputum consistency and cough frequency, improve comfort and respiratory patency of patients, and has positive significance in accelerating their postoperative rehabilitation.

Weaning from mechanical ventilation in neurocritical care

In the intensive care unit (ICU), weaning from mechanical ventilation follows a step-by-step process that has been well established in the general ICU population. However, little data is available in brain injury patients, who are often intubated to protect airways and prevent central hypoventilation. In this narrative review, we describe the general principles of weaning and how these principles can be adapted to brain injury patients. We focus on three major issues regarding weaning from mechanic ventilation in brain injury patients: (1) sedation protocol, (2) weaning and extubation protocol and criteria, (3) criteria, timing and technique for tracheostomy.

Tracheostomy for COVID-19: evolving best practice

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2021. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2021 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .

Outcomes and Timing of Bedside Percutaneous Tracheostomy of COVID-19 Patients over a Year in the Intensive Care Unit

Background: The benefits and timing of percutaneous dilatational tracheostomy (PDT) in Intensive Care Unit (ICU) COVID-19 patients are still controversial. PDT is considered a high-risk procedure for the transmission of SARS-CoV-2 to healthcare workers (HCWs). The present study analyzed the optimal timing of PDT, the clinical outcomes of patients undergoing PDT, and the safety of HCWs performing PDT. Methods: Of the 133 COVID-19 patients who underwent PDT in our ICU from 1 April 2020 to 31 March 2021, 13 patients were excluded, and 120 patients were enrolled. A trained medical team was dedicated to the PDT procedure. Demographic, clinical history, and outcome data were collected. Patients who underwent PDT were stratified into two groups: an early group (PDT ≤ 12 days after orotracheal intubation (OTI) and a late group (>12 days after OTI). An HCW surveillance program was also performed. Results: The early group included 61 patients and the late group included 59 patients. The early group patients had a shorter ICU length of stay and fewer days of mechanical ventilation than the late group (p < 0.001). On day 7 after tracheostomy, early group patients required fewer intravenous anesthetic drugs and experienced an improvement of the ventilation parameters PaO₂/FiO₂ ratio, PEEP, and FiO₂ (p < 0.001). No difference in the case fatality ratio between the two groups was observed. No SARS-CoV-2 infections were reported in the HCWs performing the PDTs. Conclusions: PDT was safe and effective for COVID-19 patients since it improved respiratory support parameters, reduced ICU length of stay and duration of mechanical ventilation, and optimized the weaning process. The procedure was safe for all HCWs involved in the dedicated medical team. The development of standardized early PDT protocols should be implemented, and PDT could be considered a first-line approach in ICU COVID-19 patients requiring prolonged mechanical ventilation.

Percutaneous dilatational tracheotomy in high-risk ICU patients

Background

Percutaneous dilatational tracheotomy (PDT) has become an established procedure in intensive care units (ICU). However, the safety of this method has been under debate given the growing number of critically ill patients with high bleeding risk receiving anticoagulation, dual antiplatelet therapy (DAPT) or even a combination of both, i.e. triple therapy. Therefore, the purpose of this study, including such a high proportion of patients on antithrombotic therapy, was to investigate whether PDT in high-risk ICU patients is associated with elevated procedural complications and to analyse the risk factors for bleeding occurring during and after PDT.

Methods

PDT interventions conducted in ICUs at 12 European sites between January 2016 and October 2019 were retrospectively analysed for procedural complications. For subgroup analyses, patient stratification into clinically relevant risk groups based on anticoagulation and antiplatelet treatment regimens was performed and the predictors of bleeding occurrence were analysed.

Results

In total, 671 patients receiving PDT were included and stratified into four clinically relevant antithrombotic treatment groups: (1) intravenous unfractionated heparin (iUFH, prophylactic dosage) (n = 101); (2) iUFH (therapeutic dosage) (n = 131); (3) antiplatelet therapy (aspirin and/or P2Y₁₂ receptor inhibitor) with iUFH (prophylactic or therapeutic dosage) except for triple therapy (n = 290) and (4) triple therapy (DAPT with iUFH in therapeutic dosage) (n = 149). Within the whole cohort, 74 (11%) bleedings were reported to be procedure-related. Bleeding occurrence during and after PDT was independently associated with low platelet count (OR 0.73, 95% CI [0.56, 0.92], p = 0.009), chronic kidney disease (OR 1.75, 95% CI [1.01, 3.03], p = 0.047) and previous stroke (OR 2.13, 95% CI [1.1, 3.97], p = 0.02).

