Tracheostomy-related data from an intensive care unit for two consecutive years before the COVID-19 pandemic

BACKGROUND Tracheostomy is commonly used in intensive care unit(ICU)patients who are expected to be on long-term mechanical ventilation or suffer from emergency upper airway obstruction.However,some studies have conflicting findings regarding the optimal technique and its timing and benefits.AIM To provide evidence of practice,characteristics,and outcome concerning tracheostomy in an ICU of a tertiary care hospital.METHODS This was a retrospective cohort study including adult critical care patients in a single ICU for two consecutive years.Patients’demographic characteristics,severity of illness(APACHE II score),level of consciousness[Glasgow Coma Scale(GCS)],comorbidities,timing and type of tracheostomy procedure performed and outcome were recorded.We defined late as tracheostomy placement after 8 days or no tracheotomy.RESULTS Data of 660 patients were analyzed(median age of 60 years),median APACHE II score of 19 and median GCS score of 12 at admission.Tracheostomy was performed in 115 patients,of whom 63 had early and 52 late procedures.Early tracheostomy was mainly executed in case of altered level of consciousness and severe critical illness polyneuromyopathy,however there were no significant statistical results(47.6%vs 36.5%,P=0.23)and(23.8%vs 19.2%,P=0.55)respectively.Regarding the method selected,early surgical tracheostomy(ST)was conducted in patients with maxillofacial injuries(50.0%vs 0.0%,P=0.033),whereas late surgical tracheostomy was selected for patients with goiter(44.4%vs 0.0%P=0.033).Patients with early tracheostomy spent significantly fewer days on mechanical ventilation(15.3±8.5 vs 22.8±9.6,P<0.001)and in ICU in general(18.8±9.1 vs 25.4±11.5,P<0.001).Percutaneous dilatation tracheostomy(PDT)vs ST was preferable in older critical care patients in the case of Central Nervous System underlying cause of admission(62.5%vs 26.3%,P=0.004).ST was the method of choice in compromised airway(31.6%,vs 7.3%P=0.008).A large proportion of patients(88/115)with tracheostomy managed to wean from mechanical ventilation and were transferred out of the ICU(100%vs 17.4%,P<0.001).CONCLUSION PDT was performed more frequently in our cohort.This technique did not affect mechanical ventilation days,ventilator-associated pneumonia(VAP),ICU length of stay,or survival.No complications were observed in the percutaneous or surgical tracheostomy groups.Patients undergoing early tracheostomy benefited in terms of mechanical ventilation days and ICU length of stay but not of discharge status,presence of VAP,or survival.

Cervical Spondylodiscitis Revealed by Tracheostomy Infected: A Rare Case Report Management and Outcome

Background: Spondylodiscitis is a spinal infection rare affecting primarily the intervertebral disk and the adjacent vertebral bodies. His diagnosis is difficult and often delayed or missed due to the rarity of the disease. Cervical spondylodiscitis has quite rare findings regarding the common location of spinal abscesses in the lumbar and thoracic regions. To obtain the best patient outcomes, these spinal infections require prompt diagnosis and appropriate treatment. Case description: A 44-year-old boy was admitted to the neurosurgery department of our hospital for heaviness in 4 limbs without gait disorders in context infected tracheostomy after staying in intensive care. MRI spine showed a spine deformity with lyse C4C5 epiduritis and spinal cord compressed. Antibiotics intravenous were started for 1 month the patient benefited from a corpectomy with an iliac graft and anterior cervical plate. The anatomopathological examination revealed an inflammation not specific. He was therefore put on antibiotics for 6 weeks. Three months later the neck pain and limb pain resolved after treatment and a complete return of lower extremity strength. Conclusion: Cervical spondylodiscitis has increased and become more aggressive. While radical surgical debridement, stable reconstruction together with antibiotic therapy remained a reliable approach to achieve complete healing of the inflammation, anterior alone surgery became more applicable.

Late Complication of Tracheostomy: Larynx-Shaped Reorganization of the Tracheal Rings or the True Larynx?

Tracheostomy is a well-established, commonly used surgical procedure, whose early and late complications are widely described in literature. Some of them remain still poorly known, though. One of these rare complications is a peculiar larynx-shaped reorganization of the tracheal rings and cricoid cartilage. This tracheal narrowing seems to be non- symptomatic and not life-threatening, at least as long as the reduction of the lumen is <50% - 75%. Such a finding has never been described so far in the literature, and should be kept in mind as one of late complication of tracheostomy.

