Purpose
Tracheostomy is one of the most frequently performed procedures in intensive care medicine. The two main approaches are open surgical tracheostomy (ST) and percutaneous dilatational ...tracheostomy (PDT). This systematic review summarizes and analyzes the existing evidence regarding perioperative and postoperative parameters of safety.
Methods
A systematic literature search was conducted in the Cochrane Library, EMBASE, LILACS, and MEDLINE to identify all randomized controlled trials (RCTs) comparing complications of ST and PDT and to define the strategy with the lower risk of potentially life-threatening events. Risk of bias was assessed using the criteria outlined in the Cochrane Handbook.
Results
Twenty-four citations comprising 1795 procedures (PDT:
n
= 926; ST:
n
= 869) were found suitable for systematic review. No significant difference in the risk of a potentially life-threatening event (risk difference (RD) 0.01, 95% CI − 0.03 to 0.05,
P
= 0.62,
I
2
= 47%) was found between PDT and ST. There was no difference in mortality (RD − 0.00, 95% CI − 0.01 to 0.01,
P
= 0.88,
I
2
= 0%). An increased rate of technical difficulties was shown for PDT (RD 0.04, 95% CI 0.01, 0.08,
P
= 0.01,
I
2
= 60%). Stomal infection occurred more often with ST (RD − 0.05, 95% CI − 0.08 to − 0.02,
P
= 0.003,
I
2
= 60%). Both techniques can be safely performed on the ICU. Meta-analysis of the duration of procedure was not possible owing to high heterogeneity (
I
2
= 99%).
Conclusion
ST and PDT are safe techniques with low incidence of complications. Both techniques can be performed successfully in an ICU setting. ST can be performed on every patient whereas PDT is restricted by several contraindications like abnormal anatomy, previous surgery, coagulopathies, or difficult airway of the patient.
Systematic review registration
PROSPERO CRD42015021967
Objective
To report the long‐term outcome of utilization of a silicone stent to support the management of a permanent tracheostomy.
Study design
Short case series.
Animals
Two client‐owned ...brachycephalic dogs.
Methods
Two brachycephalic dogs with stage III laryngeal collapse underwent permanent tracheostomy. After the tracheostomy had healed, a silicone stent was inserted to support the stoma and facilitate home care. One dog wore a commercially available silicone stent for the follow‐up period of 2 years. For the dog in Case 2, a 3D‐printed, medical‐grade silicone stent with an increased length was designed, as the dog had developed skin sores from the commercial device.
Results
Both dogs tolerated the silicone stent well. Stent care was managed by the owners without need for assistance. They reported that the silicone stent facilitated cleaning of the stoma surroundings and that they felt an increased confidence in airway patency, as the device prevented the tracheal stoma from collapsing. In Case 1, tracheoscopy 1 year after first stent insertion revealed minimal visible changes to the tracheal stoma. In Case 2, the 3D printed silicone stent led to a remission of skin sores and the dog wore the device comfortably until succumbing to an unrelated disease 13 months later.
Conclusion
The insertion of a silicone stent is a simple and cost‐effective method to improve home care of dogs with permanent tracheostomy. Larger dogs, as in Case 2, may benefit from custom‐designed 3D‐printed stents.
In emergency airway management, the occurrence of surgical tracheotomy complications is increased and may be fatal for the patient. However, the factors that play a role in complication occurrence ...and lead to lethal outcome are not known. The objective of this study was to determine predictors associated with the occurrence of complications and mortality after emergency surgical tracheostomy.
Retrospective study with a systematic review of the literature.
Tertiary medical academic center.
We included 402 adult patients who underwent emergency surgical tracheostomy under local anesthesia due to upper airway obstruction. Demographic, clinical, complication occurrence, and mortality data were collected. For statistical analysis, univariable and multivariable logistic regression methods were used.
In multivariable analysis, significant positive predictors of complication occurrence were previously performed tracheotomy (odds ratio OR 3.67, 95% confidence interval CI, 0.75-17.88), neck pathology (OR 2.05, 95% CI 1.1-1.77), and tracheotomy performed outside the operating room (OR 5.88, 95% CI, 1.58-20). General in-hospital mortality was 4%, but lethal outcome as a direct result of tracheotomy complications occurred in only 4 patients (1%) because of intraoperative and postoperative complications.
The existence of neck pathology and situations in which tracheotomy was performed outside the operating room in uncontrolled conditions were significant prognostic factors for complication occurrence. Tracheotomy-related mortality was greater in patients with intraoperative and early postoperative complications. Clinicians should be aware of the increased risk in specific cases, to prepare, prevent, or manage unwanted outcomes in further treatment and care.
We aimed to discern clinico-demographic predictors of large (≥8) tracheostomy tube size placement, and, secondarily, to assess the effect of large tracheostomy tube size and other parameters on odds ...of decannulation before hospital discharge.
Factors determining choice of tracheostomy tube size are not well-characterized in the current literature, despite evidence linking large tracheostomy tube size with posttracheotomy tracheal stenosis. The effect of tracheostomy tube size on timing of decannulation is also unknown, an important consideration given reported associations between endotracheal tube size and probability of failed extubation.
We collected information pertaining to patients who underwent tracheotomy at 1 of 10 U.S. health care institutions between 2010 and 2019. Tracheostomy tube size was dichotomized (≥8 and <8). Multivariable logistic regression models were fit to identify predictors of (1) large tracheostomy tube size, and (2) decannulation before hospital discharge.
