Speech and Swallowing Function Outcome Following Early Tracheostomy in Patients Who Underwent Neurosurgical Intervention

Management of tracheostomies in the intensive care unit: a scoping review

OBJECTIVES

While there is an extensive body of literature surrounding the decision to insert, and methods for inserting, a tracheostomy, the optimal management of tracheostomies within the intensive care unit (ICU) from after insertion until ICU discharge is not well understood. The objective was to identify and map the key concepts relating to, and identify research priorities for, postinsertion management of adult patients with tracheostomies in the ICU.

DESIGN

Scoping review of the literature.

DATA SOURCES

PubMed, Embase and Cumulative Index to Nursing and Allied Health Literature were searched from inception to 3 October 2019. Additional sources were searched for published and unpublished literature.

ELIGIBILITY CRITERIA

We included studies of any methodology that addressed the a priori key questions relating to tracheostomy management in the ICU. No restrictions were placed on language or year of publication.

DATA EXTRACTION AND SYNTHESIS

Titles and abstracts were screened by two reviewers. Studies that met inclusion criteria were reviewed in full by two reviewers, with discrepancies resolved by a third. Data were extracted for included studies, and results mapped along the prespecified research questions.

RESULTS

6132 articles were screened, and 102 articles were included for detailed analysis. Protocolised weaning was found to be successful in liberating patients from the ventilator in several cohort studies. Observational studies showed that strategies that use T-pieces and high-flow oxygen delivery improve weaning success. Several lines of evidence, including one clinical trial, support early cuff deflation as a safe and effective strategy as it results in a reduced time to wean, shorter ICU stays and fewer complications. Early tracheostomy downsizing and/or switching to cuffless tubes was found to be of benefit in one study. A substantial body of evidence supports the use of speaking valves to facilitate communication. While this does not influence time to wean or incidence of complications, it is associated with a major benefit in patient satisfaction and experience. Use of care bundles and multidisciplinary team approaches have been associated with reduced complications and improved outcomes in several observational studies.

CONCLUSIONS

The limited body of evidence supports use of weaning protocols, early cuff deflation, use of speaking valves and multidisciplinary approaches. Clinical trials examining post-tracheostomy management strategies in ICUs are a priority.

Outcomes after percutaneous dilatation tracheostomy: Patients view 6 years after the procedure

BACKGROUND

Percutaneous dilatational tracheostomy have been performed increasingly since its introduction in 1985, and is today one of the most commonly performed operative procedures in intensive care units. The aim of this study was to document patient-reported outcomes from percutaneous dilatational tracheostomy after hospital discharge.

METHODS

This study is based on retrospective extraction of data from the databases in the ICU at Haukeland University Hospital from 2004 to 2016. Patients alive by April 2018 and with a code for dilatation tracheostomy were sent a questionnaire about their experiences with having a tracheostomy performed. The occurrence of problems and their relations were registered.

RESULTS

Of 5769 admitted patients, 900 patients ≥ 15 years (15.7%) had a percutaneous dilatation tracheostomy performed. The median time from admission to follow-up was 6.1 years, and the 30 days mortality in those who received a tracheostomy was 315/900 (35%). Of the 441 survivors contacted, 181 answered the questionnaire and a total of 293 problems were reported. The majority of these problems were reported as no or moderate in 115 patients (78.3%). The presence of any problem was significantly associated with occurrence for other problems; however, there were no significant differences related to the elapsed time since the ICU stay. Pain and difficulties with breathing were the two single factors most often related to occurrence of other problems.

CONCLUSION

Although self-reported problems after percutaneous tracheostomy occurring after hospital discharge were often reported, most (78.3%) were considered by the patients to be moderate.

Current Status of Indications, Timing, Management, Complications, and Outcomes of Tracheostomy in Traumatic Brain Injury Patients

Tracheostomy is the commonest bedside surgical procedure performed on patients needing mechanical ventilation with traumatic brain injury (TBI). The researchers made an effort to organize a narrative review of the indications, timing, management, complications, and outcomes of tracheostomy in relation to neuronal and brain-injured patients following TBI. The study observations were collated from the published literature, namely original articles, book chapters, case series, randomized studies, systematic reviews, and review articles. Information sorting was restricted to tracheostomy and its association with TBI. Care was taken to review the correlation of tracheostomy with clinical correlates including indications, scheduling, interventions, prognosis, and complications of the patients suffering from mild, moderate and severe TBIs using Glasgow Coma Scale, Glasgow Outcome Scale, intraclass correlation coefficient, and other internationally acclaimed outcome scales. Tracheostomy is needed to overcome airway obstruction, prolonged respiratory failure and as indispensable component of mechanical ventilation due to diverse reasons in intensive care unit. Researchers are divided over early tracheostomy or late tracheostomy from days to weeks. The conventional classic surgical technique of tracheostomy has been superseded by percutaneous techniques by being less invasive with lesser complications, classified into early and late complications that may be life threatening. Additional studies have to be conducted to validate and streamline varied observations to frame evidence-based practice for successful weaning and decannulation. Tracheostomy is a safer option in critically ill TBI patients for which a universally accepted protocol for tracheostomy is needed that can help to optimize indications and outcomes.

The Outcome Analysis and Complication Rates of Tracheostomy Tube Insertion in Critically Ill Neurosurgical Patients; A Data Mining Study

Objectives:

To assess the impact, timing, the intra and early post-operative complications and the survival outcome of tracheostomy in critically ill neurosurgery patients.

Methods:

This study was a retrospective data mining where data was collected from hospital records from 175 consecutive patients who underwent tracheostomy in the department of Neurosurgery at the Narayna Medical College Hospital, Nellore, India from Jan 2016 to April 2018. A proforma was used to note down the details on the patient status before and after tracheostomy: Glasgow coma scale (GCS), procedure and intra and post-operative complications, type of tracheostomy cannula, details of decannulation, respiration difficulties, and problems with wound, swallowing difficulties, and voice difficulties, stay in intensive care unit (ICU) and hospital and survival status of the patient.

Results:

In our series, mean age of TBI cases was 47.42±16.62; mean hospital stay and ICU stay was 18.81±10.22 and 12.58±7.36 days respectively. In all age groups, more tracheostomy was needed in cranial injury cases and surgery was major intervention. Commoner complications were mucous deposition (6.86%), blockage of tracheostomy canula (6.29%), bleeding from multiple attempts (6.06%), excessive bleeding (2.94%). Cranial injury needed tracheostomy more in all age groups and more done at operation theatre without significant improvement of GCS score. Survival was statistically higher after tracheostomy irrespective of GCS status or venue of intervention.

Conclusion:

Tracheostomy should be considered as soon as the need for airway access is identified during intervention of the critically ill neurosurgical patients.