Comparative Analysis of Frequency and Structure of Complications after Various Options of Tracheostomy

The article presents a new technique developed by RSCS named after acad. V. Vakhidov for performing percutaneous dilatational tracheostomy by using the improved Howard-Kelly forceps, which ensures stable traction of the guidewire and reduces the risk of trauma to surrounding tissues. In order to assess the feasibility and necessity of carrying out a modified method of tracheostomy, a comparative analysis of the frequency and structure of complications after various options for tracheostomy was carried out, taking into account the presence or absence of risk factors for an adverse outcome.

Sequential invasive-noninvasive mechanical ventilation weaning strategy for patients after tracheostomy

BACKGROUND: Because the continuity and integrity of the trachea are likely damaged to some extent after tracheostomy, the implementation of sequential ventilation has certain difficulties, and sequential invasive-noninvasive ventilation on patients after tracheostomy is less common in practice. The present study aimed to investigate the feasibility of invasive-noninvasive sequential weaning strategy in patients after tracheostomy.METHODS: Fifty patients including 24 patients with withdrawal of mechanical ventilation(conventional group) and 26 patients with sequential invasive-noninvasive weaning by directly plugging of tracheostomy(sequential group) were analyzed retrospectively after appearance of pulmonary infection control(PIC) window. The analysis of arterial blood gases, ventilator-associated pneumonia(VAP) incidence, the total duration of mechanical ventilation, the success rate of weaning and total cost of hospitalization were compared between the two groups.RESULTS: Arterial blood gas analysis showed that the sequential weaning group was better than the conventional weaning group 1 and 24 hours after invasive ventilation. The VAP incidence was lowered, the duration of mechanical ventilation shortened, the success rate of weaning increased, and the total cost of hospitalization decreased.CONCLUSION: Sequential invasive-noninvasive ventilator weaning is feasible in patients after tracheostomy.

Urgent tracheostomy： four-year experience in a tertiary hospital

BACKGROUND: Urgent airway management is one of the most important responsibilities of otolaryngologists, often requiring a multidisciplinary approach. Urgent surgical airway intervention is indicated when an acute airway obstruction occurs or there are intubation difficulties. In these situations, surgical tracheostomy becomes extremely important.METHODS: We retrospectively studied the patients who underwent surgical tracheostomy from 2011 to 2014 by an otolaryngologist team at the operating theater of the emergency department of a tertiary hospital. Indications, complications and clinical evolution of the patients were reviewed.RESULTS: The study included 56 patients(44 men and 12 women) with a median age of 55 years. The procedure was performed under local anesthesia in 21.4% of the patients. Two(3.6%) patients were subjected to conversion from cricothyrostomy to tracheostomy. Head and neck neoplasm was indicated in 44.6% of the patients, deep neck infection in 19.6%, and bilateral vocal fold paralysis in 10.7%. Stridor was the most frequent signal(51.8%). Of the 56 patients, 15 were transferred to another hospital. Among the other 41 patients, 21 were decannulated(average time: 4 months), and none of them were cancer patients. Complications occurred in 5(12.2%) patients: hemorrhage in 3, surgical wound infection in 1, and cervico-thoracic subcutaneous emphysema in 1. No death was related to the procedure.CONCLUSION: Urgent tracheostomy is a life-saving procedure for patients with acute airway obstruction or with diffi cult intubation. It is a safe and effective procedure, with a low complication rate, and should be performed before the patient's clinical status turns into a surgical emergency situation.

