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Chinta S, Haleem A, Sibala DR, Kumar KD, Pendyala N, Aftab OM, Choudhry HS, Hegazin M, Eloy JA. Association Between Modified Frailty Index and Postoperative Outcomes of Tracheostomies. Otolaryngol Head Neck Surg 2024; 170:1307-1313. [PMID: 38329229 DOI: 10.1002/ohn.667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 12/11/2023] [Accepted: 12/17/2023] [Indexed: 02/09/2024]
Abstract
OBJECTIVE The 5-item modified frailty index (mFI-5) has been used to stratify patients based on the risk of postoperative complications in several surgical procedures but has not yet been done in tracheostomies. This study investigates the association between the mFI-5 score and tracheostomy complications. STUDY DESIGN Retrospective database review. SETTING United States hospitals. METHODS The National Surgical Quality Improvement Program database was queried for tracheostomy patients between 2005 and 2018. The mFI-5 was calculated for each patient by assigning 1 point for each of the following comorbidities: diabetes mellitus, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and functionally dependent health status. Univariate and multivariable analyses were conducted to determine associations between the mFI-5 score and postoperative complications. RESULTS A total of 4438 patients undergoing tracheostomies were queried and stratified into the following groups: mFI = 0 (N = 1741 [39.2%], mFI = 1 (N = 1720 [38.8%]), mFI = 2 (N = 726 [16.4%]), and mFI of 3 or higher (N = 251 [5.7%]). Univariate analysis showed that patients with higher mFI-5 scores had a greater proportion of smoking, dyspnea, obesity, steroid use, emergency cases, complications, reoperations, and mortality (P < .001). Multivariable analyses found associations between mFI-5 score and any complication (odds ratio [OR]: 1.49, 95% confidence interval [CI]: 1.03-2.16, P = .035), mortality (OR: 2.32, 95% CI: 1.15-4.68, P = .019), and any medical complication (OR: 2.75, 95% CI: 1.88-4.02, P < .001). CONCLUSION This study suggests an association between the mFI-5 score and postoperative complications in tracheostomies. mFI-5 score can be used to stratify tracheostomy patients by operative risk.
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Affiliation(s)
- Sree Chinta
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Afash Haleem
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Dhiraj R Sibala
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Keshav D Kumar
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Navya Pendyala
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Owais M Aftab
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Hannaan S Choudhry
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Michael Hegazin
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
| | - Jean Anderson Eloy
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NewJersey, USA
- Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Department of Otolaryngology and Facial Plastic, Surgery, Saint Barnabas Medical Center-RWJBarnabas Health, Livingston, New Jersey, USA
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Twose P, Cottam J, Jones G, Lowes J, Nunn J. A 5-Year Review of a Tracheostomy Quality Improvement Initiative: Reducing Adverse Event Frequency and Severity. Otolaryngol Head Neck Surg 2024. [PMID: 38529665 DOI: 10.1002/ohn.736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 02/14/2024] [Accepted: 02/29/2024] [Indexed: 03/27/2024]
Abstract
OBJECTIVE The number of tracheostomies performed annually in resource-rich countries is estimated at 250,000. While an essential procedure, approximately 20% to 30% of patients will experience at least 1 tracheostomy-related adverse event. Within tracheostomy care and across wider health care environments, quality improvement (QI) programs have been shown to reduce patient harm and improve outcomes. Herein we report on a 5-year long, tracheostomy QI initiative aimed at improving patient experience and reducing the frequency and severity of adverse events. METHODS A 5-year (ongoing) QI initiative led by the Cardiff and Vale University Health Board tracheostomy team, within a tertiary, 1000-bedded hospital in South Wales, United Kingdom. The QI initiative has focused on 3 main themes: (1) Education and training; (2) Clinical oversight and decision making; and (3) improved data collection. Data were collected from existing tracheostomy databases. RESULTS Over the past 5 years, we have observed a sustained reduction in both the frequency and severity of adverse events, with less than 1 patient per 100 experiencing a moderate or severe adverse event. This has resulted in improvements in patient experience and a cost reduction of £GBP364,726 per annum. DISCUSSION Our 5-year ongoing tracheostomy QI initiative has resulted in improved outcomes with increased achievement of tracheostomy weaning markers and sustained reductions in both the frequency and severity of adverse events. IMPLICATIONS FOR PRACTICE A continuous focus on QI is associated with improved patient and service outcomes. These improvements can be spread and scaled to benefit more patients and organizations.
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Affiliation(s)
- Paul Twose
- Physiotherapy Department, Cardiff and Vale University Health Board, Cardiff, UK
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Julia Cottam
- Finance Department, Cardiff and Vale University Health Board, Cardiff, UK
| | - Gemma Jones
- Speech and Language Department, Cardiff and Vale University Health Board, Cardiff, UK
| | - Jennifer Lowes
- Critical Care, Cardiff and Vale University Health Board, Cardiff, UK
| | - Jason Nunn
- Physiotherapy Department, Cardiff and Vale University Health Board, Cardiff, UK
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Haron A, Li L, Davies EA, Alexander PD, McGrath BA, Cooper G, Weightman A. Increasing the precision of simulated percutaneous dilatational tracheostomy-a pilot prototype device development study. iScience 2024; 27:109098. [PMID: 38380258 PMCID: PMC10877963 DOI: 10.1016/j.isci.2024.109098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 11/30/2023] [Accepted: 01/30/2024] [Indexed: 02/22/2024] Open
Abstract
Percutaneous dilatational tracheostomy (PDT) is a bedside medical procedure which sites a new tracheostomy tube in the front of the neck. The critical first step is accurate placement of a needle through the neck tissues into the trachea. Misplacement occurs in around 5% of insertions, causing morbidity, mortality, and delays to recovery. We aimed to develop and evaluate a prototype medical device to improve precision of initial PDT-needle insertion. The Guidance for Tracheostomy (GiFT) system communicates the relative locations of intra-tracheal target sensor and PDT-needle sensor to the operator. In simulated "difficult neck" models, GiFT significantly improved accuracy (mean difference 10.0 mm, ANOVA p < 0.001) with ten untrained laboratory-based participants and ten experienced medical participants. GiFT resulted in slower time-to-target (mean difference 56.1 s, p < 0.001) than unguided attempts, considered clinically insignificant. Our proof-of-concept study highlights GiFT's potential to significantly improve PDT accuracy, reduce procedural complications and offer bedside PDT to more patients.
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Affiliation(s)
- Athia Haron
- School of Engineering, Faculty of Science and Engineering, The University of Manchester, Manchester, UK
| | - Lutong Li
- School of Engineering, Faculty of Science and Engineering, The University of Manchester, Manchester, UK
| | - Eryl A. Davies
- Greenlane Department of Cardiothoracic and ORL Anaesthesia, Auckland City Hospital, Auckland, New Zealand
| | - Peter D.G. Alexander
- Manchester University NHS Foundation Trust, School of Biological Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - Brendan A. McGrath
- Manchester University NHS Foundation Trust, Manchester Academic Critical Care, Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Glen Cooper
- School of Engineering, Faculty of Science and Engineering, The University of Manchester, Manchester, UK
| | - Andrew Weightman
- School of Engineering, Faculty of Science and Engineering, The University of Manchester, Manchester, UK
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Bilgin G, Unal F, Yanaz M, Baskan AKILIC, Uzuner S, Ayhan Y, Onay ZR, Kalyoncu M, Tortop DMAVI, Arslan H, Oksay SCAN, Kostereli E, Yazan H, Atag E, Ergenekon AP, Ekizoglu NBAS, Yegit CYILMAZ, Gokdemir Y, Uyan ZS, Kilinc AA, Cokugras H, Eralp EERDEM, Cakir E, Karadag B, Oktem S, Karakoc F, Girit S. Long-term outcomes of standardized training for caregivers of children with tracheostomies: The IStanbul PAediatric Tracheostomy (ISPAT) project. Pediatr Pulmonol 2024; 59:331-341. [PMID: 37983721 DOI: 10.1002/ppul.26749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 10/23/2023] [Accepted: 10/28/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND AND OBJECTIVES: Children with tracheostomies are at increased risk of tracheostomy-related complications and require extra care. Standardized training programs for caregivers can improve tracheostomy care and reduce complications. In this study, we compared caregiver knowledge and skill scores after a standardized theoretical and practical training program on tracheostomy care (IStanbul PAediatric Tracheostomy (ISPAT) project) immediately and 1 year post-training and evaluated how this training affected the children's clinical outcomes. MATERIALS AND METHODS We included 32 caregivers (31 children) who had received standardized training a year ago and administered the same theoretical and practical tests 1 year after training completion. We recorded tracheostomy-related complications and the number and reasons for admission to the healthcare centers. All data just before the training and 1 year after training completion were compared. RESULTS After 1 year of training completion, the median number of correct answers on the theoretical test increased to 16.5 from 12 at pretest (p < 0.001). Compared with pretest, at 1-year post-training practical skills assessment scores, including cannula exchange and aspiration, were significantly higher (both p < 0.001) and mucus plug, bleeding, and stoma infection reduced significantly (p = 0.002, 0.022, and 0.004, respectively). Hands-on-training scores were better than pretest but declined slightly at 1 year compared to testing immediately after training. Emergency admission decreased from 64.5% to 32.3% (p = 0.013). Hospitalization decreased from 61.3% to 35.5% (p = 0.039). CONCLUSION Our findings indicate that caregiver training can lead to a persistent increase in knowledge and skill for as long as 1 year, as well as improvements in several measurable outcomes, although a slight decrease in scores warrants annual repetitions of the training program.
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Affiliation(s)
- Gulay Bilgin
- Faculty of Medicine, Division of Pediatric Pulmonology, Medeniyet University, Istanbul, Turkey
| | - Fusun Unal
- Faculty of Medicine, Division of Pediatric Pulmonology, Medipol University, Istanbul, Turkey
| | - Muruvvet Yanaz
- Faculty of Medicine, Division of Pediatric Pulmonology, Marmara University, Istanbul, Turkey
| | - Azer K I L I C Baskan
- Cerrahpasa Faculty of Medicine, Division of Pediatric Pulmonology, Istanbul University, Istanbul, Turkey
| | - Selcuk Uzuner
- Faculty of Medicine, Istanbul Bezmialem University, Istanbul, Turkey
| | - Yetkin Ayhan
- Faculty of Medicine, Division of Pediatric Pulmonology, Medeniyet University, Istanbul, Turkey
| | - Zeynep Reyhan Onay
- Faculty of Medicine, Division of Pediatric Pulmonology, Medeniyet University, Istanbul, Turkey
| | - Mine Kalyoncu
- Faculty of Medicine, Division of Pediatric Pulmonology, Marmara University, Istanbul, Turkey
| | - Deniz M A V I Tortop
- Faculty of Medicine, Division of Pediatric Pulmonology, Medeniyet University, Istanbul, Turkey
| | - Huseyin Arslan
- Cerrahpasa Faculty of Medicine, Division of Pediatric Pulmonology, Istanbul University, Istanbul, Turkey
| | - Sinem C A N Oksay
- Faculty of Medicine, Division of Pediatric Pulmonology, Medeniyet University, Istanbul, Turkey
| | - Ebru Kostereli
- Faculty of Medicine, Division of Pediatric Pulmonology, Koc University, Istanbul, Turkey
| | - Hakan Yazan
- Health Sciences University, Umraniye Training and Research Hospital, Division of Pediatric Pulmonology, Istanbul, Turkey
| | - Emine Atag
- Faculty of Medicine, Division of Pediatric Pulmonology, Medipol University, Istanbul, Turkey
| | - Almala Pınar Ergenekon
- Faculty of Medicine, Division of Pediatric Pulmonology, Marmara University, Istanbul, Turkey
| | - Nilay B A S Ekizoglu
- Sureyyapasa Chest Diseases and Thoracic Surgery Training Hospital, Division of Pediatric Pulmonology, Istanbul, Turkey
| | - Cansu Y I L M A Z Yegit
- Faculty of Medicine, Division of Pediatric Pulmonology, Marmara University, Istanbul, Turkey
| | - Yasemin Gokdemir
- Faculty of Medicine, Division of Pediatric Pulmonology, Marmara University, Istanbul, Turkey
| | - Zeynep Seda Uyan
- Faculty of Medicine, Division of Pediatric Pulmonology, Koc University, Istanbul, Turkey
| | - Ayse Ayzıt Kilinc
- Cerrahpasa Faculty of Medicine, Division of Pediatric Pulmonology, Istanbul University, Istanbul, Turkey
| | - Haluk Cokugras
- Cerrahpasa Faculty of Medicine, Division of Pediatric Pulmonology, Istanbul University, Istanbul, Turkey
| | - Ela E R D E M Eralp
- Faculty of Medicine, Division of Pediatric Pulmonology, Marmara University, Istanbul, Turkey
| | - Erkan Cakir
- Faculty of Medicine, Division of Pediatric Pulmonology, Istinye University, Istanbul, Turkey
| | - Bulent Karadag
- Faculty of Medicine, Division of Pediatric Pulmonology, Marmara University, Istanbul, Turkey
| | - Sedat Oktem
- Faculty of Medicine, Division of Pediatric Pulmonology, Medipol University, Istanbul, Turkey
| | - Fazilet Karakoc
- Faculty of Medicine, Division of Pediatric Pulmonology, Marmara University, Istanbul, Turkey
| | - Saniye Girit
- Faculty of Medicine, Division of Pediatric Pulmonology, Medeniyet University, Istanbul, Turkey
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Zhao J, Zheng W, Xuan NX, Zhou QC, Wu WB, Cui W, Tian BP. The impact of delayed tracheostomy on critically ill patients receiving mechanical ventilation: a retrospective cohort study in a chinese tertiary hospital. BMC Anesthesiol 2024; 24:39. [PMID: 38262946 PMCID: PMC10804499 DOI: 10.1186/s12871-024-02411-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/10/2024] [Indexed: 01/25/2024] Open
Abstract
OBJECTIVES The timing of tracheostomy for critically ill patients on mechanical ventilation (MV) is a topic of controversy. Our objective was to determine the most suitable timing for tracheostomy in patients undergoing MV. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS One thousand eight hundred eighty-four hospitalisations received tracheostomy from January 2011 to December 2020 in a Chinese tertiary hospital. METHODS Tracheostomy timing was divided into three groups: early tracheostomy (ET), intermediate tracheostomy (IMT), and late tracheostomy (LT), based on the duration from tracheal intubation to tracheostomy. We established two criteria to classify the timing of tracheostomy for data analysis: Criteria I (ET ≤ 5 days, 5 days < IMT ≤ 10 days, LT > 10 days) and Criteria II (ET ≤ 7 days, 7 days < IMT ≤ 14 days, LT > 14 days). Parameters such as length of ICU stay, length of hospital stay, and duration of MV were used to evaluate outcomes. Additionally, the outcomes were categorized as good prognosis, poor prognosis, and death based on the manner of hospital discharge. Student's t-test, analysis of variance (ANOVA), Mann-Whitney U test, Kruskal-Wallis test, Chi-square test, and Fisher's exact test were employed as appropriate to assess differences in demographic data and individual characteristics among the ET, IMT, and LT groups. Univariate Cox regression model and multivariable Cox proportional hazards regression model were utilized to determine whether delaying tracheostomy would increase the risk of death. RESULTS In both of two criterion, patients with delayed tracheostomies had longer hospital stays (p < 0.001), ICU stays (p < 0.001), total time receiving MV (p < 0.001), time receiving MV before tracheostomy (p < 0.001), time receiving MV after tracheostomy (p < 0.001), and sedation durations. Similar results were also found in sub-population diagnosed as trauma, neurogenic or digestive disorders. Multinomial Logistic regression identified LT was independently associated with poor prognosis, whereas ET conferred no clinical benefits compared with IMT. CONCLUSIONS In a mixed ICU population, delayed tracheostomy prolonged ICU and hospital stays, sedation durations, and time receiving MV. Multinomial logistic regression analysis identified delayed tracheostomies as independently correlated with worse outcomes. TRIAL REGISTRATION ChiCTR2100043905. Registered 05 March 2021. http://www.chictr.org.cn/listbycreater.aspx.