Conclusion

In this international, multicenter study bronchoscopy-guided PDT was a safe and low-complication airway management option, even in a cohort of high risk for bleeding on cardiovascular ICUs. Low platelet count, chronic kidney disease and previous stroke were identified as independent risk factors of bleeding during and after PDT but not triple therapy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-021-00906-5.

Diagnosis and treatment of neurogenic dysphagia - S1 guideline of the German Society of Neurology

Introduction

Neurogenic dysphagia defines swallowing disorders caused by diseases of the central and peripheral nervous system, neuromuscular transmission, or muscles. Neurogenic dysphagia is one of the most common and at the same time most dangerous symptoms of many neurological diseases. Its most important sequelae include aspiration pneumonia, malnutrition and dehydration, and affected patients more often require long-term care and are exposed to an increased mortality. Based on a systematic pubmed research of related original papers, review articles, international guidelines and surveys about the diagnostics and treatment of neurogenic dysphagia, a consensus process was initiated, which included dysphagia experts from 27 medical societies.

Recommendations

This guideline consists of 53 recommendations covering in its first part the whole diagnostic spectrum from the dysphagia specific medical history, initial dysphagia screening and clinical assessment, to more refined instrumental procedures, such as flexible endoscopic evaluation of swallowing, the videofluoroscopic swallowing study and high-resolution manometry. In addition, specific clinical scenarios are captured, among others the management of patients with nasogastric and tracheotomy tubes. The second part of this guideline is dedicated to the treatment of neurogenic dysphagia. Apart from dietary interventions and behavioral swallowing treatment, interventions to improve oral hygiene, pharmacological treatment options, different modalities of neurostimulation as well as minimally invasive and surgical therapies are dealt with.

Conclusions

The diagnosis and treatment of neurogenic dysphagia is challenging and requires a joined effort of different medical professions. While the evidence supporting the implementation of dysphagia screening is rather convincing, further trials are needed to improve the quality of evidence for more refined methods of dysphagia diagnostics and, in particular, the different treatment options of neurogenic dysphagia. The present article is an abridged and translated version of the guideline recently published online (https://www.awmf.org/uploads/tx_szleitlinien/030-111l_Neurogene-Dysphagie_2020-05.pdf).

Actualización de la Declaración de consenso en medicina critica para la atención multidisciplinaria del paciente con sospecha o confirmación diagnóstica de COVID-19

Antecedentes y objetivos

La enfermedad por coronavirus de 2019 (COVID-19) es una enfermedad ocasionada por el nuevo coronavirus del síndrome respiratorio agudo grave (SARS-CoV-2). Se identificó por primera vez en diciembre de 2019 en la ciudad de Wuhan, en los meses siguientes se expandió rápidamente a todos los continentes y la Organización Mundial de la Salud (OMS) la reconoció como una pandemia global el 11 de marzo de 2020. La mayoría de los individuos son asintomáticos pero una baja proporción ingresan a cuidados intensivos con una alta morbimortalidad. Este consenso tiene como objetivo actualizar la declaratoria inicial emitida por la Asociación Colombiana de Medicina Crítica (AMCI) para el manejo del paciente críticamente enfermo con COVID-19, dentro de las áreas críticas de las instituciones de salud.

Métodos

Este estudio utilizó dos técnicas de consenso formal para construir las recomendaciones finales: Delphi modificada y grupos nominales. Se construyeron preguntas por la estrategia PICO. 10 grupos nominales desarrollaron recomendaciones para cada unidad temática. El producto del consenso fue evaluado y calificado en una ronda Delphi y se discutió de forma virtual por los relatores de cada núcleo y los representantes de sociedades médicas científicas afines al manejo del paciente con COVID-19.

Resultados

80 expertos nacionales participaron en la actualización del consenso AMCI, especialistas en Medicina Critica y Cuidados Intensivos, Nefrología, Neurología, Neumología, bioeticistas, Medicina interna, Anestesia, Cirugía General, Cirugía de cabeza y cuello, Cuidados Paliativos, Enfermeras Especialistas en Medicina crítica, Terapeutas respiratorias especialistas en medicina crítica y Fisioterapia, con experiencia clínica en la atención del paciente críticamente enfermo. La declaratoria emite recomendaciones en los ámbitos más relevantes para la atención en salud de los casos de COVID-19, al interior de las unidades de cuidados intensivos, en el contexto nacional de Colombia.

Conclusiones

Un grupo significativo multidisciplinario de profesionales expertos en medicina crítica emiten, mediante técnicas de consenso formal, recomendaciones sobre la mejor práctica para la atención del paciente críticamente enfermo con COVID-19. Las recomendaciones deben ser adaptadas a las condiciones específicas, administrativas y estructurales de las distintas unidades de cuidados intensivos del país.