Percutaneous Dilational Tracheostomy in the Emergent Setting

Objective: Since its inception, the use of the percutaneous dilational tracheostomy (PDT) has been contraindicated in the setting of an emergent airway. Emerging in the literature are several cases of successful emergent PDTs. Here we present our experience with the use of PDT in managing emergent airways. Study Design: All patients who underwent emergent PDT, using the Ciaglia Blue Rhino Introducer Set (Cook Critical Care, Bloomington,IN), in an academic county hospital setting between February 2010 and May 2012 were included in the study. Electronic medical records were reviewed for demographic and procedural data. Results: Twelve patients were included in the study with ages ranging from 20 to 87 (mean 57) years-old. The most common reason for emergent airway was trauma (7 patients), followed by obstructing neck mass (2 patients), septic shock (2 patients), and angioedema (1 patient). Seven PDTs were performed in the OR, four at bedside and one in the ER. Three of the 12 patients had emergent cricothyroidotomies in place that malfunctioned, requiring emergent conversion. No patients suffered from short term complications. One patient developed a neck abscess at the site of the PDT one month post operatively, two patients had accidental decanulation post operatively, and both were replaced without complication. Conclusions: PDT can be used in the emergent setting in the hands of trained practitioners with minimal complications. A larger, prospective trial is needed to make conclusions regarding patient care.

Fractured tracheostomy tube obturator: A rare cause of respiratory distress in a tracheostomized patient

Foreign body aspiration is a worldwide health problem which often results in life threatening complications. Tracheostomy tube fracture resulting in airway obstruction is a serious condition which has been reported in the medical literature. We report a rare case of a tracheostomy obturator fractured and lodged in tracheobronchial tree in a patient who presented with acute respiratory distress. Rigid or flexible bronchoscopy is frequently necessary for the diagnosis as well as the treatment. In adults, removal of the foreign body can be attempted during a diagnostic examination with a fiberoptic bronchoscope under lignocaine local infiltration with sedation, which may help to avoid any further invasive procedures. Flexible bronchoscopy should always be considered in foreign body aspiration. A periodic review of the techniques of tracheostomy care, including timely check-ups for signs of wear and tear, can possibly eliminate such avoidable late complications.

Timing of tracheostomy in mechanically ventilated COVID-19 patients

According to the World Health Organization as of September 16,2021,there have been over 226 million documented cases of coronavirus disease 2019(COVID-19),which has resulted in more than 4.6 million deaths and approximately 14%develop a more severe disease that requires respiratory assistance such as intubation.Early tracheostomy is recommended for patients that are expected to be on prolonged mechanical ventilation;however,supporting data has not yet been provided for early tracheostomies in COVID-19 patients.The aim of this study was to explore established guidelines for performing tracheostomies in patients diagnosed with COVID-19.Factors considered were patient outcomes such as mortality,ventilator-associated pneumonia,intensive care unit length of stay,complications associated with procedures,and risks to healthcare providers that performed tracheostomies.Various observational studies,meta-analyses,and systematic reviews were collected through a PubMed Database search.Additional sources were found through Google.The search was refined to publications in English and between the years of 2003 and 2021.The keywords used were“Coronavirus”and/or“guidelines”and/or“tracheostomy”and/or“intensive care”.Twenty-three studies were retained.Due to the complex presentation of the respiratory virus COVID-19,previously established guidelines for tracheostomies had to be reevaluated to determine if these guidelines were still applicable to these critically ill ventilated patients.More specifically,medical guidelines state benefits to early tracheostomies in critically ill ventilated non-COVID-19 patients.However,after having conducted this review,the assumptions about the benefits of early tracheostomies in critically ill ventilated patients may not be appropriate for COVID-19 patients.

Intraoperative Tracheostomy Tube Customization

Objectives: This article describes how to make a customized tracheostomy tube immediately in the operating room setting. This is particularly critical when a commercial customized tracheostomy tube cannot be readily obtained. Study Design: Case presentation. Methods/Results: A 73-year-old female was seen in our clinic for management of a recurrent invasive paraganglioma of the thyroid. She underwent a total laryngopharyngectomy, cervical esophagectomy, and anterolateral thigh free flap reconstruction followed by post-operative radiation. In follow-up, the patient presented with dyspnea related to two areas of stenosis, one at the level of her stoma and one at the distal trachea. The patient was therefore taken to the operating room urgently for dilation and placement of a tracheostomy tube. Available tracheostomy tubes were tried and ill fitting as each tube narrowed the patient’s stoma or abutted her distal granulation tissue. To custom create a tracheostomy tube, we used a standard rib shearer to shorten a #6 uncuffed tracheostomy tube by 2 cm. The edges were further smoothed and beveled using sand paper and a diamond burr drill. The finished product was a wide diameter tube with a custom length suited to our patient. Conclusions: Although a simple solution, the use of a rib shearer provides a quick and feasible solution to creating custom length tracheostomy tubes in situations where custom length tubes are needed yet unavailable.