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Affiliation(s)
- Jie Zhao
- Department of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Rd, Hangzhou, 310009, China
- Department of Critical Care Medicine, The First Affiliated Hospital, Ningbo University, Ningbo, Zhejiang, China
| | - Wei Zheng
- Department of Critical Care Medicine, Zhejiang Daishan First People's Hospital, The Second Affiliated Hospital Daishan Branch, Zhejiang University School of Medicine, Zhoushan, China
| | - Nan-Xian Xuan
- Department of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Rd, Hangzhou, 310009, China
| | - Qi-Chao Zhou
- Department of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Rd, Hangzhou, 310009, China
| | - Wei-Bing Wu
- Department of Critical Care Medicine, Zhejiang Qingyuan People's Hospital, The Second Affiliated Hospital Qingyuan Branch, Zhejiang University School of Medicine, Lishui, China
| | - Wei Cui
- Department of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Rd, Hangzhou, 310009, China
| | - Bao-Ping Tian
- Department of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Rd, Hangzhou, 310009, China.
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Brenner MJ, Morrison M, Pandian V. Survivorship in ICU patients undergoing tracheostomy for respiratory failure: from triggers to interprofessional team-based care. Trauma Surg Acute Care Open 2024; 9:e001335. [PMID: 38274025 PMCID: PMC10806454 DOI: 10.1136/tsaco-2023-001335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024] Open
Affiliation(s)
- Michael J Brenner
- Department of Otolaryngology Head and Neck Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
- Global Tracheostomy Collaborative, Chicago, Illinois, USA
| | | | - Vinciya Pandian
- Global Tracheostomy Collaborative, Chicago, Illinois, USA
- Department of Nursing Faculty, Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
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Selekwa M, Maina I, Yeh T, Nkya A, Ncogoza I, Nuss RC, Mushi BP, Haddadi S, Van Loon K, Mbaga E, Massawe W, Roberson DW, Dharsee N, Musimu B, Xu MJ. Tracheostomy care quality improvement in low- and middle-income countries: A scoping review. PLOS Glob Public Health 2023; 3:e0002294. [PMID: 37943736 PMCID: PMC10635432 DOI: 10.1371/journal.pgph.0002294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 10/09/2023] [Indexed: 11/12/2023]
Abstract
Tracheostomy is a lifesaving, essential procedure performed for airway obstruction in the case of head and neck cancers, prolonged ventilator use, and for long-term pulmonary care. While successful quality improvement interventions in high-income countries such as through the Global Tracheostomy Collaborative significantly reduced length of hospital stay and decreased levels of anxiety among patients, limited literature exists regarding tracheostomy care and practices in low and middle-income countries (LMIC), where most of the world resides. Given limited literature, this scoping review aims to summarize published tracheostomy studies in LMICs and highlight areas in need of quality improvement and clinical research efforts. Based on the PRISMA guidelines, a scoping review of the literature was performed through MEDLINE/PubMed and Embase using terms related to tracheostomy, educational and quality improvement interventions, and LMICs. Publications from 2000-2022 in English were included. Eighteen publications representing 10 countries were included in the final analysis. Seven studies described baseline needs assessments, 3 development of training programs for caregivers, 6 trialed home-based or hospital-based interventions, and finally 2 articles discussed development of standardized protocols. Overall, studies highlighted the unique challenges to tracheostomy care in LMICs including language, literacy barriers, resource availability (running water and electricity in patient homes), and health system access (financial costs of travel and follow-up). There is currently limited published literature on tracheostomy quality improvement and care in LMICs. Opportunities to improve quality of care include increased efforts to measure complications and outcomes, implementing evidence-based interventions tailored to LMIC settings, and using an implementation science framework to study tracheostomy care in LMICs.
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Affiliation(s)
- Msiba Selekwa
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Ivy Maina
- Department of Otolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Tiffany Yeh
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Aslam Nkya
- Department of Otolaryngology-Head & Neck Surgery, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Isaie Ncogoza
- Department of Surgery, College of Medicine & Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Roger C. Nuss
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts, United States of America
| | - Beatrice P. Mushi
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Sumaiya Haddadi
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Katherine Van Loon
- Department of Medicine, Division of Hematology/Oncology, University of California San Francisco, San Francisco, California, United States of America
| | - Elia Mbaga
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Willybroad Massawe
- Department of Otolaryngology-Head & Neck Surgery, Muhimbili National Hospital, Dar es Salaam, Tanzania
- Department of Otolaryngology-Head and Neck Surgery, Muhimbili University of Health and Allied Science, Dar es Salaam, Tanzania
| | - David W. Roberson
- Bayhealth Medical Group, Dover, Delaware, United States of America
- Global Tracheostomy Collaborative, Raleigh, North Carolina, United States of America
| | - Nazima Dharsee
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Ocean Road Cancer Institute, Dar es Salaam, Tanzania
| | - Baraka Musimu
- Department of Otolaryngology-Head and Neck Surgery, Muhimbili University of Health and Allied Science, Dar es Salaam, Tanzania
| | - Mary Jue Xu
- Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, United States of America
- National Clinician Scholars Program, University of California San Francisco, San Francisco, California, United States of America
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Egbers PH, Sutt AL, Petersson JE, Bergström L, Sundman E. High-flow via a tracheostomy tube and speaking valve during weaning from mechanical ventilation and tracheostomy. Acta Anaesthesiol Scand 2023; 67:1403-1413. [PMID: 37437910 DOI: 10.1111/aas.14305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 06/12/2023] [Accepted: 06/20/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND Weaning from mechanical ventilation and tracheostomy after prolonged intensive care consume enormous resources with optimal management not currently well described. Restoration of respiratory flow via the upper airway is essential and early cuff-deflation using a one-way valve (OWV) is recommended. However, extended OWV use may cause dry airways and thickened secretions which challenge the weaning process. High-flow therapy via the tracheostomy tube (HFT-T) humidifies inspired air and may be connected via an in-line OWV (HFT-T-OWV) alleviating these problems. We aim to provide clinical and experimental data on the safety of HFT-T-OWV along with a practical guide to facilitate clinical use during weaning from mechanical ventilation and tracheostomy. METHODS Data on adverse events of HFT-T-OWV were retrieved from a quality register for patients treated at an intensive care rehabilitation center between 2019 and 2022. Benchtop experiments were performed to measure maximum pressures and pressure support generated by HFT-T-OWV at 25-60 L/min flow using two different HFT-T adapters (interfaces). In simulated airway obstruction using a standard OWV (not in-line) maximum pressures were measured with oxygen delivered via the side port at 1-3 L/min. RESULTS Of 128 tracheostomized patients who underwent weaning attempts, 124 were treated with HFT-T-OWV. The therapy was well tolerated, and no adverse events related to the practice were detected. The main reason for not using HFT-T-OWV was partial upper airway obstruction using a OWV. Benchtop experiments demonstrated HFT-T-OWV maximum pressures <4 cmH2 O and pressure support 0-0.6 cmH2 O. In contrast, 1-3 L/min supplemental oxygen via a standard OWV caused pressures between 84 and 148 cmH2 O during simulated airway obstruction. CONCLUSIONS Current study clinical data and benchtop experiments indicate that HFT-T-OWV was well tolerated and appeared safe. Pressure support was low, but humidification may enable extended use of a OWV without dry airway mucosa and thickened secretions. Results suggest the treatment could offer advantages to standard OWV use, with or without supplementary oxygen, as well as to HFT-T without a OWV, for weaning from mechanical ventilation and tracheostomy. However, for definitive treatment recommendations, randomized clinical trials are needed.
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Affiliation(s)
- Peter H Egbers
- Medical Centre of Leeuwarden, Leeuwarden, The Netherlands
| | - Anna-Liisa Sutt
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- School of Medicine, University of Queensland, Brisbane, Australia
- Consulting Speech and Language Therapist, Bank Partners, The Royal London Hospital, London, UK
| | - Jenny E Petersson
- Remeo Intensive Care Rehabilitation Center, Stockholm, Sweden
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Liza Bergström
- Remeo Intensive Care Rehabilitation Center, Stockholm, Sweden
- Division of Neurology, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Eva Sundman
- Remeo Intensive Care Rehabilitation Center, Stockholm, Sweden
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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9
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Ninan A, Grubb LM, Brenner MJ, Pandian V. Effectiveness of interprofessional tracheostomy teams: A systematic review. J Clin Nurs 2023; 32:6967-6986. [PMID: 37395139 DOI: 10.1111/jocn.16815] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 05/19/2023] [Accepted: 06/19/2023] [Indexed: 07/04/2023]
Abstract
AIM(S) To systematically locate, evaluate and synthesize evidence regarding effectiveness of interprofessional tracheostomy teams in increasing speaking valve use and decreasing time to speech and decannulation, adverse events, lengths of stay (intensive care unit (ICU) and hospital) and mortality. In addition, to evaluate facilitators and barriers to implementing an interprofessional tracheostomy team in hospital settings. DESIGN Systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Johns Hopkins Nursing Evidence-Based Practice Model's guidance. METHODS Our clinical question: Do interprofessional tracheostomy teams increase speaking valve use and decrease time to speech and decannulation, adverse events, lengths of stay and mortality? Primary studies involving adult patients with a tracheostomy were included. Eligible studies were systematically reviewed by two reviewers and verified by another two reviewers. DATA SOURCES MEDLINE, CINAHL and EMBASE. RESULTS Fourteen studies met eligibility criteria; primarily pre-post intervention cohort studies. Percent increase in speaking valve use ranged 14%-275%; percent reduction in median days to speech ranged 33%-73% and median days to decannulation ranged 26%-32%; percent reduction in rate of adverse events ranged 32%-88%; percent reduction in median hospital length of stay days ranged 18-40 days; no significant change in overall ICU length of stay and mortality rates. Facilitators include team education, coverage, rounds, standardization, communication, lead personnel and automation, patient tracking; barrier is financial. CONCLUSION Patients with tracheostomy who received care from a dedicated interprofessional team showed improvements in several clinical outcomes. IMPLICATIONS FOR PATIENT CARE Additional high-quality evidence from rigorous, well-controlled and adequately powered studies are necessary, as are implementation strategies to promote broader adoption of interprofessional tracheostomy team strategies. Interprofessional tracheostomy teams are associated with improved safety and quality of care. IMPACT Evidence from review provides rationale for broader implementation of interprofessional tracheostomy teams. REPORTING METHOD PRISMA and Synthesis Without Meta-analysis (SWiM). PATIENT/PUBLIC CONTRIBUTION None.
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Affiliation(s)
- Ashly Ninan
- Johns Hopkins University, Baltimore, Maryland, USA
| | - Lisa M Grubb
- Department of Nursing Faculty, Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| | - Michael J Brenner
- Department of Otolaryngology-Head & Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA
- Global Tracheostomy Collaborative, Raleigh, North Carolina, USA
| | - Vinciya Pandian
- Department of Nursing Faculty, and Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, Maryland, USA
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10
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Twose P, Terblanche E, Jones U, Firshman P, Merriweather J, Rock C, Wallace S. Protected therapy services for critical care: A subanalysis of the UK-wide workforce survey. Aust Crit Care 2023; 36:821-827. [PMID: 36604266 DOI: 10.1016/j.aucc.2022.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 11/07/2022] [Accepted: 11/13/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The existing United Kingdom (UK) allied health professional (AHP) workforce in critical care does not meet national standards, with widespread variation in the source of funding, service availability, and regularity of input. OBJECTIVES The aim of this subanalysis was to determine the impact of protected services on the involvement of AHPs on direct and nondirect aspects of patient care. METHODS This is a subanalysis of the previously published AHPs in critical care UK-wide workforce survey, an observational study using online surveys distributed to 245 critical care units across the UK. RESULTS/FINDINGS Services with protected funding provided more daily input within critical care. This was most apparent for occupational therapy where daily input varied from 82.1% of units with protected services compared to just 10.3% in those without (p < 0.001). For all professions, most notably occupational therapy and speech and language therapy, protected services increased the regularity in which specific interventions were completed and had impact on involvement in nonclinical aspects of care including involved in multidisciplinary team meetings, clinical governance, and research. CONCLUSIONS The absence of protected AHP services reduces compliance with national standards for therapy workforce. Based on these findings, UK and international critical care guidelines should promote protected AHP services for critical care.
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Affiliation(s)
- Paul Twose
- School of Healthcare Sciences, Cardiff University, UK; Physiotherapy Department, Cardiff and Vale UHB, UK.
| | - Ella Terblanche
- Kings College London, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, London SE1 8WA, UK.
| | - Una Jones
- School of Healthcare Sciences, Cardiff University, UK.
| | | | | | - Claire Rock
- Mid and South Essex NHS Foundation Trust, UK.
| | - Sarah Wallace
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, UK.
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11
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Duggal R, Davis RJ, Appachi S, Tierney WS, Hopkins BD, Bryson PC. Interdisciplinary assessment of tracheostomy care knowledge: An opportunity for quality improvement. Am J Otolaryngol 2023; 44:103865. [PMID: 37004318 DOI: 10.1016/j.amjoto.2023.103865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 03/19/2023] [Indexed: 04/03/2023]
Abstract
PURPOSE A 2013 AAOHNS consensus statement called for reduced variation in tracheostomy care. Multidisciplinary approaches and standardized protocols have been shown to improve tracheostomy outcomes. This study aims to identify inconsistencies in knowledge in order to design standardized education targeting these areas to improve quality of care. MATERIALS AND METHODS An online, multiple-choice tracheostomy care knowledge assessment was administered to nurses and respiratory therapists in ICUs, stepdown units, and regular nursing floors, as well as residents in otolaryngology, general surgery, and thoracic surgery. The survey was administered and data were recorded using the Select Survey online platform. RESULTS 173 nurses, respiratory therapists, and residents participated in this study. Over 75 % of respondents identified correct answers to questions addressing basic tracheostomy care, such as suctioning and humidification. Significant variation was observed in identification and management of tracheostomy emergencies, and appropriate use of speaking valves. Only 47 % of all respondents identified all potential signs of tracheostomy tube displacement. Respiratory therapists with over 20 years of experience (p = 0.001), were more likely to answer correctly than those with less. Nurses were less likely than respiratory therapists to have received standardized tracheostomy education (p = 0.006) and were less likely than others to choose the appropriate scenario for speaking valve use (p = 0.042), highlighting the need for interdisciplinary education. CONCLUSIONS An interdisciplinary assessment of tracheostomy care knowledge demonstrates variation, especially in identification and management of tracheostomy emergencies and appropriate use of speaking valves. Design of a standardized educational program targeting these areas is underway.