How to ventilate obstructive and asthmatic patients

Exacerbations are part of the natural history of chronic obstructive pulmonary disease and asthma. Severe exacerbations can cause acute respiratory failure, which may ultimately require mechanical ventilation. This review summarizes practical ventilator strategies for the management of patients with obstructive airway disease. Such strategies include non-invasive mechanical ventilation to prevent intubation, invasive mechanical ventilation, from the time of intubation to weaning, and strategies intended to prevent post-extubation acute respiratory failure. The role of tracheostomy, the long-term prognosis, and potential future adjunctive strategies are also discussed. Finally, the physiological background that underlies these strategies is detailed.

Consensus Document of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC), the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) and the Spanish Society of Anesthesiology and Resuscitation (SEDAR) on Tracheotomy in Patients With COVID-19 Infection

The current COVID-19 pandemic has rendered up to 15% of patients under mechanical ventilation. Because the subsequent tracheotomy is a frequent procedure, the three societies mostly involved (SEMICYUC, SEDAR and SEORL-CCC) have setup a consensus paper that offers an overview about indications and contraindications of tracheotomy, be it by puncture or open, clarifying its respective advantages and enumerating the ideal conditions under which they should be performed, as well as the necessary steps. Regular and emergency situations are displayed together with the postoperative measures.

[Consensus document of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC), the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) and the Spanish Society of Anesthesiology and Resuscitation (SEDAR) on tracheotomy in patients with COVID-19 infection]

The current COVID-19 pandemic has rendered up to 15% of patients under mechanical ventilation. Because the subsequent tracheotomy is a frequent procedure, the three societies mostly involved (SEMICYUC, SEDAR and SEORL-CCC) have setup a consensus paper that offers an overview about indications and contraindications of tracheotomy, be it by puncture or open, clarifying its respective advantages and enumerating the ideal conditions under which they should be performed, as well as the necessary steps. Regular and emergency situations are displayed together with the postoperative measures.

Consensus Document of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC), the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) and the Spanish Society of Anesthesiology and Resuscitation (SEDAR) on Tracheotomy in Patients with COVID-19 Infection

The current COVID-19 pandemic has rendered up to 15% of patients under mechanical ventilation. Because the subsequent tracheotomy is a frequent procedure, the three societies mostly involved (SEMICYUC, SEDAR and SEORL-CCC) have setup a consensus paper that offers an overview about indications and contraindications of tracheotomy, be it by puncture or open, clarifying its respective advantages and enumerating the ideal conditions under which they should be performed, as well as the necessary steps. Regular and emergency situations are displayed together with the postoperative measures.

Consensus document of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC), the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) and the Spanish Society of Anesthesiology and Resuscitation (SEDAR) on tracheotomy in patients with COVID-19 infection

The current COVID-19 pandemic has rendered up to 15% of patients under mechanical ventilation. Because the subsequent tracheotomy is a frequent procedure, the three societies mostly involved (SEMICYUC, SEDAR and SEORL-CCC) have setup a consensus paper that offers an overview about indications and contraindications of tracheotomy, be it by puncture or open, clarifying its respective advantages and enumerating the ideal conditions under which they should be performed, as well as the necessary steps. Regular and emergency situations are displayed together with the postoperative measures.

Consensus Document of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC), the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) and the Spanish Society of Anesthesiology and Critical Care (SEDAR) on Tracheotomy in Patients with COVID-19 Infection

The current COVID-19 pandemic has rendered up to 15% of patients under mechanical ventilation. Because the subsequent tracheotomy is a frequent procedure, the three societies mostly involved (SEMICYUC, SEDAR and SEORL-CCC) have setup a consensus paper that offers an overview about indications and contraindications of tracheotomy, be it by puncture or open, clarifying its respective advantages and enumerating the ideal conditions under which they should be performed, as well as the necessary steps. Regular and emergency situations are displayed together with the postoperative measures.

[Consensus document of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC), the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) and the Spanish Society of Anesthesiology and Resuscitation (SEDAR) on tracheotomy in patients with COVID-19 infection]

The current COVID-19 pandemic has rendered up to 15% of patients under mechanical ventilation. Because the subsequent tracheotomy is a frequent procedure, the three societies mostly involved (SEMICYUC, SEDAR and SEORL-CCC) have setup a consensus paper that offers an overview about indications and contraindications of tracheotomy, be it by puncture or open, clarifying its respective advantages and enumerating the ideal conditions under which they should be performed, as well as the necessary steps. Regular and emergency situations are displayed together with the postoperative measures.