Is tracheostomy suitable for securing airway after facial fi rearm injuries？

BACKGROUND： Head and neck region have many vital structures, and facial fi rearm injuries（FFIs） more likely lead to life-threatening situations than other body injuies. These injuries have highpotential of airway compromise associated with signifi cant morbidity and mortality.METHODS： We describe an 11-year-old boy who had received tracheostomy after a FFIcomplicated with pneumothorax and subcutaneous emphysema 8 hours after the procedure. Thepatient was treated at the Department of Emergency and Critical Care, Gazi University School ofMedicine, Turkey.RESULTS： The patient was discharged without any complications from the Critical Care Unitafter treatment for fi ve days.CONCLUSIONS： Airway management is of utmost importance in resuscitation of FFI, butit is always difficult to secure via the orotracheal route due to the deformed facial structures.Tracheostomy is an option for airway management in FFI affecting head and neck region. However,tracheostomy may be associated with life-threatening complications, which should be closelymonitored with early intervention.

Tracheostomy and venovenous extracorporeal membrane oxygenation for difficult airway patient with carinal melanoma:A case report and literature review

BACKGROUND Anesthesia for tracheal tumor resection is challenging,particularly in patients with a difficult upper airway.We report a case of a difficult upper airway with a metastatic tracheal tumor causing near-total left bronchial obstruction and requiring emergency tracheostomy and venovenous extracorporeal membrane oxygenation(VV-ECMO)support for rigid bronchoscopy-assisted tumor resection.CASE SUMMARY A 41-year-old man with a history of right retromolar melanoma treated by tumor excision and myocutaneous flap reconstruction developed progressive dyspnea on exertion and syncope episodes.Chest computed tomography revealed a 3.0-cm tracheal mass at the carinal level,causing 90%tracheal lumen obstruction.Flexible bronchoscopy revealed a pigmented tracheal mass at the carinal level causing critical carinal obstruction.Because of aggravated symptoms,emergency rigid bronchoscopy for tumor resection and tracheal stenting were planned with standby VV-ECMO.Due to limited mouth opening,tracheostomy was necessary for rigid bronchoscopy access.While transferring the patient to the operating table,sudden desaturation occurred and awake fiberoptic nasotracheal intubation was performed for ventilation support.Femoral and internal jugular vein were catheterized to facilitate possible VV-ECMO deployment.During tracheostomy,progressive desaturation developed and VV-ECMO was instituted immediately.After tumor resection and tracheal stenting,VV-ECMO was weaned smoothly,and the patient was sent for intensive postoperative care.Two days later,he was transferred to the ward for palliative immunotherapy and subsequently discharged uneventfully.CONCLUSION In a difficult airway patient with severe airway obstruction,emergency tracheostomy for rigid bronchoscopy access and standby VV-ECMO can be life-saving,and ECMO can be weaned smoothly after tumor excision.During anesthesia for patients with tracheal tumors causing critical airway obstruction,spontaneous ventilation should be maintained at least initially,and ECMO deployment should be prepared for high-risk patients,such as those with obstructive symptoms,obstructed tracheal lumen>50%,or distal trachea location.

Intention Formation Process for the Use of Tracheostomy and Invasive Ventilation in Patients with Amyotrophic Lateral Sclerosis

Background: Little is known about the intention formation process regarding the use of tracheostomy and invasive ventilation (TIV) in amyotrophic lateral sclerosis (ALS) patients in the course of disease progression. Objective: To clarify the intention formation process in the use of TIV in ALS patients for the purpose of providing decision-making support. Methods: We conducted a follow-up study of 14 patients using semi-structured interviews, participant observation, and medical records review. Results: The patients’ various intentions regarding the use of TIV were formed as their symptoms progressed (e.g., declining motor, swallowing, and respiratory functions). Other factors influencing their decision were their considerations, such as their ability to communicate after receiving TIV treatment, the degree of support they would receive from professionals after TIV treatment, palliative care for physical distress, value of life after TIV treatment, and to what degree they would be a burden on their families. Conclusion: Patients’ intentions regarding the use of TIV were diverse and changeable. The decision of whether or not to use TIV was made out of conviction as well as considering individual experiences of symptom progression and quality of life after TIV use.