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Affiliation(s)
- Radhika Duggal
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, United States of America.
| | - Ruth J Davis
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Swathi Appachi
- Department of Otolaryngology-Head and Neck Surgery, Cleveland Clinic Head and Neck Institute, Cleveland, OH, United States of America
| | - William S Tierney
- Department of Otolaryngology-Head and Neck Surgery, Cleveland Clinic Head and Neck Institute, Cleveland, OH, United States of America
| | - Brandon D Hopkins
- Department of Otolaryngology-Head and Neck Surgery, Cleveland Clinic Head and Neck Institute, Cleveland, OH, United States of America
| | - Paul C Bryson
- Department of Otolaryngology-Head and Neck Surgery, Cleveland Clinic Head and Neck Institute, Cleveland, OH, United States of America
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12
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Zaga CJ, Berney S, Hepworth G, Cameron TS, Baker S, Giddings C, Howard ME, Bellomo R, Vogel AP. Tracheostomy clinical practices and patient outcomes in three tertiary metropolitan hospitals in Australia. Aust Crit Care 2023; 36:327-335. [PMID: 35490111 DOI: 10.1016/j.aucc.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 02/24/2022] [Accepted: 03/06/2022] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND There is a paucity of literature in Australia on patient-focused tracheostomy outcomes and process outcomes. Exploration of processes of care enables teams to identify and address existing barriers that may prevent earlier therapeutic interventions that could improve patient outcomes following critical care survival. OBJECTIVES The objectives of this study were to examine and provide baseline data and associations between tracheostomy clinical practices and patient outcomes across three large metropolitan hospitals. METHODS We performed a retrospective multisite observational study in three tertiary metropolitan Australian health services who are members of the Global Tracheostomy Collaborative. Deidentified data were entered into the Global Tracheostomy Collaborative database from Jan 2016 to Dec 2019. Descriptive statistics were used for the reported outcomes of length of stay, mortality, tracheostomy-related adverse events and complications, tracheostomy insertion, airway, mechanical ventilation, communication, swallowing, nutrition, length of cannulation, and decannulation. Pearson's correlation coefficient and one-way analyses of variance were performed to examine associations between variables. RESULTS The total cohort was 380 patients. The in-hospital mortality of the study cohort was 13%. Overall median hospital length of stay was 46 days (interquartile range: 31-74). Length of cannulation was shorter in patients who did not experience any tracheostomy-related adverse events (p= 0.036) and who utilised nonverbal communication methods (p = 0.041). Few patients (8%) utilised verbal communication methods while mechanically ventilated, compared with 80% who utilised a one-way speaking valve while off the ventilator. Oral intake was commenced in 20% of patients prior to decannulation. Patient nutritional intake varied prior to and at the time of decannulation. Decannulation occurred in 83% of patients. CONCLUSIONS This study provides baseline data for tracheostomy outcomes across three large metropolitan Australian hospitals. Most outcomes were comparable with previous international and local studies. Future research is warranted to explore the impact of earlier nonverbal communication and interventions targeting the reduction in tracheostomy-related adverse events.
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Affiliation(s)
- Charissa J Zaga
- Department of Speech Pathology, Division of Allied Health, Austin Health Melbourne, Australia; Tracheostomy Review and Management Service, Austin Hospital, Melbourne, Australia; Institute of Breathing and Sleep, Austin Health, Melbourne, Australia; Centre for Neuroscience of Speech, The University of Melbourne, Melbourne, Australia.
| | - Sue Berney
- Institute of Breathing and Sleep, Austin Health, Melbourne, Australia; Department of Physiotherapy, Division of Allied Health, Austin Health, Melbourne, Australia; Department of Physiotherapy, School of Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Graham Hepworth
- Statistical Consulting Centre, The University of Melbourne, Melbourne, Australia
| | - Tanis S Cameron
- Tracheostomy Review and Management Service, Austin Hospital, Melbourne, Australia
| | - Sonia Baker
- Department of Speech Pathology, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Charles Giddings
- Department of Ear, Nose and Throat Surgery, Monash Health, Melbourne, Australia
| | - Mark E Howard
- Institute of Breathing and Sleep, Austin Health, Melbourne, Australia; Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia; Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia
| | - Adam P Vogel
- Centre for Neuroscience of Speech, The University of Melbourne, Melbourne, Australia; Department of Neurodegeneration, Hertie Institute for Clinical Brian Research, Tübingen, Germany; Redenlab, Mebourne, Australia
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13
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Laxton V, Maratos FA, Hewson DW, Baird A, Stupple EJN. 5S solutions to promote medication efficiency and safety. Comment on Br J Anaesth 2023; 130: e416-8. Br J Anaesth 2023; 130:e492-e493. [PMID: 37031023 PMCID: PMC10078938 DOI: 10.1016/j.bja.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/10/2023] [Accepted: 03/11/2023] [Indexed: 04/10/2023] Open
Affiliation(s)
- Victoria Laxton
- College of Health, Psychology and Social Care, University of Derby, Derby, UK; TRL, Wokingham, UK
| | - Frances A Maratos
- College of Health, Psychology and Social Care, University of Derby, Derby, UK
| | - David W Hewson
- Academic Unit of Injury, Recovery and Inflammation Sciences, School of Medicine, University of Nottingham, Nottingham, UK; Department of Anaesthesia and Critical Care, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK.
| | - Andrew Baird
- College of Health, Psychology and Social Care, University of Derby, Derby, UK
| | - Edward J N Stupple
- College of Health, Psychology and Social Care, University of Derby, Derby, UK
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Del Toro‐Diez E, Ríos De Choudens CS, Lajud SA, Pascual‐Marrero J, Baez‐Bermejo A. Tracheostomy Outcomes on Trauma Patients. OTO Open 2023; 7:e48. [PMID: 37113162 PMCID: PMC10098676 DOI: 10.1002/oto2.48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 02/26/2023] [Indexed: 04/29/2023] Open
Abstract
Objective Tracheostomies are performed in trauma patients for multiple purposes. Approaches to the procedure are usually directed by individual expertise and local preferences. Though generally safe, a tracheostomy can cause serious complications. This study aims to identify complications associated with tracheostomies performed at the level I Trauma Center of the Puerto Rico Medical Center (PRMC) to have an advanced foundation to develop and implement guidelines to improve patient outcomes. Study Design A retrospective cross-sectional study. Setting Level I Trauma Center of the PRMC. Methods Medical charts of 113 trauma adult patients that underwent tracheostomy at the PRMC from 2018 to 2020 were reviewed. Data collected included patient demographics, surgical approach, initial tracheostomy tube size (ITTS), intubation period, and flexible laryngoscopic findings. Complications occurring during and after tracheostomy were documented. The unadjusted relationship of the independent variables and outcome measures was assessed using χ 2 and Fisher's test for categorical variables and the Wilcoxon-Mann-Whitney rank-sum test for continuous ones. Results Abnormal airway findings detected on flexible laryngoscopic examination were reported in 30 patients in the open tracheostomy (OT) group and 43 patients in the percutaneous tracheostomy group (p = 0.007). Peristomal granulation tissue was reported in 10 patients with an ITTS 8, while in only 1 patient with an ITTS 6 (p = 0.026). Conclusion This study showed several key findings in our cohort. The OT surgical approach was associated with fewer long-term complications when compared to the percutaneous approach. Also, a statistically significant difference in peristomal granulation tissue findings was found between the ITTS, ITTS-6 and ITTS-8, the smaller size being associated with fewer abnormal findings.
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Affiliation(s)
- Edgar Del Toro‐Diez
- Department of Otolaryngology–Head and Neck Surgery, School of MedicineUniversity of Puerto RicoSan JuanPuerto RicoUSA
| | - Camila S. Ríos De Choudens
- Department of Otolaryngology–Head and Neck Surgery, School of MedicineUniversity of Puerto RicoSan JuanPuerto RicoUSA
| | - Shayanne A. Lajud
- Department of Otolaryngology–Head and Neck Surgery, School of MedicineUniversity of Puerto RicoSan JuanPuerto RicoUSA
- Department of Otolaryngology–Head and Neck SurgeryUniversity of TorontoTorontoCanada
| | - Jeamarie Pascual‐Marrero
- Department of Otolaryngology–Head and Neck Surgery, School of MedicineUniversity of Puerto RicoSan JuanPuerto RicoUSA
| | - Adriana Baez‐Bermejo
- Department of Otolaryngology–Head and Neck Surgery, School of MedicineUniversity of Puerto RicoSan JuanPuerto RicoUSA
- Department of Pharmacology, School of MedicineUniversity of Puerto RicoSan JuanPuerto RicoUSA
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15
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Nyanzi DJ, Atwine D, Kamoga R, Birungi C, Nansubuga CA, Nyaiteera V, Nakku D. Tracheostomy-related indications, early complications and their predictors among patients in low resource settings: a prospective cohort study in the pre-COVID-19 era. BMC Surg 2023; 23:59. [PMID: 36934224 PMCID: PMC10024521 DOI: 10.1186/s12893-023-01960-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 03/09/2023] [Indexed: 03/20/2023] Open
Abstract
BACKGROUND Tracheostomy is a life-saving procedure whose outcomes may vary between hospitals based on disparities in their existing expertise. We aimed at establishing the indications, early tracheostomy-related complications and their associated factors in Uganda. METHODS In a prospective cohort study, we consecutively enrolled one-hundred patients, both adults and children 2 h post-tracheostomy procedure. At baseline, information on patients' socio-demographics, tracheostomy indications, pre- and post-procedural characteristics was collected through researcher administered questionnaires and from medical records. Clinical examination was performed at baseline but also at either day 7 or whenever a tracheostomy-related complication was suspected during the 7 days follow-up. Comparison of patients' baseline characteristics, tracheostomy indications and complications across two hospitals was done using Pearson's chi-square. For predictors of early tracheostomy complications, bivariate and multivariate analysis models were fitted using binomial regression in STATA 13.0 software. RESULTS All patients underwent surgical tracheostomy. Majority were adults (84%) and males (70%). The commonest tracheostomy indications were; pulmonary toilet (58%) and anticipated prolonged intubation (42%). Overall, 53% (95% CI: 43.0 - 62.7) had early complications with the commonest being tube obstruction (52.6%). Independent predictors of early tracheostomy-related complications were; anticipated prolonged intubation as an indication (RR = 1.8, 95%CI: 1.19 - 2.76), Bjork flap tracheal incision (RR = 1.6, 95%CI: 1.09 - 2.43), vertical tracheal incision (RR = 1.53, 95%CI: 1.02 - 2.27), and age below 18 years (RR = 1.22, 95%CI: 1.00 - 1.47). CONCLUSION Pulmonary toilet is the commonest tracheostomy indication at major hospitals in Uganda. The incidence of early tracheostomy complications is high and majorly related to post-procedure tracheostomy tube management. Having anticipated prolonged intubation as an indication for tracheostomy, a Bjork flap or vertical tracheal incisions and being a child were associated with increased risk of complications. Emphasis on multidisciplinary team care, standardization of tracheostomy care protocols, and continuous collection of patient data as well as paying attention to patient quality of life factors such as early return to oral feeding, ambulation and normal speech may have great potential for improved quality of tracheostomy care in low resource settings.
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Affiliation(s)
- Daniel J Nyanzi
- Department of Otolaryngology, School of Medicine, Kabale University, Kabale, Uganda.
- Department of Clinical Research, SOAR Research Foundation, Mbarara, Uganda.
- Department of Otolaryngology, Mbarara University of Science and Technology, Mbarara, Uganda.
| | - Daniel Atwine
- Department of Clinical Research, SOAR Research Foundation, Mbarara, Uganda
- Department of Otolaryngology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Ronald Kamoga
- Department of Anatomy, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Caroline Birungi
- Department of Clinical Research, SOAR Research Foundation, Mbarara, Uganda
| | - Caroline A Nansubuga
- Department of Pediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Victoria Nyaiteera
- Department of Otolaryngology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Doreen Nakku
- Department of Otolaryngology, Mbarara University of Science and Technology, Mbarara, Uganda
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Mc Mahon A, Griffin S, Gorman E, Lennon A, Kielthy S, Flannery A, Cherian BS, Josy M, Marsh B. Patient-Centred Outcomes Following Tracheostomy in Critical Care. J Intensive Care Med 2023:8850666231160669. [PMID: 36883211 PMCID: PMC10374991 DOI: 10.1177/08850666231160669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
INTRODUCTION Around 20% of intensive care unit (ICU) patients undergo tracheostomy insertion and expect high-quality care concentrating on patient-centered outcomes including communication, oral intake, and mobilization. The majority of data has focused on timing, mortality, and resource utilization, with a paucity of information on quality of life following tracheostomy. METHODS Single center retrospective study including all patients requiring tracheostomy from 2017 to 2019. Information collected on demographics, severity of illness, ICU and hospital length of stay (LOS), ICU and hospital mortality, discharge disposition, sedation, time to vocalization, swallow and mobilization. Outcomes were compared for early versus late tracheostomy (early = <day 10) and age category (≤ 65 vs ≥ 66 years). RESULTS In total, 304 patients were included and 71% male, median age 59, APACHE II score 17. Median ICU and hospital LOS 16 and 56 days, respectively. ICU and hospital mortality 9.9% and 22.4%. Median time to tracheostomy 8 days, 8.55% open. Following tracheostomy, median days of sedation was 0, time to noninvasive ventilation (NIV) 1 day (94% of patients achieving this), ventilator-free breathing (VFB) 5 days (72%), speaking valve 7 days (60%), dynamic sitting 5 days (64%), and swallow assessment 16 days (73%). Early tracheostomy was associated with shorter ICU LOS (13 vs 26 days, P < .0001), reduced sedation (6 vs 12 days, P < .0001), faster transition to level 2 care (6 vs 10 days, P < .003), NIV (1 vs 2 days, P < .003), and VFB (4 vs 7 days, P < .005). Older patients received less sedation, had higher APACHE II scores and mortality (36.1%) and 18.5% were discharged home. Median time to VFB was 6 days (63.9%), speaking valve 7 days (64.7%), swallow assessment 20.5 days (66.7%), and dynamic sitting 5 days (62.2%). CONCLUSION Patient-centered outcomes are a worthy goal to consider when selecting patients for tracheostomy in addition to mortality or timing alone, including in older patients.