Timing, Complications, and Safety of Tracheotomy in Critically Ill Patients With COVID-19

IMPORTANCE

The current coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented needs for invasive ventilation, with 10% to 15% of intubated patients subsequently requiring tracheotomy.

OBJECTIVE

To assess the complications, safety, and timing of tracheotomy performed for critically ill patients with COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study assessed consecutive patients admitted to the intensive care unit (ICU) who had COVID-19 that required tracheotomy. Patients were recruited from March 16 to April 10, 2020, at a tertiary referral center.

EXPOSURES

A surgical tracheotomy was performed for all patients following recommended criteria for use of personal protective equipment (PPE).

MAIN OUTCOMES AND MEASURES

The number of subthyroid operations, the tracheal entrance protocol, and use of PPE. Infections among the surgeons were monitored weekly by reverse-transcriptase polymerase chain reaction of nasopharyngeal swab samples. Short-term complications, weaning, and the association of timing of tracheotomy (early [≤10 days] vs late [>10 days]) with total required days of invasive ventilation were assessed.

RESULTS

A total of 50 patients (mean [SD] age, 63.8 [9.2] years; 33 [66%] male) participated in the study. All tracheotomies were performed at the bedside. The median time from intubation to tracheotomy was 9 days (interquartile range, 2-24 days). A subthyroid approach was completed for 46 patients (92%), and the tracheal protocol was adequately achieved for 40 patients (80%). Adequate PPE was used, with no infection among surgeons identified 4 weeks after the last tracheotomy. Postoperative complications were rare, with minor bleeding (in 6 patients [12%]) being the most common complication. The successful weaning rate was higher in the early tracheotomy group than in the late tracheotomy group (adjusted hazard ratio, 2.55; 95% CI, 0.96-6.75), but the difference was not statistically significant. There was less time of invasive mechanical ventilatory support with early tracheotomy compared with late tracheotomy (mean [SD], 18 [5.4] vs 22.3 [5.7] days). The reduction of invasive ventilatory support was achieved at the expense of the pretracheotomy period.

CONCLUSIONS AND RELEVANCE

In this cohort study, with the use of a standardized protocol aimed at minimizing COVID-19 risks, bedside open tracheotomy was a safe procedure for patients and surgeons, with minimal complications. Timing of tracheotomy may be important in reducing time of invasive mechanical ventilation, with potential implications to intensive care unit availability during the COVID-19 pandemic.

High-Flow Oxygen with Capping or Suctioning for Tracheostomy Decannulation

BACKGROUND

When patients with a tracheostomy tube reach a stage in their care at which decannulation appears to be possible, it is common practice to cap the tracheostomy tube for 24 hours to see whether they can breathe on their own. Whether this approach to establishing patient readiness for decannulation leads to better outcomes than one based on the frequency of airway suctioning is unclear.

METHODS

In five intensive care units (ICUs), we enrolled conscious, critically ill adults who had a tracheostomy tube; patients were eligible after weaning from mechanical ventilation. In this unblinded trial, patients were randomly assigned either to undergo a 24-hour capping trial plus intermittent high-flow oxygen therapy (control group) or to receive continuous high-flow oxygen therapy with frequency of suctioning being the indicator of readiness for decannulation (intervention group). The primary outcome was the time to decannulation, compared by means of the log-rank test. Secondary outcomes included decannulation failure, weaning failure, respiratory infections, sepsis, multiorgan failure, durations of stay in the ICU and hospital, and deaths in the ICU and hospital.

RESULTS

The trial included 330 patients; the mean (±SD) age of the patients was 58.3±15.1 years, and 68.2% of the patients were men. A total of 161 patients were assigned to the control group and 169 to the intervention group. The time to decannulation was shorter in the intervention group than in the control group (median, 6 days [interquartile range, 5 to 7] vs. 13 days [interquartile range, 11 to 14]; absolute difference, 7 days [95% confidence interval, 5 to 9]). The incidence of pneumonia and tracheobronchitis was lower, and the duration of stay in the hospital shorter, in the intervention group than in the control group. Other secondary outcomes were similar in the two groups.

CONCLUSIONS

Basing the decision to decannulate on suctioning frequency plus continuous high-flow oxygen therapy rather than on 24-hour capping trials plus intermittent high-flow oxygen therapy reduced the time to decannulation, with no evidence of a between-group difference in the incidence of decannulation failure. (REDECAP ClinicalTrials.gov number, NCT02512744.).