Unusual bronchoscopic value in percutaneous dilatational tracheostomy:A case report

BACKGROUND The usage of bronchoscopy during percutaneous dilatational tracheostomy remains under debate.The proponents of bronchoscopy advocating safety of the procedure,whereas the critics raising the concerns about the cost,possible delay in the procedure,and waiting for the device.CASE SUMMARY We are highlighting a case of percutaneous dilatational tracheostomy where bronchoscopy aided in diagnosing a rare situation of wire entrapment within the endotracheal tube,treated by withdrawing the wire from the endotracheal tube with good outcome.CONCLUSION The bronchoscopy guided approach permitted early diagnosis and helped to end the procedure without complication or possible major surgery in a case of accidental wire puncture of the endotracheal tube.

Clinical characteristics of COVID-19 patients who underwent tracheostomy and its effect on outcome:A retrospective observational study

BACKGROUND The exponential rise in Coronavirus disease 2019(COVID-19)cases has resulted in an increased number of patients requiring prolonged ventilatory support and subsequent tracheostomy.With the limited availability of literature regarding the outcomes of COVID-19 patients with tracheostomy,we attempted to study the clinical characteristics and multiple parameters affecting the outcomes in these patients.AIM To determine all-cause mortality following tracheostomy and its association with various risk factors in COVID-19 patients.METHODS This retrospective study included 73 adult COVID-19 patients admitted to the ICU between 1 April,2020 and 30 September,2021 who underwent tracheostomy as a result of acute respiratory failure due to COVID-19.The data collected included demographics(age,sex),comorbidities,type of oxygen support at admission,severity of COVID-19,complications,and other parameters such as admission to tracheostomy,intubation to tracheostomy,ICU stay,hospital stay,and outcome.RESULTS This study included 73 adult patients with an average age of 52±16.67 years,of which 52%were men.The average time for admission to tracheostomy was 18.12±12.98 days while intubation to tracheostomy was 11.97±9 days.The mortality rate was 71.2%and 28.8%of patients were discharged alive.The mean duration of ICU and hospital stay was 25±11 days and 28.21±11.60 days,respectively.Greater age,severe COVID-19,mechanical ventilation,shock and acute kidney injury were associated with poor prognosis;however,early tracheostomy in intubated patients resulted in better outcomes.CONCLUSION Patients with severe COVID-19 requiring mechanical ventilation have a poor prognosis but patients with early tracheostomy may benefit with no added risk.We recommend that the timing of tracheostomy be decided on a case-by-case basis and a well-designed randomised controlled trial should be performed to elucidate the potential benefit of early tracheostomy in such patients.

An unusual cause of late tracheostomy bleed

Human myiasis is common in the tropical and subtropical areas of the world. Tracheostomal myiasis is a rare entity, and only 7 such cases have been reported in literature. Our study emphasizes the importance of health education with regards to hygiene, sanitation and home tracheostomy tube care especially in immunocompromised individuals.

Stenting for the Management of Posttracheostomy Tracheomalacia: Case Report

In patients who undergo prolonged endotracheal intubation, tracheostomy is performed to prevent the tracheal and laryngeal trauma which may be caused by the intubation tube. In this report, a patient who was intubated after a cerebrovascular embolism and required a tracheostomy for 6 months due to decannulation problems is presented. The patient subsequently developed a tracheomalacia. A stent was inserted and seen to provide functional support. Upon removal of the stent, the tracheomalacia improved. Although surgical therapy is claimed to provide higher success rate, stenting may also be a viable option for the management of tracheomalacia and improve the quality of life in patients with good general condition.

A Fatal Arterio-Tracheal Fistula Post-Tracheostomy: A Case Report in a Sub-Saharan Setting

Fatal bleeding in patients with tracheostomy is an uncommon incident, in the order of 0.1% to 1% of cases. It is secondary in 70% of cases to the innominate artery fistula in the tracheal lumen. The fistula is generally created after the necrosis of tracheal rings. The incriminated factors are the type of cannula used, the site of tracheal opening below the 3rd tracheal ring, tracheal infections and the proximity of the innominate artery to the tracheal axis. The outcome of this incident is fatal in most cases. We report the case of a 59-year-old patient with a tracheostomy on the 11th day of his admission to intensive care for severe head trauma secondary to a road accident. On the 22nd day of his admission, the occurrence of a cataclysmic and fatal haemorrhage through the tracheostomy tube evoked an arterio-tracheal fistula of the innominate artery.