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Affiliation(s)
- A Mc Mahon
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - S Griffin
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - Emma Gorman
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - Aoife Lennon
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - Stephen Kielthy
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - Andrea Flannery
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - Bindu Sam Cherian
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - Minu Josy
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - B Marsh
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
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17
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Marget MJ, Dunn R, Morgan CL. Association of APACHE-II Scores With 30-Day Mortality After Tracheostomy: A Retrospective Study. Laryngoscope 2023; 133:273-278. [PMID: 35548918 DOI: 10.1002/lary.30211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 03/29/2022] [Accepted: 04/27/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE The objective of this study was to assess whether the Acute Physiology, Age, Chronic Health Evaluation II (APACHE-II) score is a reliable predictor of 30-day mortality in the setting of adult patients with ventilator-dependent respiratory failure (VDRF) who undergo tracheostomy. METHODS This is a retrospective, single-institution study. Potential subjects were identified using the current procedural terminology codes for the tracheostomy procedure and International Classification of Diseases, 10th Revision, codes for VDRF. APACHE-II scores were retrospectively calculated. Tracheostomies were performed in our population over an 18-month period (November 2018 through April 2020). Our study population did not include patients with novel coronavirus. The primary outcome was mortality at 30 days after tracheostomy. RESULTS A total of 238 patients with VDRF who had a tracheostomy were included in this study. Twenty-eight (11.8%) patients died within 30 days of tracheostomy. The mean (standard deviation) APACHE-II score was 22.5 (10.2) for patients who died within 30 days of tracheostomy and 19.8 (7.4) for patients living within 30 days of tracheostomy (p = 0.30). Patients with APACHE-II scores greater than or equal to 30 showed higher odds of death within 30 days of tracheostomy (odds ratio, 3.0; 95% CI, 1.14-7.89, p = 0.03). CONCLUSION An APACHE-II score of 30 and above is associated with mortality within 30 days of tracheostomy in patients with VDRF. APACHE-II scores may be a promising tool for assessing risk of mortality in patients with VDRF after tracheostomy. LEVEL OF EVIDENCE 3 Laryngoscope, 133:273-278, 2023.
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Affiliation(s)
- Matthew J Marget
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Hospital, Detroit, Michigan, U.S.A
| | - Raven Dunn
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Hospital, Detroit, Michigan, U.S.A
| | - Christie L Morgan
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Hospital, Detroit, Michigan, U.S.A
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18
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Wallace S, McGowan S, Sutt AL. Benefits and options for voice restoration in mechanically ventilated intensive care unit patients with a tracheostomy. J Intensive Care Soc 2023; 24:104-111. [PMID: 36874291 PMCID: PMC9975806 DOI: 10.1177/17511437221113162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Communication difficulties and their effects on patients who are mechanically ventilated are commonly reported and well described. The possibility of restoring speech for patients has obvious benefits, not only for meeting patient's immediate needs, but for helping them to re-engage in relationships and participate meaningfully in their recovery and rehabilitation. This opinion piece by a group of United Kingdom (UK) based Speech and Language Therapy experts working in critical care describes the various ways by which a patient's own voice can be restored. Common barriers to using different techniques and potential solutions are explored. We therefore hope that this will encourage intensive care unit (ICU) multi-disciplinary teams to advocate and facilitate early verbal communication in these patients.
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Affiliation(s)
- Sarah Wallace
- Department of Speech Voice and Swallowing, Wythenshawe Hospital, Manchester University NHS Foundation Trust, UK.,Manchester Academic Critical Care, Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, UK
| | - Sue McGowan
- Therapy Services, National Hospital for Neurology and Neurosurgery, UK
| | - Anna-Liisa Sutt
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia.,Speech and Language Therapy, The Royal London Hospital, UK
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Hall N, Rousseau N, Hamilton DW, Simpson AJ, Powell S, Brodlie M, Powell J. Providing care for children with tracheostomies: a qualitative interview study with parents and health professionals. BMJ Open 2023; 13:e065698. [PMID: 36720577 PMCID: PMC9890767 DOI: 10.1136/bmjopen-2022-065698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES To explore the experience of caring for children with tracheostomies from the perspectives of parents and health professional caregivers. DESIGN Qualitative semistructured interview study. SETTING One region in England covered by a tertiary care centre that includes urban and remote rural areas and has a high level of deprivation. PARTICIPANTS A purposive sample of health professionals and parents who care for children who have, or have had, tracheostomies and who received care at the tertiary care centre. INTERVENTION Interviews undertaken by telephone or video link. PRIMARY AND SECONDARY OUTCOME MEASURES Qualitative reflexive thematic analysis with QSR Nvivo 12. RESULTS This paper outlines key determinants and mediators of the experiences of caregiving and the impact on psychological and physical health and quality of life of parents and their families, confidence of healthcare providers and perceived quality of care. For parents, access to care packages and respite care at home as well as communication and relationships with healthcare providers are key mediators of their experience of caregiving, whereas for health professionals, an essential influence is multidisciplinary team working and support. We also highlight a range of challenges focused on the shared care space, including: a lack of standardisation in access to different support teams, care packages and respite care, irregular training and updates, and differences in health provider expertise and experiences across departments and shift patterns, exacerbated in some settings by limited contact with children with tracheostomies. CONCLUSIONS Understanding the experiences of caregiving can help inform measures to support caregivers and improve quality standards. Our findings suggest there is a need to facilitate further standardisation of care and support available for parent caregivers and that this may be transferable to other regions. Potential solutions to be explored could include the development of a paediatric tracheostomy service specification, increasing use of paediatric tracheostomy specialist nurse roles, and addressing the emotional and psychological support needs of caregivers.
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Affiliation(s)
- Nicola Hall
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Nikki Rousseau
- Surgical, Diagnostic and Devices Division, University of Leeds, Leeds, UK
| | - David W Hamilton
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - A John Simpson
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Steven Powell
- Department of Paediatric Otolaryngology, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Malcolm Brodlie
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Paediatric Respiratory Medicine, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Jason Powell
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Paediatric Otolaryngology, Great North Children's Hospital, Newcastle upon Tyne, UK
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20
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Mukai N, Okada M, Konishi S, Okita M, Ogawa S, Nishikawa K, Annen S, Ohshita M, Matsumoto H, Murata S, Harima Y, Kikuchi S, Aibara S, Sei H, Aoishi K, Asayama R, Sato E, Takagi T, Tanaka-Nishikubo K, Teraoka M, Hato N, Takeba J, Sato N. Cricotracheostomy for patients with severe COVID-19: A case control study. Front Surg 2023; 10:1082699. [PMID: 36733889 PMCID: PMC9888534 DOI: 10.3389/fsurg.2023.1082699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 01/03/2023] [Indexed: 01/18/2023] Open
Abstract
Background Tracheostomy is an important procedure for the treatment of severe coronavirus disease-2019 (COVID-19). Older age and obesity have been reported to be associated with the risk of severe COVID-19 and prolonged intubation, and anticoagulants are often administered in patients with severe COVID-19; these factors are also related to a higher risk of tracheostomy. Cricotracheostomy, a modified procedure for opening the airway through intentional partial cricoid cartilage resection, was recently reported to be useful in cases with low-lying larynx, obesity, stiff neck, and bleeding tendency. Here, we investigated the usefulness and safety of cricotracheostomy for severe COVID-19 patients. Materials and methods Fifteen patients with severe COVID-19 who underwent cricotracheostomy between January 2021 and April 2022 with a follow-up period of ≥ 14 days were included in this study. Forty patients with respiratory failure not related to COVID-19 who underwent traditional tracheostomy between January 2015 and April 2022 comprised the control group. Data were collected from medical records and comprised age, sex, body mass index, interval from intubation to tracheostomy, use of anticoagulants, complications of tracheostomy, and decannulation. Results Age, sex, and days from intubation to tracheostomy were not significantly different between the COVID-19/cricotracheostomy and control/traditional tracheostomy groups. Body mass index was significantly higher in the COVID-19 group than that in the control group (P = 0.02). The rate of use of anticoagulants was significantly higher in the COVID-19 group compared with the control group (P < 0.01). Peri-operative bleeding, subcutaneous emphysema, and stomal infection rates were not different between the groups, while stomal granulation was significantly less in the COVID-19 group (P = 0.04). Conclusions These results suggest that cricotracheostomy is a safe procedure in patients with severe COVID-19.
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Affiliation(s)
- Naoki Mukai
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Masahiro Okada
- Department of Otolaryngology, Head and Neck Surgery, Ehime University Graduate School of Medicine, Toon, Japan,Correspondence: Masahiro Okada
| | - Saki Konishi
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Mitsuo Okita
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Siro Ogawa
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Kosuke Nishikawa
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Toon, Japan,Department of Bone and Joint Surgery, Ehime University School of Medicine, Toon, Japan
| | - Suguru Annen
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Muneaki Ohshita
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Hironori Matsumoto
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Satoru Murata
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Yutaka Harima
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Satoshi Kikuchi
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Shiori Aibara
- Department of Otolaryngology, Head and Neck Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Hirofumi Sei
- Department of Otolaryngology, Head and Neck Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Kunihide Aoishi
- Department of Otolaryngology, Head and Neck Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Rie Asayama
- Department of Otolaryngology, Head and Neck Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Eriko Sato
- Department of Otolaryngology, Head and Neck Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Taro Takagi
- Department of Otolaryngology, Head and Neck Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Kaori Tanaka-Nishikubo
- Department of Otolaryngology, Head and Neck Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Masato Teraoka
- Department of Otolaryngology, Head and Neck Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Naohito Hato
- Department of Otolaryngology, Head and Neck Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Jun Takeba
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Norio Sato
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Toon, Japan
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21
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Newman H, Clunie G, Wallace S, Smith C, Martin D, Pattison N. What matters most to adults with a tracheostomy in ICU and the implications for clinical practice: a qualitative systematic review and metasynthesis. J Crit Care 2022; 72:154145. [PMID: 36174431 DOI: 10.1016/j.jcrc.2022.154145] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 08/22/2022] [Accepted: 08/27/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Tracheostomy is a common surgical procedure in ICU. Whilst often life-saving, it can have important impacts on patients. Much of the literature on tracheostomy focuses on timing and technique of insertion, risk factors and complications. More knowledge of patient experience of tracheostomy in ICU is needed to support person-centred care. MATERIALS AND METHODS Qualitative systematic review and metasynthesis of the literature on adult experience of tracheostomy in ICU. Comprehensive search of four bibliographic databases and grey literature. Title and abstract screening and full text eligibility was completed independently by two reviewers. Metasynthesis was achieved using thematic synthesis, supported by a conceptual framework of humanised care. RESULTS 2971 search returns were screened on title and abstract and 127 full texts assessed for eligibility. Thirteen articles were included for analysis. Five descriptive and three analytical themes were revealed. The over-arching theme was 'To be seen and heard as a whole person'. Patients wanted to be treated as a human, and having a voice made this easier. CONCLUSIONS Voice restoration should be given high priority in the management of adults with a tracheostomy in ICU. Staff training should focus on both technical skills and compassionate care to improve person-centred outcomes.
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Affiliation(s)
- Helen Newman
- University College London, Division of Surgery and Interventional Science, Royal Free Hospital, 3(rd) Floor, Pond Street, London NW3 2QG, UK; Therapies Department, Barnet Hospital, Royal Free London NHS Foundation Trust, Wellhouse Lane, Barnet EN5 3DJ, UK.
| | - Gemma Clunie
- Sackler MSK Lab, Department of Surgery and Cancer, Imperial College London, 2(nd) Floor, Michael Uren Building, White City Campus, W12 0BZ, UK; Speech and Language Therapy, Charing Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Road, W6 8RF, UK
| | - Sarah Wallace
- Department of Speech Voice and Swallowing, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Southmoor Road, Manchester M23 9LT, UK; Division of Infection Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology Medicine and Health, University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | - Christina Smith
- Department of Language and Cognition, Psychology and Language Sciences, University College London, London, UK
| | - Daniel Martin
- University College London, Division of Surgery and Interventional Science, Royal Free Hospital, 3(rd) Floor, Pond Street, London NW3 2QG, UK; Peninsula Medical School, University of Plymouth, John Bull Building, Plymouth, Devon PL6 8BU, UK
| | - Natalie Pattison
- University of Hertfordshire, College Lane, Hatfield AL109AB, UK; East and North Hertfordshire NHS Trust, Coreys Mill Lane, Stevenage SG14AB, UK
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22
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Standiford TC, Farlow JL, Brenner MJ, Blank R, Rajajee V, Baldwin NR, Chinn SB, Cusac JA, De Cardenas J, Malloy KM, McDonough KL, Napolitano LM, Sjoding MW, Stoneman EK, Washer LL, Park PK. COVID-19 Transmission to Health Care Personnel During Tracheostomy Under a Multidisciplinary Safety Protocol. Am J Crit Care 2022; 31:452-460. [PMID: 35953441 DOI: 10.4037/ajcc2022538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Tracheostomies are highly aerosolizing procedures yet are often indicated in patients with COVID-19 who require prolonged intubation. Robust investigations of the safety of tracheostomy protocols and provider adherence and evaluations are limited. OBJECTIVES To determine the rate of COVID-19 infection of health care personnel involved in COVID-19 tracheostomies under a multidisciplinary safety protocol and to investigate health care personnel's attitudes and suggested areas for improvement concerning the protocol. METHODS All health care personnel involved in tracheostomies in COVID-19-positive patients from April 9 through July 11, 2020, were sent a 22-item electronic survey. RESULTS Among 107 health care personnel (80.5%) who responded to the survey, 5 reported a positive COVID-19 test result (n = 2) or symptoms of COVID-19 (n = 3) within 21 days of the tracheostomy. Respondents reported 100% adherence to use of adequate personal protective equipment. Most (91%) were familiar with the tracheostomy protocol and felt safe (92%) while performing tracheostomy. Suggested improvements included creating dedicated tracheostomy teams and increasing provider choices surrounding personal protective equipment. CONCLUSIONS Multidisciplinary engagement in the development and implementation of a COVID-19 tracheostomy protocol is associated with acceptable safety for all members of the care team.
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Affiliation(s)
- Taylor C Standiford
- Taylor C. Standiford is a second-year resident, Department of Otolaryngology-Head & Neck Surgery, University of California, San Francisco
| | - Janice L Farlow
- Janice L. Farlow is a head and neck surgical oncology fellow, Department of Otolaryngology-Head & Neck Surgery, The Ohio State University, Columbus
| | - Michael J Brenner
- Michael J. Brenner is an associate professor, Department of Otolaryngology-Head & Neck Surgery, University of Michigan, Ann Arbor
| | - Ross Blank
- Ross Blank is an assistant professor, Department of Anesthesiology, University of Michigan, Ann Arbor
| | - Venkatakrishna Rajajee
- Venkata-krishna Rajajee is a professor, Department of Neurosurgery, University of Michigan, Ann Arbor
| | - Noel R Baldwin
- Noel R. Baldwin is a registered nurse, Critical Care Medicine Unit, University of Michigan, Ann Arbor
| | - Steven B Chinn
- Steven B. Chinn is an assistant professor, Department of Otolaryngology-Head & Neck Surgery, University of Michigan, Ann Arbor
| | - Jessica A Cusac
- Jessica A. Cusac is a respiratory therapist, clinical specialist, University Hospital/Cardiovascular Center, University of Michigan, Ann Arbor
| | - Jose De Cardenas
- Jose De Cardenas is an associate professor, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor
| | - Kelly M Malloy
- Kelly M. Malloy is an associate professor, Department of Otolaryngology-Head & Neck Surgery, University of Michigan, Ann Arbor
| | - Kelli L McDonough
- Kelli L. McDonough is a clinical research project manager, Department of Surgery, University of Michigan, Ann Arbor
| | - Lena M Napolitano
- Lena M. Napolitano is a professor, Department of Surgery, University of Michigan, Ann Arbor
| | - Michael W Sjoding
- Michael W. Sjoding is an assistant professor, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor
| | - Emily K Stoneman
- Emily K. Stoneman is an associate professor, Division of Infectious Disease, Department of Medicine, University of Michigan, Ann Arbor
| | - Laraine L Washer
- Laraine L. Washer is a professor, Division of Infectious Disease, Department of Medicine, University of Michigan, Ann Arbor
| | - Pauline K Park
- Pauline K. Park is a professor, Department of Surgery, University of Michigan, Ann Arbor
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23
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Plunkett A, Plunkett E. Positive approaches to safety: Learning from what we do well. Paediatr Anaesth 2022; 32:1223-1229. [PMID: 35716150 DOI: 10.1111/pan.14509] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 05/28/2022] [Accepted: 06/03/2022] [Indexed: 11/29/2022]
Abstract
Historical and current methodologies in patient safety are based on a deficit-based model, defining safety as the absence of harm. This model is aligned with the human innate negativity bias and the general philosophy of health care: to diagnose and cure illness and to relieve suffering. While this approach has underpinned measurable progress in healthcare outcomes, a common narrative in the healthcare literature indicates that this progress is stalling or slowing. It is important to learn from and improve poor outcomes, but the deficit-based approach has some theoretical limitations. In this article, we discuss some of the theoretical limitations of the prevailing approach to patient safety and introduce emerging, complementary approaches in this field of practice. Safety-II and resilience engineering represent a new paradigm of safety, characterized by focusing on the entirety of work, with a system-wide lens, rather than single incidents of failure. More overtly positive approaches are available, specifically focusing on success-both outstanding success and everyday success-including exnovation, appreciative inquiry, learning from excellence and positive deviance. These approaches are not mutually exclusive. The new methods described in this article are not intended as replacements of the current methods, rather they are presented as complementary tools, designed to allow the reader to take a balanced and holistic view of patient safety.
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Affiliation(s)
- Adrian Plunkett
- Paediatric Intensive Care Unit, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Emma Plunkett
- Department of Anaesthesia, University Hospitals Birmingham, Birmingham, UK
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24
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Boggiano S, Williams T, Gill SE, Alexander PDG, Khwaja S, Wallace S, McGrath BA. Multidisciplinary management of laryngeal pathology identified in patients with COVID-19 following trans-laryngeal intubation and tracheostomy. J Intensive Care Soc 2022; 23:425-432. [PMID: 36751349 PMCID: PMC9679906 DOI: 10.1177/17511437211034699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background COVID-19 disease often requires invasive ventilatory support. Trans-laryngeal intubation of the trachea may cause laryngeal injury, possibly compounded by coronavirus infection. Fibreoptic Endoscopic Evaluation of Swallowing (FEES) provides anatomical and functional assessment of the larynx, guiding multidisciplinary management. Our aims were to observe the nature of laryngeal abnormalities in patients with COVID-19 following prolonged trans-laryngeal intubation and tracheostomy, and to describe their impact on functional laryngeal outcomes, such as tracheostomy weaning. Methods A retrospective observational cohort analysis was undertaken between March and December 2020, at a UK tertiary hospital. The Speech and Language Therapy team assessed patients recovering from COVID-19 with voice/swallowing problems identified following trans-laryngeal intubation or tracheostomy using FEES. Laryngeal pathology, treatments, and outcomes relating to tracheostomy and oral feeding were noted. Results Twenty-five FEES performed on 16 patients identified a median of 3 (IQR 2-4) laryngeal abnormalities, with 63% considered clinically significant. Most common pathologies were: oedema (n = 12, 75%); abnormal movement (n = 12, 75%); atypical lesions (n = 11, 69%); and erythema (n = 6, 38%). FEES influenced management: identifying silent aspiration (88% of patients who aspirated (n = 8)), airway patency issues impacting tracheostomy weaning (n = 8, 50%), targeted dysphagia therapy (n = 7, 44%); ENT referral (n = 6, 38%) and reflux management (n = 5, 31%). Conclusions FEES is beneficial in identifying occult pathologies and guiding management for laryngeal recovery. In our cohort, the incidence of laryngeal pathology was higher than a non-COVID-19 cohort with similar characteristics. We recommend multidisciplinary investigation and management of patients recovering from COVID-19 who required prolonged trans-laryngeal intubation and/or tracheostomy to optimise laryngeal recovery.
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Affiliation(s)
- Sarah Boggiano
- Department of Speech, Voice and Swallowing, Wythenshawe
Hospital, Wythenshawe, UK,Manchester University NHS Foundation Trust, Manchester, UK
| | - Thomas Williams
- University Hospitals of Morecambe Bay NHS Foundation Trust,
Lancaster, UK,Thomas Williams, University Hospitals of
Morecambe Bay NHS Foundation Trust, Lancaster, UK.
| | - Sonya E Gill
- Manchester University NHS Foundation Trust, Manchester, UK,Acute Intensive Care Unit, Wythenshawe Hospital, Wythenshawe,
UK
| | - Peter DG Alexander
- Manchester University NHS Foundation Trust, Manchester, UK,Acute Intensive Care Unit, Wythenshawe Hospital, Wythenshawe,
UK,Manchester Academic Critical Care, Division of Infection,
Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of
Biology, Medicine and Health, the University of Manchester, Manchester Academic
Health Science Centre, Manchester, UK
| | - Sadie Khwaja
- Manchester University NHS Foundation Trust, Manchester, UK,Department of Head & Neck Surgery, Wythenshawe Hospital,
Wythenshawe, UK
| | - Sarah Wallace
- Department of Speech, Voice and Swallowing, Wythenshawe
Hospital, Wythenshawe, UK,Manchester University NHS Foundation Trust, Manchester, UK,Acute Intensive Care Unit, Wythenshawe Hospital, Wythenshawe,
UK
| | - Brendan A McGrath
- Manchester University NHS Foundation Trust, Manchester, UK,Acute Intensive Care Unit, Wythenshawe Hospital, Wythenshawe,
UK,Manchester Academic Critical Care, Division of Infection,
Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of
Biology, Medicine and Health, the University of Manchester, Manchester Academic
Health Science Centre, Manchester, UK
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25
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Moser CH, Peeler A, Long R, Schoneboom B, Budhathoki C, Pelosi PP, Brenner MJ, Pandian V. Prevention of Tracheostomy-Related Pressure Injury: A Systematic Review and Meta-analysis. Am J Crit Care 2022; 31:499-507. [PMID: 36316177 DOI: 10.4037/ajcc2022659] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND In the critical care environment, individuals who undergo tracheostomy are highly susceptible to tracheostomy-related pressure injuries. OBJECTIVE To evaluate the effectiveness of interventions to reduce tracheostomy-related pressure injury in the critical care setting. METHODS MEDLINE, Embase, CINAHL, and the Cochrane Library were searched for studies of pediatric or adult patients in intensive care units conducted to evaluate interventions to reduce tracheostomy-related pressure injury. Reviewers independently extracted data on study and patient characteristics, incidence of tracheostomy-related pressure injury, characteristics of the interventions, and outcomes. Study quality was assessed using the Cochrane Collaboration's risk-of-bias criteria. RESULTS Ten studies (2 randomized clinical trials, 5 quasi-experimental, 3 observational) involving 2023 critically ill adult and pediatric patients met eligibility criteria. The incidence of tracheostomy-related pressure injury was 17.0% before intervention and 3.5% after intervention, a 79% decrease. Pressure injury most commonly involved skin in the peristomal area and under tracheostomy ties and flanges. Interventions to mitigate risk of tracheostomy-related pressure injury included modifications to tracheostomy flange securement with foam collars, hydrophilic dressings, and extended-length tracheostomy tubes. Interventions were often investigated as part of care bundles, and there was limited standardization of interventions between studies. Meta-analysis supported the benefit of hydrophilic dressings under tracheostomy flanges for decreasing tracheostomy-related pressure injury. CONCLUSIONS Use of hydrophilic dressings and foam collars decreases the incidence of tracheostomy-related pressure injury in critically ill patients. Evidence regarding individual interventions is limited by lack of sensitive measurement tools and by use of bundled interventions. Further research is necessary to delineate optimal interventions for preventing tracheostomy-related pressure injury.
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Affiliation(s)
- Chandler H Moser
- Chandler H. Moser is a PhD candidate, School of Nursing, Johns Hopkins University, Baltimore, Maryland
| | - Anna Peeler
- Anna Peeler is a PhD candidate, School of Nursing, Johns Hopkins University, Baltimore, Maryland
| | - Robert Long
- Robert Long is chief of anesthesia nursing, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Bruce Schoneboom
- Bruce Schoneboom (retired) was associate dean for Practice, Innovation, and Leadership, School of Nursing, Johns Hopkins University, Baltimore, Maryland
| | - Chakra Budhathoki
- Chakra Budhathoki is a biostatistician, School of Nursing and Biostatistics Core, Johns Hopkins University
| | - Paolo P Pelosi
- Paolo P. Pelosi is a chief professor, Anaesthesia and Intensive Care, and director, Specialty School in Anaesthesiology, University of Genoa, and head of the Anaesthesia and Intensive Care Unit at IRCCS San Martino-IST Hospital, Genoa, Italy
| | - Michael J Brenner
- Michael J. Brenner is an associate professor, Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, and President, Global Tracheostomy Collaborative, Raleigh, North Carolina
| | - Vinciya Pandian
- Vinciya Pandian is an associate professor, School of Nursing and Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University
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26
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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27
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Pandian V, Hopkins BS, Yang CJ, Ward E, Sperry ED, Khalil O, Gregson P, Bonakdar L, Messer J, Messer S, Chessels G, Bosworth B, Randall DM, Freeman-Sanderson A, McGrath BA, Brenner MJ. Amplifying patient voices amid pandemic: Perspectives on tracheostomy care, communication, and connection. Am J Otolaryngol 2022; 43:103525. [PMID: 35717856 PMCID: PMC9172276 DOI: 10.1016/j.amjoto.2022.103525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 05/30/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To investigate perspectives of patients, family members, caregivers (PFC), and healthcare professionals (HCP) on tracheostomy care during the COVID-19 pandemic. METHODS The cross-sectional survey investigating barriers and facilitators to tracheostomy care was collaboratively developed by patients, family members, nurses, speech-language pathologists, respiratory care practitioners, physicians, and surgeons. The survey was distributed to the Global Tracheostomy Collaborative's learning community, and responses were analyzed. RESULTS Survey respondents (n = 191) from 17 countries included individuals with a tracheostomy (85 [45 %]), families/caregivers (43 [22 %]), and diverse HCP (63 [33.0 %]). Overall, 94 % of respondents reported concern that patients with tracheostomy were at increased risk of critical illness from SARS-CoV-2 infection and COVID-19; 93 % reported fear or anxiety. With respect to prioritization of care, 38 % of PFC versus 16 % of HCP reported concern that patients with tracheostomies might not be valued or prioritized (p = 0.002). Respondents also differed in fear of contracting COVID-19 (69 % PFC vs. 49 % HCP group, p = 0.009); concern for hospitalization (55.5 % PFC vs. 27 % HCP, p < 0.001); access to medical personnel (34 % PFC vs. 14 % HCP, p = 0.005); and concern about canceled appointments (62 % PFC vs. 41 % HCP, p = 0.01). Respondents from both groups reported severe stress and fatigue, sleep deprivation, lack of breaks, and lack of support (70 % PFC vs. 65 % HCP, p = 0.54). Virtual telecare seldom met perceived needs. CONCLUSION PFC with a tracheostomy perceived most risks more acutely than HCP in this global sample. Broad stakeholder engagement is necessary to achieve creative, patient-driven solutions to maintain connection, communication, and access for patients with a tracheostomy.
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Affiliation(s)
- Vinciya Pandian
- Immersive Learning and Digital Innovation, Johns Hopkins School of Nursing, Baltimore, MD, United States of America; Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, MD, United States of America.
| | - Brandon S Hopkins
- Department of Otolaryngology, Head and Neck Surgery, The Cleveland Clinic, Cleveland, OH, United States of America.
| | - Christina J Yang
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein School of Medicine/Montefiore Medical Center, Bronx, New York, NY, United States of America.
| | - Erin Ward
- Global Tracheostomy Collaborative, Raleigh, NC, United States of America; Family Liaison, Multidisciplinary Tracheostomy Team, Boston Children's Hospital, Boston, MA, United States of America; MTM-CNM Family Connection, Inc., Methuen, MA, United States of America(1)
| | - Ethan D Sperry
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States of America
| | - Ovais Khalil
- Johns Hopkins University School of Nursing, Baltimore, MD, United States of America.
| | - Prue Gregson
- Tracheostomy Review and Management Services, Austin Health, Melbourne, VIC, Australia.
| | - Lucy Bonakdar
- Tracheostomy Review and Management Services, Austin Health, Melbourne, VIC, Australia.
| | - Jenny Messer
- Austin Health Tracheostomy Patient & Family Forum
| | - Sally Messer
- Austin Health Tracheostomy Patient & Family Forum
| | - Gabby Chessels
- Austin Health Tracheostomy Patient & Family Forum, Tracheostomy Review and Management Services, Heidelberg Repatriation Hospital, Heidelberg Heights, VIC, Australia.
| | | | - Diane M Randall
- Memorial Regional Health System, Fort Lauderdale, FL, United States of America.
| | - Amy Freeman-Sanderson
- Graduate School of Health, University of Technology, Sydney, NSW, Australia; Critical Care Division, The George Institute for Global Health, Sydney, NSW, Australia.
| | - Brendan A McGrath
- Anaesthesia & Intensive Care Medicine, Manchester University Hospital NHS Foundation Trust, Wythenshawe, Manchester, United Kingdom; Manchester Academic Critical Care, Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom.
| | - Michael J Brenner
- Department of Otolaryngology-Head & Neck Surgery, University of Michigan Medical Center, Ann Arbor, MI, United States of America; Global Tracheostomy Collaborative, Raleigh, NC, United States of America.
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Battaglini D, Premraj L, White N, Sutt AL, Robba C, Cho SM, Di Giacinto I, Bressan F, Sorbello M, Cuthbertson B, Bassi GL, Suen J, Fraser J, Pelosi P. Tracheostomy outcomes in critically ill COVID-19 patients: a systematic review, meta-analysis, and meta-regression. Br J Anaesth 2022; 129:679-692. [PMID: 36182551 PMCID: PMC9345907 DOI: 10.1016/j.bja.2022.07.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/12/2022] [Accepted: 07/12/2022] [Indexed: 11/22/2022] Open
Abstract
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.
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Budde AM, Kadar RB, Jabaley CS. Airway misadventures in adult critical care: a concise narrative review of managing lost or compromised artificial airways. Curr Opin Anaesthesiol 2022; 35:130-136. [PMID: 35131969 DOI: 10.1097/aco.0000000000001105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Loss or compromise of artificial airways in critically ill adults can lead to serious adverse events, including death. In contrast to primary emergency airway management, the optimal management of such scenarios may not be well defined or appreciated. RECENT FINDINGS Endotracheal tube cuff leaks may compromise both oxygenation and ventilation, and supraglottic cuff position must first be recognized and distinguished from other reasons for gas leakage during positive pressure ventilation. Although definitive management involves tube exchange, if direct visualization is possible temporizing measures can often be considered. Unplanned extubation confers variable and context-specific risks depending on patient anatomy and physiological status. Because risk factors for unplanned extubation are well established, bundled interventions can be employed for mitigation. Tracheostomy tube dislodgement accounts for a substantial proportion of death and disability related to airway management in critical care settings. Consensus guidelines and algorithmic management of such scenarios are key elements of risk mitigation. SUMMARY Management of lost or otherwise compromised artificial airways is a key skill set for adult critical care clinicians alongside primary emergency airway management.