The effect of high-flow oxygen via tracheostomy on respiratory pattern and diaphragmatic function in patients with prolonged mechanical ventilation:A randomized,physiological,crossover study

Background Compared to conventional oxygen devices,high-flow oxygen treatment(HFOT)through the nasal cannulae has demonstrated clinical benefits.Limited data exist on whether such effects are also present in HFOT through tracheostomy.Hence,we aimed to examine the short-term effects of HFOT through tracheostomy on diaphragmatic function and respiratory parameters in tracheostomized patients on prolonged mechanical ventilation.Methods A randomized,crossover,physiological study was conducted in our ICU between December 2020 and April 2021,in patients with tracheostomy and prolonged mechanical ventilation.The patients underwent a 30-min spontaneous breathing trial(SBT)and received oxygen either via T-piece or by HFOT through tracheostomy,followed by a washout period of 15-min breathing through the T-piece and receipt of 30-min oxygen with the other modality in a randomized crossover manner.At the start and end of each session,blood gasses,breathing frequency(f),and tidal volume(VT)via a Wright's spirometer were measured,along with diaphragm ultrasonography including diaphragm excursion and diaphragmatic thickening fraction,which expressed the inspiratory muscle effort.Results Eleven patients were enrolled in whom 19 sessions were uneventfully completed;eight patients were studied twice on two different days with alternate sessions;and three patients were studied once.Patients were randomly assigned to start the SBT with a T-piece(n=10 sessions)or with HFOT(n=9 sessions).With HFOT,VT and minute ventilation(VE)significantly increased during SBT(from[465±119]mL to[549±134]mL,P<0.001 and from[12.4±4.3]L/min to[13.1±4.2]L/min,P<0.05,respectively),but they did not change significantly during SBT with T-piece(from[495±132]mL to[461±123]mL and from[12.8±4.4]mL to[12.0±4.4]mL,respectively);f/VT decreased during HFOT(from[64±31]breaths/(min∙L)to[49±24]breaths/(min∙L),P<0.001),but it did not change significantly during SBT with T-piece(from[59±28]breaths/(min∙L)to[64±33]breaths/(min∙L));partial pressure of arterial oxygen increased during HFOT(from[99±39]mmHg to[132±48]mmHg,P<0.001),but it decreased during SBT with T-piece(from[124±50]mmHg to[83±22]mmHg,P<0.01).In addition,with HFOT,diaphragmatic excursion increased(from[12.9±3.3]mm to[15.7±4.4]mm,P<0.001),but it did not change significantly during SBT with T-piece(from[13.4±3.3]mm to[13.6±3.3]mm).The diaphragmatic thickening fraction did not change during SBT either with T-piece or with HFOT.Conclusion In patients with prolonged mechanical ventilation,HFOT through tracheostomy compared with T-piece improves ventilation,pattern of breathing,and oxygenation without increasing the inspiratory muscle effort.Trial Registration Clinicaltrials.gov ldentifer:NCT04758910.

Severe Cut Throat Injury in a Child: A Case Report and Review of Literature

Background: Cut-throat injury is a potentially fatal condition that may be associated with serious morbidity and mortality. The neck region is particularly at risk of serious injuries due to the location of vital structures, including nerves, viscera, and major vessels. Although cut-throat injury is said to be rare in children, its occurrence has been reported in some series. Management of this condition requires a multidisciplinary approach for a better outcome. Aim: The aim of this report is to highlight the successful management of an alarming case of severe cut-throat injury with associated laryngeal injury in a child. Case presentation: A 12-year-old boy presented with a cut-throat following an assault by an unknown person. Examination revealed an acutely ill child, conscious but pale. He sustained a deep transverse laceration that transected the thyroid cartilage, exposing the laryngeal cavity. An assessment of Zone II penetrating neck injury was made. He was resuscitated, and had emergency neck exploration, tracheostomy, and repair of the injuries. The patient was followed up for 6 months, and had a good voice outcome, with no significant complication. Conclusion: Cut-throat injury is rare in children. But it is a potentially life-threatening condition. It is therefore important to recognize this entity and develop effective protocol of management in our environment.