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Affiliation(s)
- Anna M Budde
- Division of Critical Care Medicine, Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Rachel B Kadar
- Section of Critical Care Medicine, Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Craig S Jabaley
- Division of Critical Care Medicine, Department of Anesthesiology, Emory University School of Medicine
- Emory Critical Care Center, Atlanta, GA
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Gardner LA, Jones R, Rassekh C, Atkins J. Tracheostomy and Laryngectomy Airway Safety Events: An Analysis of Patient Safety Reports From 84 Hospitals. PatientSaf 2022. [DOI: 10.33940/data/2022.3.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Tracheostomy- and laryngectomy-related airway safety events can lead to life-threatening situations, permanent harm, or death. We conducted a statewide population-based study to learn about these events and the relationship with associated factors, interventions, and outcomes to identify potential areas for improvement.
Methods: We queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) to find tracheostomy- and laryngectomy-related airway safety event reports involving adults age 18 years and older that occurred between January 1, 2018, and December 31, 2020.
Results: Reports related to tracheostomies and laryngectomies accounted for 97.3% and 2.7% of the total, respectively. The four most frequent tracheostomy-related complications were unplanned decannulations, 71.4%; uncontrolled bleeding/hemorrhage, 9.2%; and partial/total occlusion and mucus plug/thick secretions, which each accounted for 6.9%.
Conclusions: Safe airway management for patients with a tracheostomy or laryngectomy requires staff who are knowledgeable and confident, and have the necessary skills and equipment to provide immediate attention when complications arise. We discuss potential safety strategies to reduce the risk of unplanned decannulations, uncontrolled bleeding/hemorrhage, and partial/total occlusions, as well as issues related to equipment, knowledge/training, and communication.
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Moser CH, Freeman-Sanderson A, Keeven E, Higley KA, Ward E, Brenner MJ, Pandian V. Tracheostomy care and communication during COVID-19: Global interprofessional perspectives. Am J Otolaryngol 2022; 43:103354. [PMID: 34968814 PMCID: PMC8695522 DOI: 10.1016/j.amjoto.2021.103354] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 12/13/2021] [Indexed: 12/26/2022]
Abstract
Objective Investigate healthcare providers, caregivers, and patient perspectives on tracheostomy care barriers during COVID-19. Study design Cross-sectional anonymous survey Setting Global Tracheostomy Collaborative Learning Community Methods A 17-item questionnaire was electronically distributed, assessing demographic and occupational data; challenges in ten domains of tracheostomy care; and perceptions regarding knowledge and preparedness for navigating the COVID-19 pandemic. Results Respondents (n = 115) were from 20 countries, consisting of patients/caregivers (10.4%) and healthcare professionals (87.0%), including primarily otolaryngologists (20.9%), nurses (24.3%), speech-language pathologists (18.3%), respiratory therapists (11.3%), and other physicians (12.2%). The most common tracheostomy care problem was inability to communicate (33.9%), followed by mucus plugging and wound care. Need for information on how to manage cuffs and initiate speech trials was rated highly by most respondents, along with other technical and knowledge areas. Access to care and disposable supplies were also prominent concerns, reflecting competition between community needs for routine tracheostomy supplies and shortages in intensive care units. Integrated teamwork was reported in 40 to 67% of respondents, depending on geography. Forty percent of respondents reported concern regarding personal protective equipment (PPE), and 70% emphasized proper PPE use. Conclusion While safety concerns, centering on personal protective equipment and pandemic resources are prominent concerns in COVID-19 tracheostomy care, patient-centered concerns must also be prioritized. Communication and speech, adequate supplies, and care standards are critical considerations in tracheostomy. Stakeholders in tracheostomy care can partner to identify creative solutions for delays in restoring communication, supply disruptions, and reduced access to tracheostomy care in both inpatient and community settings.
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Affiliation(s)
- Chandler H Moser
- School of Nursing, Johns Hopkins University, Baltimore, MD, United States.
| | - Amy Freeman-Sanderson
- Graduate School of Health, University of Technology, Sydney, NSW, Australia; Royal Prince Alfred Hospital, Sydney, NSW, Australia; Critical Care Division, The George Institute for Global Health, Sydney, NSW, Australia.
| | - Emily Keeven
- Patient Care Services, Children's Mercy Hospitals and Clinics, University of Kansas Health System, Kansas City, MO, United States.
| | - Kylie A Higley
- Children's Mercy Hospitals and Clinics, University of Kansas Health System, Kansas City, MO, United States; Global Tracheostomy Collaborative, Raleigh, NC, United States.
| | - Erin Ward
- Global Tracheostomy Collaborative, Raleigh, NC, United States; Family Liaison, Boston Children's Hospital Tracheostomy Team, Boston Children's Hospital, Boston, MA, United States; MTM-CNM Family Connection, Inc., Methuen, MA, United States
| | - Michael J Brenner
- Global Tracheostomy Collaborative, Raleigh, NC, United States; Department of Otolaryngology - Head & Neck Surgery, University of Michigan Medical School, Ann Arbor, MI, United States.
| | - Vinciya Pandian
- Department of Nursing Faculty, Johns Hopkins University School of Nursing; Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, MD, United States.
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Abstract
OBJECTIVES To explore the impact of the COVID-19 pandemic on the experiences of caregivers of children with tracheostomies. DESIGN Qualitative semistructured interviews. SETTING All participants were currently, or had previously cared for, a tracheostomised child who had attended a tertiary care centre in the North of England. Health professionals were purposively sampled to include accounts from a range of professions from primary, community, secondary and tertiary care. PARTICIPANTS Carers of children with tracheostomies (n=34), including health professionals (n=17) and parents (n=17). INTERVENTIONS Interviews were undertaken between July 2020 and February 2021 by telephone or video link. MAIN OUTCOME MEASURE Qualitative reflexive thematic analysis with QSR NVivo V.12. RESULTS The pandemic has presented an additional and, for some, substantial challenge when caring for tracheostomised children, but this was not always felt to be the most overriding concern. Interviews demonstrated rapid adaptation, normalisation and varying degrees of stoicism and citizenship around constantly changing pandemic-related requirements, rules and regulations. This paper focuses on four key themes: 'reconceptualising safe care and safe places'; 'disrupted support and isolation'; 'relationships, trust and communication'; and 'coping with uncertainty and shifting boundaries of responsibility'. These are described within the context of the impact on the child, the emotional and physical well-being of carers and the challenges to maintaining the values of family-centred care. CONCLUSIONS As we move to the next phase of the pandemic, we need to understand the impact on vulnerable groups so that their needs can be prioritised.
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Affiliation(s)
- Nicola Hall
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
| | - Nikki Rousseau
- Surgical, Diagnostic and Devices Division, University of Leeds, Leeds, UK
| | - David W Hamilton
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
| | - A John Simpson
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Steven Powell
- Department of Paediatric Otolaryngology, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Malcolm Brodlie
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Department of Paediatric Respiratory Medicine, Great North Children's Hospital, Newcastle Upon Tyne, UK
| | - Jason Powell
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Department of Paediatric Otolaryngology, Great North Children's Hospital, Newcastle upon Tyne, UK
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Quinton BA, Tierney WS, Bryson PC, Bribriesco A, Gillespie CT, Hopkins BD. An institution-wide tracheostomy rounding team: Initial caregiver perceptions. Am J Otolaryngol 2022; 43:103367. [PMID: 34991021 DOI: 10.1016/j.amjoto.2021.103367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 12/13/2021] [Accepted: 12/18/2021] [Indexed: 11/01/2022]
Abstract
PURPOSE To analyze and present the initial findings of provider perceptions regarding the impact of the implementation of a hospital-wide Tracheostomy Rounding Team (TRT) on the delivery of tracheostomy care at the Cleveland Clinic. MATERIALS AND METHODS Based on prior literature, a novel multidisciplinary TRT was designed and implemented at the Cleveland Clinic in December of 2018. After the TRT began clinical care, a previously validated RedCap survey was administered anonymously to 358 caregivers to assess provider experience, comfort, and prior education regarding tracheostomy management. Survey results were collected, and descriptive statistics were applied. Answers were compared between providers who interacted with the TRT clinically and those who did not. RESULTS 42.9% of providers who interacted with the TRT clinically reported that the TRT improved hands-on assistance with tracheostomy care, and 36.7% reported that the TRT improved the identification of safety concerns. Similarly, 34.7% reported that the TRT improved the overall quality of tracheostomy care at the Cleveland Clinic. Providers with active exposure to the TRT additionally reported statistically higher comfort with multiple topics surrounding tracheostomy care. CONCLUSIONS The implementation of this team improved provider comfort in managing patients with tracheostomies both qualitatively and quantifiably. This intervention offered a perceived benefit to patient care at our institution. Further study of the impact of this team on quantitative patient outcomes is forthcoming.
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Affiliation(s)
- Brooke A Quinton
- Case Western Reserve University School of Medicine, 10900 Euclid Ave, Cleveland, OH 44106, USA
| | - William S Tierney
- Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Paul C Bryson
- Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | | | - Colin T Gillespie
- Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Brandon D Hopkins
- Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, USA..
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Wandell GM, Merati AL, Meyer TK. Update on Tracheostomy and Upper Airway Considerations in the Head and Neck Cancer Patient. Surg Clin North Am 2022. [DOI: 10.1016/j.suc.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Brenner MJ, Davies EA, McGrath BA. Reducing variation in tracheostomy care can improve outcomes. Br J Anaesth 2022; 128:e282-e284. [PMID: 35144800 PMCID: PMC8820959 DOI: 10.1016/j.bja.2022.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/06/2022] [Accepted: 01/07/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
- Michael J Brenner
- Department of Otolaryngology-Head & Neck Surgery, University of Michigan, Ann Arbor, MI, USA; Global Tracheostomy Collaborative, Raleigh, NC, USA
| | - Eryl A Davies
- Acute Intensive Care Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.
| | - Brendan A McGrath
- Acute Intensive Care Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK; Manchester Academic Critical Care, Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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Yilmaz Yegit C, Kilinc AA, Can Oksay S, Unal F, Yazan H, Köstereli E, Gulieva A, Arslan H, Uzuner S, Onay ZR, Kilic Baskan A, Collak A, Atag E, Ergenekon AP, Bas Ikizoğlu N, Ay P, Oktem S, Gokdemir Y, Girit S, Cakir E, Uyan ZS, Cokugras H, Karadag B, Karakoc F, Erdem Eralp E. The ISPAT project: Implementation of a standardized training program for caregivers of children with tracheostomy. Pediatr Pulmonol 2022; 57:176-184. [PMID: 34562057 DOI: 10.1002/ppul.25704] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 08/15/2021] [Accepted: 09/15/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Tracheostomy-related morbidity and mortality mainly occur due to decannulation, misplacement, or obstruction of the tube. A standardized training can improve the skills and confidence of the caregivers in tracheostomy care (TC). OBJECTIVE Our primary aim was to evaluate the efficiency of standardized training program on the knowledge and skills (changing-suctioning the tracheostomy tube) of the participants regarding TC. MATERIALS AND METHODS Sixty-five caregivers of children with tracheostomy were included. First, participants were evaluated with written test about TC and participated in the practical tests. Then, they were asked to participate in a standardized training session, including theoretical and practical parts. Baseline and postintervention assessments were compared through written and practical tests conducted on the same day. RESULTS A significant improvement was observed in the written test score after the training. The median number of correct answers of the written test including 23 questions increased 26%, from 12 to 18 (p < .001). The median number of correct steps in tracheostomy tube change (from 9 to 16 correct steps out of 16 steps, 44% increase) and suctioning the tracheostomy tube (from 9 to 17 correct steps out of 18 steps, 44% increase) also improved significantly after the training (p < .001, for both). CONCLUSION Theoretical courses and practical hands-on-training (HOT) courses are highly effective in improving the practices in TC. A standardized training program including HOT should be implemented before discharge from the hospital. Still there is a need to assess the impact of the program on tracheostomy-related complications, morbidity, and mortality in the long term.
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Affiliation(s)
- Cansu Yilmaz Yegit
- Division of Pediatric Pulmonology, Marmara University, School of Medicine, Istanbul, Turkey
| | - Ayse Ayzit Kilinc
- Division of Pediatric Pulmonology, İstanbul University-Cerrahpaşa, Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Sinem Can Oksay
- Division of Pediatric Pulmonology, Istanbul Medeniyet University, Faculty of Health Sciences, Istanbul, Turkey
| | - Fusun Unal
- Division of Pediatric Pulmonology, Istanbul Medipol University, School of Medicine, Istanbul, Turkey
| | - Hakan Yazan
- Division of Pediatric Pulmonology, Istanbul Bezmialem University, School of Medicine, Istanbul, Turkey
| | - Ebru Köstereli
- Division of Pediatric Pulmonology, Koc University, School of Medicine, Istanbul, Turkey
| | - Aynur Gulieva
- Division of Pediatric Pulmonology, Marmara University, School of Medicine, Istanbul, Turkey
| | - Hüseyin Arslan
- Division of Pediatric Pulmonology, Istanbul Medipol University, School of Medicine, Istanbul, Turkey
| | - Selçuk Uzuner
- Division of Pediatrics, Istanbul Bezmialem University, School of Medicine, Istanbul, Turkey
| | - Zeynep Reyhan Onay
- Division of Pediatric Pulmonology, Istanbul Medeniyet University, Faculty of Health Sciences, Istanbul, Turkey
| | - Azer Kilic Baskan
- Division of Pediatric Pulmonology, İstanbul University-Cerrahpaşa, Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Abdulhamit Collak
- Division of Pediatrics, Istanbul Bezmialem University, School of Medicine, Istanbul, Turkey
| | - Emine Atag
- Division of Pediatric Pulmonology, Istanbul Medipol University, School of Medicine, Istanbul, Turkey
| | - Almala Pinar Ergenekon
- Division of Pediatric Pulmonology, Marmara University, School of Medicine, Istanbul, Turkey
| | - Nilay Bas Ikizoğlu
- Division of Pediatric Pulmonology, Sureyyapasa Chest Diseases and Thoracic Surgery Training Hospital
| | - Pinar Ay
- Division of Public Health, Marmara University, School of Medicine, Istanbul, Turkey
| | - Sedat Oktem
- Division of Pediatric Pulmonology, Istanbul Medipol University, School of Medicine, Istanbul, Turkey
| | - Yasemin Gokdemir
- Division of Pediatric Pulmonology, Marmara University, School of Medicine, Istanbul, Turkey
| | - Saniye Girit
- Division of Pediatric Pulmonology, Istanbul Medeniyet University, Faculty of Health Sciences, Istanbul, Turkey
| | - Erkan Cakir
- Division of Pediatric Pulmonology, Istanbul Bezmialem University, School of Medicine, Istanbul, Turkey
| | - Zeynep Seda Uyan
- Division of Pediatric Pulmonology, Koc University, School of Medicine, Istanbul, Turkey
| | - Haluk Cokugras
- Division of Pediatric Pulmonology, İstanbul University-Cerrahpaşa, Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Bulent Karadag
- Division of Pediatric Pulmonology, Marmara University, School of Medicine, Istanbul, Turkey
| | - Fazilet Karakoc
- Division of Pediatric Pulmonology, Marmara University, School of Medicine, Istanbul, Turkey
| | - Ela Erdem Eralp
- Division of Pediatric Pulmonology, Marmara University, School of Medicine, Istanbul, Turkey
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Zaga CJ, Sweeney JM, Cameron TS, Campbell MC, Warrillow SJ, Howard ME. Factors associated with short versus prolonged tracheostomy length of cannulation and the relationship between length of cannulation and adverse events. Aust Crit Care 2021; 35:535-542. [PMID: 34742631 DOI: 10.1016/j.aucc.2021.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 09/12/2021] [Accepted: 09/21/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Tracheostomy management and care is multifaceted and costly, commonly involving complex patients with prolonged hospitalisation. Currently, there are no agreed definitions of short and prolonged length of tracheostomy cannulation (LOC) and no consensus regarding the key factors that may be associated with time to decannulation. OBJECTIVES The aims of this study were to identify the factors associated with short and prolonged LOC and to examine the number of tracheostomy-related adverse events of patients who had short LOC versus prolonged LOC. METHODS A retrospective observational study was undertaken at a large metropolitan tertiary hospital. Factors known at the time of tracheostomy insertion, including patient, acuity, medical, airway, and tracheostomy factors, were analysed using Cox proportional hazards model and Kaplan-Meier survival curves, with statistically significant factors then analysed using univariate logistic regression to determine a relationship to short or prolonged LOC as defined by the lowest and highest quartiles of the study cohort. The number of tracheostomy-related adverse events was analysed using the Kaplan-Meier survival curve. RESULTS One hundred twenty patients met the inclusion criteria. Patients who had their tracheostomy performed for loss of upper airway were associated with short LOC (odds ratio [OR]: 2.30 (95% confidence interval [CI]: 1.01-5.25) p = 0.049). Three factors were associated with prolonged LOC: an abdominal/gastrointestinal tract diagnosis (OR: 5.00 [95% CI: 1.40-17.87] p = 0.013), major surgery (OR: 2.51 [95% CI: 1.05-6.01] p = 0.038), and intubation for >12 days (OR: 0.30 [95% CI: 0.09-0.97] p = 0.044). Patients who had one or ≥2 tracheostomy-related adverse events had a high likelihood of prolonged LOC (OR: 5.21 [95% CI: 1.95-13.94] p = ≤0.001 and OR: 12.17 [95% CI: 2.68-55.32] p ≤ 0.001, respectively). CONCLUSION Some factors that are known at the time of tracheostomy insertion are associated with duration of tracheostomy cannulation. Tracheostomy-related adverse events are related to a high risk of prolonged LOC.
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Affiliation(s)
- Charissa J Zaga
- Department of Speech Pathology, Austin Health, Melbourne, Australia; Tracheostomy Review and Management Service, Austin Health, Melbourne, Australia; Institute of Breathing and Sleep, Austin Health, Melbourne, Australia.
| | - Joanne M Sweeney
- Department of Speech Pathology, Austin Health, Melbourne, Australia; Tracheostomy Review and Management Service, Austin Health, Melbourne, Australia
| | - Tanis S Cameron
- Tracheostomy Review and Management Service, Austin Health, Melbourne, Australia
| | - Matthew C Campbell
- Department of Ear Nose and Throat Surgery Department, Austin Health, Melbourne, Australia
| | | | - Mark E Howard
- Institute of Breathing and Sleep, Austin Health, Melbourne, Australia; Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Australia
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Affiliation(s)
| | - Brendan A McGrath
- Manchester University NHS Foundation Trust, Manchester, UK.,Manchester Academic Critical Care, School of Biological Sciences, The University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Vinciya Pandian
- 15851Johns Hopkins University School of Nursing, Baltimore, MD, USA.,Outcomes After Critical Illness and Surgery (OACIS) Research Group, 1466Johns Hopkins University, Baltimore, MD, USA
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Chorath K, Hoang A, Rajasekaran K, Moreira A. Association of Early vs Late Tracheostomy Placement With Pneumonia and Ventilator Days in Critically Ill Patients: A Meta-analysis. JAMA Otolaryngol Head Neck Surg 2021; 147:450-459. [PMID: 33704354 DOI: 10.1001/jamaoto.2021.0025] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Importance The timing of tracheostomy placement in adult patients undergoing critical care remains unestablished. Previous meta-analyses have reported mixed findings regarding early vs late tracheostomy placement for ventilator-associated pneumonia (VAP), ventilator days, mortality, and length of intensive care unit (ICU) hospitalization. Objective To compare the association of early (≤7 days) vs late tracheotomy with VAP and ventilator days in critically ill adults. Data Sources A search of MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, references of relevant articles, previous meta-analyses, and gray literature from inception to March 31, 2020, was performed. Study Selection Randomized clinical trials comparing early and late tracheotomy with any of our primary outcomes, VAP or ventilator days, were included. Data Extraction and Synthesis Two independent reviewers conducted all stages of the review. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline was followed. Pooled odds ratios (ORs) or the mean difference (MD) with 95% CIs were calculated using a random-effects model. Main Outcomes and Measures Primary outcomes included VAP and duration of mechanical ventilation. Intensive care unit days and mortality (within the first 30 days of hospitalization) constituted secondary outcomes. Results Seventeen unique trials with a cumulative 3145 patients (mean [SD] age range, 32.9 [12.7] to 67.9 [17.6] years) were included in this review. Individuals undergoing early tracheotomy had a decrease in the occurrence of VAP (OR, 0.59 [95% CI, 0.35-0.99]; 1894 patients) and experienced more ventilator-free days (MD, 1.74 [95% CI, 0.48-3.00] days; 1243 patients). Early tracheotomy also resulted in fewer ICU days (MD, -6.25 [95% CI, -11.22 to -1.28] days; 2042 patients). Mortality was reported for 2445 patients and was comparable between groups (OR, 0.66 [95% CI, 0.38-1.15]). Conclusions and Relevance Compared with late tracheotomy, early intervention was associated with lower VAP rates and shorter durations of mechanical ventilation and ICU stay, but not with reduced short-term, all-cause mortality. These findings have substantial clinical implications and may result in practice changes regarding the timing of tracheotomy in severely ill adults requiring mechanical ventilation.
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Affiliation(s)
- Kevin Chorath
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia
| | - Ansel Hoang
- Division of Neonatology, Department of Pediatrics, University of Texas Health-San Antonio
| | | | - Alvaro Moreira
- Division of Neonatology, Department of Pediatrics, University of Texas Health-San Antonio
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Sella Weiss O, Gvion A, Mcrae J. Speech and language therapists' management of ventilated patients and patients with tracheostomy in Israel. Int J Lang Commun Disord 2021; 56:1053-1063. [PMID: 34357667 DOI: 10.1111/1460-6984.12655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 06/06/2021] [Accepted: 06/15/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND There is increased involvement of speech and language therapists (SLTs) in critical care and long-term units supporting patients with ventilatory needs and complex dysphagia. SLTs have a range of specialist knowledge in the function of the pharynx and larynx to enable them to support therapeutic interventions and contribute to the management of those patients. In Israel, there are currently no designated courses or training programmes for SLTs to establish advanced clinical skills in tracheostomy and ventilator management. There are currently standards of care for SLT working in designated wards for ventilated patients, however not in acute wards, critical care, and internal medicine wards where ventilated patients can be hospitalized. AIMS To identify the skills and expertise of the Israeli SLT workforce working with tracheostomy patients. Specifically, to identify their level of training, access to training, client population, work settings, and level of work confidence. METHODS The study involved electronic distribution of a 55-item online survey to SLTs in Israel. The questions included demographic information, training, confidence, and clinical support. RESULTS Responses were received from 47 SLTs. The majority (40.4%) spent between 1% and 9% of their clinical time with ventilated patients. Almost 80% work with seniors (≥65 years) and almost 70% work with adults (18-65 years) half the time or more. In inpatient rehabilitation, 46.8% reported that they manage patients with tracheostomy half the time or more. In outpatient rehabilitation settings, 21.3% reported that they manage patients with tracheostomy half the time or more. Prior to managing complex airway patients independently, 55.3% received less than 5 h formal tracheostomy training whilst 68.1% received less than 5 h training on ventilated patients. Multidisciplinary teams (MDTs) existed for tracheostomy patients (85.1%) and ventilated patients (70.2%) and high levels of confidence were reported for managing patients with tracheostomies (mode of 4 in a scale of 0-5, where 5 means fully confident) and ventilated patients (mode of 3 in a scale of 0-5). A significant relationship was found between level of confidence and presence of an MDT. CONCLUSIONS Limited training access was found for SLTs working with this complex population. A competency framework needs to be established with access to training and supervision. MDT existence contributes to confidence. Most respondents worked in rehabilitation settings, and very few worked in acute care, critical care, and internal medicine wards. It seems reasonable that in order to change this, minimal standards of care should be established on these wards. WHAT THIS PAPER ADDS What is already known on the subject Speech and language therapists (SLTs) have an important role in critical care and long-term units supporting patients with complex dysphagia and undergo formal training and supervision in UK and Australia. What this paper adds to existing knowledge In Israel, most SLTs work with tracheostomy and ventilated adult patients in rehabilitation settings, whilst few work in acute, critical care, and internal medicine wards. There are limited opportunities for formal training and supervision, although MDT support enhances clinical confidence. What are the potential or actual clinical implications of this work? SLTs in Israel would benefit from establishing a competency framework for tracheostomy and ventilator patient management to support training, standards of care, and increase clinical involvement in acute settings. This will enhance clinical outcomes for their large population of complex airway patients.
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Affiliation(s)
- Oshrat Sella Weiss
- Department of Communication Sciences and Disorders, University of Haifa, Haifa, Israel
- Speech and Language Department, Reuth Rehabilitation Hospital, Tel Aviv, Israel
| | - Aviah Gvion
- Speech and Language Department, Reuth Rehabilitation Hospital, Tel Aviv, Israel
- Department of Communication Sciences and Disorders, Ono Academic College, Kiryat Ono, Israel
| | - Jackie Mcrae
- Center for Allied Health, St George's University of London, United Kingdom of Great Britain and Northern Ireland, London, UK
- Speech and Language Therapy Department, University College London Hospitals, NHS Foundation Trust
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Abstract
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 .
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Affiliation(s)
- Thomas Williams
- Academic Foundation Trainee, University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, UK
| | - Brendan A McGrath
- Acute Intensive Care Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.
- Manchester Academic Critical Care, Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.
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Graham JM, Fisher CM, Cameron TS, Streader TG, Warrillow SJ, Chao C, Chong CK, Ellard L, Hamoline JL, McMurray KA, Phillips DJ, Ross JM, Vu Q. Emergency tracheostomy management cognitive aid. Anaesth Intensive Care 2021; 49:227-231. [PMID: 33887975 PMCID: PMC8258718 DOI: 10.1177/0310057x21989722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
| | - Caleb M Fisher
- Intensive Care Department, Austin Health, Melbourne, Australia
| | - Tanis S Cameron
- Tracheostomy Review and Management Service, Austin Health, Melbourne, Australia
| | | | | | - Caroline Chao
- Tracheostomy Review and Management Service, Austin Health, Melbourne, Australia
| | | | - Louise Ellard
- Department of Anaesthesia, Austin Health, Melbourne, Australia
| | - Jerome L Hamoline
- Tracheostomy Review and Management Service, Austin Health, Melbourne, Australia
| | - Kristy A McMurray
- Yooralla Ventilator Accommodation Support Service, Melbourne, Australia
| | - Damien J Phillips
- Department of ENT Surgery, Austin Health, Melbourne, Australia.,Department of ENT Surgery, The Royal Children's Hospital Melbourne, Melbourne, Australia
| | - Jacqueline M Ross
- Tracheostomy Review and Management Service, Austin Health, Melbourne, Australia
| | - Quevy Vu
- Tracheostomy Review and Management Service, Austin Health, Melbourne, Australia
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43
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Affiliation(s)
- S Wallace
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - B A McGrath
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,University of Manchester Academic Critical Care, Wythenshawe Hospital, Manchester, UK
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Rosero EB, Corbett J, Mau T, Joshi GP. Intraoperative Airway Management Considerations for Adult Patients Presenting With Tracheostomy: A Narrative Review. Anesth Analg 2021; 132:1003-1011. [PMID: 33369928 DOI: 10.1213/ane.0000000000005330] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Tracheotomy is a surgical procedure through which a tracheostomy, an opening into the trachea, is created. Indications for tracheostomy include facilitation of airway management during prolonged mechanical ventilation, treatment of acute upper airway obstruction when tracheal intubation is unfeasible, management of chronic upper airway obstructive conditions, and planned airway management for major head and neck surgery. Patients who have a recent or long-term tracheostomy may present for a variety of surgical or diagnostic procedures performed under general anesthesia or sedation/analgesia. Airway management of these patients can be challenging and should be planned ahead of time. Anesthesia personnel should be familiar with the different components of cuffed and uncuffed tracheostomy devices and their connectivity to the anesthesia circuits. An appropriate airway management plan should take into account the indication of the tracheostomy, the maturity status of the stoma, the type and size of tracheostomy tube, the expected patient positioning, and presence of patient's concurrent health conditions. Management of the patient with a T-tube is highlighted. Importantly, there is a need for multidisciplinary care involving anesthesiologists, surgical specialists, and perioperative nurses. The aim of this narrative review is to discuss the anesthesia care of patients with a tracheostomy. Key aspects on relevant tracheal anatomy, tracheostomy tubes/devices, alternatives of airway management, and possible complications related to tracheostomy are summarized with a recommendation for an algorithm to manage intraoperative tracheostomy tube dislodgement.
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Affiliation(s)
- Eric B Rosero
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas
| | - John Corbett
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas
| | - Ted Mau
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Girish P Joshi
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas
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45
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Archer SK, Iezzi CM, Gilpin L. Swallowing and Voice Outcomes in Patients Hospitalized With COVID-19: An Observational Cohort Study. Arch Phys Med Rehabil 2021; 102:1084-90. [PMID: 33529610 DOI: 10.1016/j.apmr.2021.01.063] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 12/31/2022]
Abstract
Objective To evaluate the presentations and outcomes of inpatients with coronavirus disease 2019 (COVID-19) presenting with dysphonia and dysphagia to investigate trends and inform potential pathways for ongoing care. Design Observational cohort study. Setting An inner-city National Health Service Hospital Trust in London, United Kingdom. Participants All adult inpatients hospitalized with COVID-19 (N=164) who were referred to Speech and Language Therapy (SLT) for voice and/or swallowing assessment for 2 months starting in April 2020. Interventions SLT assessment, advice, and therapy for dysphonia and dysphagia. Main Outcome Measures Evidence of delirium, neurologic presentation, intubation, tracheostomy, and proning history were collected, along with type of SLT provided and discharge outcomes. Therapy outcome measures were recorded for swallowing and tracheostomy pre- and post-SLT intervention and Grade Roughness Breathiness Asthenia Strain Scale for voice. Results Patients (N=164; 104 men) aged 56.8±16.7 years were included. Half (52.4%) had a tracheostomy, 78.7% had been intubated (mean, 15±6.6d), 13.4% had new neurologic impairment, and 69.5% were delirious. Individualized compensatory strategies were trialed in all and direct exercises with 11%. Baseline assessments showed marked impairments in dysphagia and voice, but there was significant improvement in all during the study (P<.0001). On average, patients started some oral intake 2 days after initial SLT assessment (interquartile range [IQR], 0-8) and were eating and drinking normally on discharge, but 29.3% (n=29) of those with dysphagia and 56.1% (n=37) of those with dysphonia remained impaired at hospital discharge. A total of 70.9% tracheostomized patients were decannulated, and the median time to decannulation was 19 days (IQR, 16-27). Among the 164 patients, 37.3% completed SLT input while inpatients, 23.5% were transferred to another hospital, 17.1% had voice, and 7.8% required community follow-up for dysphagia. Conclusions Inpatients with COVID-19 present with significant impairments of voice and swallowing, justifying responsive SLT. Prolonged intubations and tracheostomies were the norm, and a minority had new neurologic presentations. Patients typically improved with assessment that enabled treatment with individualized compensatory strategies. Services preparing for COVID-19 should target resources for tracheostomy weaning and to enable responsive management of dysphagia and dysphonia with robust referral pathways.
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Brenner MJ, De Cardenas J, Standiford TJ, McGrath BA. Assessing Candidacy for Tracheostomy in Ventilated Patients With Coronavirus Disease 2019: Aligning Patient-Centered Care, Stakeholder Engagement, and Health-Care Worker Safety. Chest 2021; 159:454-455. [PMID: 33422227 PMCID: PMC7831711 DOI: 10.1016/j.chest.2020.07.100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 07/10/2020] [Indexed: 12/03/2022] Open
Affiliation(s)
- Michael J Brenner
- Department of Otolaryngology-Head & Neck Surgery, University of Michigan Medical School, Ann Arbor, MI.
| | - Jose De Cardenas
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Interventional Pulmonology Program, University of Michigan Medical School, Ann Arbor, MI
| | - Theodore J Standiford
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Interventional Pulmonology Program, University of Michigan Medical School, Ann Arbor, MI
| | - Brenden A McGrath
- Anaesthesia & Intensive Care Medicine, Manchester University NHS Foundation Trust; Faculty of Biology, Medicine and Health, the University of Manchester, Manchester, UK
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Bier-Laning C, Cramer JD, Roy S, Palmieri PA, Amin A, Añon JM, Bonilla-Asalde CA, Bradley PJ, Chaturvedi P, Cognetti DM, Dias F, Di Stadio A, Fagan JJ, Feller-Kopman DJ, Hao SP, Kim KH, Koivunen P, Loh WS, Mansour J, Naunheim MR, Schultz MJ, Shang Y, Sirjani DB, St John MA, Tay JK, Vergez S, Weinreich HM, Wong EWY, Zenk J, Rassekh CH, Brenner MJ. Tracheostomy During the COVID-19 Pandemic: Comparison of International Perioperative Care Protocols and Practices in 26 Countries. Otolaryngol Head Neck Surg 2020; 164:1136-1147. [PMID: 33138722 DOI: 10.1177/0194599820961985] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The coronavirus disease 2019 (COVID-19) pandemic has led to a global surge in critically ill patients requiring invasive mechanical ventilation, some of whom may benefit from tracheostomy. Decisions on if, when, and how to perform tracheostomy in patients with COVID-19 have major implications for patients, clinicians, and hospitals. We investigated the tracheostomy protocols and practices that institutions around the world have put into place in response to the COVID-19 pandemic. DATA SOURCES Protocols for tracheostomy in patients with severe acute respiratory syndrome coronavirus 2 infection from individual institutions (n = 59) were obtained from the United States and 25 other countries, including data from several low- and middle-income countries, 23 published or society-endorsed protocols, and 36 institutional protocols. REVIEW METHODS The comparative document analysis involved cross-sectional review of institutional protocols and practices. Data sources were analyzed for timing of tracheostomy, contraindications, preoperative testing, personal protective equipment (PPE), surgical technique, and postoperative management. CONCLUSIONS Timing of tracheostomy varied from 3 to >21 days, with over 90% of protocols recommending 14 days of intubation prior to tracheostomy. Most protocols advocate delaying tracheostomy until COVID-19 testing was negative. All protocols involved use of N95 or higher PPE. Both open and percutaneous techniques were reported. Timing of tracheostomy changes ranged from 5 to >30 days postoperatively, sometimes contingent on negative COVID-19 test results. IMPLICATIONS FOR PRACTICE Wide variation exists in tracheostomy protocols, reflecting geographical variation, different resource constraints, and limited data to drive evidence-based care standards. Findings presented herein may provide reference points and a framework for evolving care standards.
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Affiliation(s)
- Carol Bier-Laning
- Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - John D Cramer
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Soham Roy
- Department of Otorhinolaryngology-Head and Neck Surgery, Children's Memorial Hermann Hospital, University of Texas Medical School, Houston, Texas, USA
| | - Patrick A Palmieri
- Office of the Vice Chancellor for Research, Universidad Norbert Wiener, Lima, Peru.,EBHC South America: A Joanna Briggs Affiliated Group, Lima, Peru
| | - Ayman Amin
- Head and Neck Department, National Cancer Institute, Cairo University, Egypt
| | - José Manuel Añon
- La Paz-Carlos III University Hospital, IdiPAZ, Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Cesar A Bonilla-Asalde
- Hospital Nacional Daniel Alcides Carrión, Lima, Perú.,Universidad Privada San Juan Bautista, Lima, Perú
| | - Patrick J Bradley
- Department of Otolaryngology, Head and Neck Oncologic Surgery, University of Nottingham, Nottingham, UK
| | - Pankaj Chaturvedi
- Department of Head & Neck Surgical Oncology, Tata Memorial Centre, Mumbai, India
| | - David M Cognetti
- Department of Otolaryngology-Head & Neck Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Philadelphia, USA
| | - Fernando Dias
- Head and Neck Surgery Service, Brazilian National Cancer Institute, Chairman, Department of Head and Neck Surgery, Post-Graduation School of Medicine, Catholic University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Johannes J Fagan
- Division of Otorhinolaryngology (ENT), University of Cape Town, Cape Town, South Africa
| | - David J Feller-Kopman
- Departments of Medicine, Anesthesiology and Otolaryngology-Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sheng-Po Hao
- Department of Otorhinolaryngology-Head & Neck Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei.,Department of Otorhinolaryngology-Head & Neck Surgery, Fu Jen Catholic University School of Medicine, New Taipei City
| | - Kwang Hyun Kim
- Department of Otolaryngology-Head and Neck Surgery and Cancer Research Institute, Bundang Jesaeng Hospital Seoul National University College of Medicine, Seoul, Korea
| | - Petri Koivunen
- Department of Otolaryngology, Oulu University Hospital, Oulu, Finland
| | - Woei Shyang Loh
- Department of Otolaryngology-Head and Neck Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jobran Mansour
- Department of Otorhinolaryngology-Head and Neck Surgery, Sheba Medical Center, Tel Hashomer, Israel
| | - Matthew R Naunheim
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Marcus J Schultz
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·CA), Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - You Shang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Davud B Sirjani
- Department of Otorhinolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Maie A St John
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Jonsson Comprehensive Cancer Center, UCLA Medical Center, Los Angeles, California, USA.,UCLA Head and Neck Cancer Program, UCLA Medical Center, Los Angeles, California, USA
| | - Joshua K Tay
- Department of Otolaryngology-Head and Neck Surgery, National University of Singapore, Singapore
| | - Sébastien Vergez
- Department of Otolaryngology-Head & Neck Surgery, University Hospital Rangueil-Larrey, Toulouse, France
| | - Heather M Weinreich
- Department of Otolaryngology, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Eddy W Y Wong
- Department of Otorhinolaryngology, Head & Neck Surgery, Chinese University of Hong Kong, Hong Kong
| | - Johannes Zenk
- Universitätsklinikum Augsburg Klinik für HNO-Heilkunde, Augsburg, Germany
| | - Christopher H Rassekh
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael J Brenner
- Department of Otolaryngology-Head & Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Global Tracheostomy Collaborative, Raleigh, North Carolina, USA
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Brenner MJ, Cramer JD, McGrath BA, Balakrishnan K, Stepan KO, Pandian V, Roberson DW, Shah RK, Chen AY, Brook I, Nussenbaum B. Oral Intubation Attempts in Patients With a Laryngectomy: A Significant Safety Threat. Otolaryngol Head Neck Surg 2020; 164:1040-1043. [PMID: 33048019 DOI: 10.1177/0194599820960728] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
It is impossible to secure the airway of a patient with "neck-only" breathing transorally or transnasally. Surgical removal of the larynx (laryngectomy) or tracheal rerouting (tracheoesophageal diversion or laryngotracheal separation) creates anatomic discontinuity. Misguided attempts at oral intubation of neck breathers may cause hypoxic brain injury or death. We present national data from the American Academy of Otolaryngology-Head and Neck Surgery, the American Head and Neck Society, and the United Kingdom's National Reporting and Learning Service. Over half of US otolaryngologist respondents reported instances of attempted oral intubations among patients with laryngectomy, with a mortality rate of 26%. UK audits similarly revealed numerous resuscitation efforts where misunderstanding of neck breather status led to harm or death. Such data underscore the critical importance of staff education, patient engagement, effective signage, and systems-based best practices to reliably clarify neck breather status and provide necessary resources for safe patient airway management.
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Affiliation(s)
- Michael J Brenner
- Department of Otolaryngology-Head and Neck Surgery, Medical School, University of Michigan, Ann Arbor, Michigan, USA
| | - John D Cramer
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Wayne State University, Detroit, Michigan, USA
| | - Brendan A McGrath
- National Tracheostomy Safety Project, National Health System, Manchester, UK
- Anaesthesia and Intensive Care Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - Karthik Balakrishnan
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Stanford University, Stanford, California, USA
| | - Katelyn O Stepan
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Vinciya Pandian
- Society of Otorhinolaryngology and Head-Neck Nurses, School of Nursing, Johns Hopkins University
| | | | - Rahul K Shah
- Children's National Medical Center, Washington, DC, USA
| | - Amy Y Chen
- Department of Otolaryngology-Head and Neck Surgery, Winship Cancer Institute, School of Medicine, Emory University, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | - Brian Nussenbaum
- American Board of Otolaryngology-Head and Neck Surgery, Houston, Texas, USA
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Schultz MJ, Teng MS, Brenner MJ. Timing of Tracheostomy for Patients With COVID-19 in the ICU—Setting Precedent in Unprecedented Times. JAMA Otolaryngol Head Neck Surg 2020; 146:887-888. [DOI: 10.1001/jamaoto.2020.2630] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Marcus J. Schultz
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, Amsterdam, the Netherlands
- Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Marita S. Teng
- Department of Otolaryngology–Head & Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michael J. Brenner
- Department of Otolaryngology–Head & Neck Surgery, University of Michigan Medical School, Ann Arbor
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50
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Meister KD, Pandian V, Hillel AT, Walsh BK, Brodsky MB, Balakrishnan K, Best SR, Chinn SB, Cramer JD, Graboyes EM, McGrath BA, Rassekh CH, Bedwell JR, Brenner MJ. Multidisciplinary Safety Recommendations After Tracheostomy During COVID-19 Pandemic: State of the Art Review. Otolaryngol Head Neck Surg 2020; 164:984-1000. [PMID: 32960148 DOI: 10.1177/0194599820961990] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE In the chronic phase of the COVID-19 pandemic, questions have arisen regarding the care of patients with a tracheostomy and downstream management. This review addresses gaps in the literature regarding posttracheostomy care, emphasizing safety of multidisciplinary teams, coordinating complex care needs, and identifying and managing late complications of prolonged intubation and tracheostomy. DATA SOURCES PubMed, Cochrane Library, Scopus, Google Scholar, institutional guidance documents. REVIEW METHODS Literature through June 2020 on the care of patients with a tracheostomy was reviewed, including consensus statements, clinical practice guidelines, institutional guidance, and scientific literature on COVID-19 and SARS-CoV-2 virology and immunology. Where data were lacking, expert opinions were aggregated and adjudicated to arrive at consensus recommendations. CONCLUSIONS Best practices in caring for patients after a tracheostomy during the COVID-19 pandemic are multifaceted, encompassing precautions during aerosol-generating procedures; minimizing exposure risks to health care workers, caregivers, and patients; ensuring safe, timely tracheostomy care; and identifying and managing laryngotracheal injury, such as vocal fold injury, posterior glottic stenosis, and subglottic stenosis that may affect speech, swallowing, and airway protection. We present recommended approaches to tracheostomy care, outlining modifications to conventional algorithms, raising vigilance for heightened risks of bleeding or other complications, and offering recommendations for personal protective equipment, equipment, care protocols, and personnel. IMPLICATIONS FOR PRACTICE Treatment of patients with a tracheostomy in the COVID-19 pandemic requires foresight and may rival procedural considerations in tracheostomy in their complexity. By considering patient-specific factors, mitigating transmission risks, optimizing the clinical environment, and detecting late manifestations of severe COVID-19, clinicians can ensure due vigilance and quality care.
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Affiliation(s)
- Kara D Meister
- Aerodigestive and Airway Reconstruction Center, Lucile Packard Children's Hospital, Stanford Children's Health, Palo Alto, California, USA.,Center for Pediatric Voice and Swallowing Disorders, Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Lucile Packard Children's Hospital, Stanford Children's Health, Palo Alto, California, USA
| | - Vinciya Pandian
- Department of Nursing Faculty, Johns Hopkins University, Baltimore, Maryland, USA.,Outcomes After Critical Illness and Surgery Research Group, Johns Hopkins University, Baltimore, Maryland, USA
| | - Alexander T Hillel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Brian K Walsh
- Department of Health Sciences, Liberty University, Lynchburg, Virginia, USA
| | - Martin B Brodsky
- Outcomes After Critical Illness and Surgery Research Group, Johns Hopkins University, Baltimore, Maryland, USA.,Department of Physical and Rehabilitation, Johns Hopkins University, Baltimore, Maryland, USA.,Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Karthik Balakrishnan
- Aerodigestive and Airway Reconstruction Center, Lucile Packard Children's Hospital, Stanford Children's Health, Palo Alto, California, USA.,Center for Pediatric Voice and Swallowing Disorders, Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Lucile Packard Children's Hospital, Stanford Children's Health, Palo Alto, California, USA
| | - Simon R Best
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Steven B Chinn
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Michigan, USA
| | - John D Cramer
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Wayne State University, Detroit, Michigan, USA
| | - Evan M Graboyes
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.,Hollings Cancer Center, Charleston, South Carolina, USA
| | - Brendan A McGrath
- University of Manchester, NHS Foundation Trust, National Tracheostomy Safety Project, Manchester, UK
| | - Christopher H Rassekh
- Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua R Bedwell
- Baylor College of Medicine, Houston, Texas, USA.,Division of Pediatric Otolaryngology-Head and Neck Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Michael J Brenner
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA; Global Tracheostomy Collaborative, Raleigh, North Carolina, USA
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