The study included 5307 patients, including 2797 (52.7%) in the large tracheostomy cohort. Patient height (odds ratio OR = 1.060 per inch; 95% confidence interval CI 1.041-1.070) and obesity (1.37; 95% CI 1.1891.579) were associated with greater odds of large tracheostomy tube; otolaryngology performing the tracheotomy was associated with significantly lower odds of large tracheostomy tube (OR = 0.155; 95% CI 0.131-0.184). Large tracheostomy tube size (OR = 1.036; 95% CI 0.885-1.213) did not affect odds of decannulation.
Obesity was linked with increased likelihood of large tracheostomy tube size, independent of patient height. Probability of decannulation before hospital discharge is influenced by multiple patient-centric factors, but not by size of tracheostomy tube.
Objectives
To determine the incidence of tracheostomy accidental decannulations (AD) among pediatric inpatients and identify risks for these events.
Study Design
Prospective cohort.
Methods
All ...tracheostomy patients (≤18 years) admitted at a tertiary children's hospital between August 2018 and April 2021 were included. AD were recorded and patient harm was classified as no harm/minor, moderate, or severe. Monthly AD incidence was described as events per 1000 tracheostomy‐days.
Results
One‐hundred seventeen AD occurred among 67 children with 33% (22/67) experiencing multiple events (median: 2.5 events, range: 2–10). Mean age at AD was 4.7 years (SD: 4.4). AD resulted from patient movement (32%, 37/117), performing tracheostomy care (27%, 31/117), repositioning or transporting (15%, 17/117), or unclear reasons (27%, 32/117). A parent or guardian was involved in 28% (33/117) of events. Nearly all AD resulted in no more than minor harm (84%, 98/117) but moderate (12%, 14/117) and severe (4%, 5/117) events did occur. There were no deaths. Tracheostomy care or repositioning were frequently responsible in acute versus subacute events (48% vs. 26%, p = 0.04). Mean monthly AD incidence was 4.7 events per 1000 tracheostomy‐days (95% CI: 3.7–5.8) and after implementation of safety initiatives, the mean rate decreased from 5.9 events (95% CI: 4.2–7.7) to 3.7 events (95% CI: 2.5–5.0) per 1000 tracheostomy‐days (p = 0.04).
Conclusions
AD in children occur at nearly 5 events per 1000 tracheostomy‐days and often result in minimal harm. Quality initiatives targeting patient movement, provider education, and tracheostomy care might reduce the frequency of these complications.
Level of Evidence
3 Laryngoscope, 133:963–969, 2023
Accidental decannulations among pediatric tracheostomy patients can be a worrisome complication. A prospective study determined that the rate of these events is about 5 per 1000 tracheostomy days and that most events result in minor harm. This information can be used to design patient safety and quality improvement initiatives for this vulnerable population.
Background
The optimal timing of tracheostomy placement in acutely brain-injured patients, who generally require endotracheal intubation for airway protection rather than respiratory failure, remains ...uncertain. We systematically reviewed trials comparing early tracheostomy to late tracheostomy or prolonged intubation in these patients.
Methods
We searched 5 databases (from inception to April 2015) to identify randomized controlled trials comparing early tracheostomy (≤10 days of intubation) with late tracheostomy (>10 days) or prolonged intubation in acutely brain-injured patients. We contacted the principal authors of included trials to obtain subgroup data. Two reviewers extracted data and assessed risk of bias. Outcomes included long-term mortality (primary), short-term mortality, duration of mechanical ventilation, complications, and liberation from ventilation without a tracheostomy. Meta-analyses used random-effects models.
Results
Ten trials (503 patients) met selection criteria; overall study quality was moderate to good. Early tracheostomy reduced long-term mortality (risk ratio RR 0.57. 95 % confidence interval (CI), 0.36–0.90;
p
= 0.02;
n
= 135), although in a sensitivity analysis excluding one trial, with an unclear risk of bias, the significant finding was attenuated (RR 0.61, 95 % CI, 0.32–1.16;
p
= 0.13;
n
= 95). Early tracheostomy reduced duration of mechanical ventilation (mean difference MD −2.72 days, 95 % CI, −1.29 to −4.15;
p
= 0.0002;
n
= 412) and ICU length of stay (MD −2.55 days, 95 % CI, −0.50 to −4.59;
p
= 0.01;
n
= 326). However, early tracheostomy did not reduce short-term mortality (RR 1.25; 95 % CI, 0.68–2.30;
p
= 0.47
n
= 301) and increased the probability of ever receiving a tracheostomy (RR 1.58, 95 % CI, 1.24–2.02; 0 < 0.001;
n
= 377).
Conclusions
Performing an early tracheostomy in acutely brain-injured patients may reduce long-term mortality, duration of mechanical ventilation, and ICU length of stay. However, waiting longer leads to fewer tracheostomy procedures and similar short-term mortality. Future research to explore the optimal timing of tracheostomy in this patient population should focus on patient-centered outcomes including patient comfort, functional outcomes, and long-term mortality.
Background
Long‐term mechanical ventilation is the most common situation for which tracheostomy is indicated for patients in intensive care units (ICUs). 'Early' and 'late' tracheostomies are two ...categories of the timing of tracheostomy. Evidence on the advantages attributed to early versus late tracheostomy is somewhat conflicting but includes shorter hospital stays and lower mortality rates.
Objectives
To evaluate the effectiveness and safety of early (≤ 10 days after tracheal intubation) versus late tracheostomy (> 10 days after tracheal intubation) in critically ill adults predicted to be on prolonged mechanical ventilation with different clinical conditions.
Search methods
This is an update of a review last published in 2012 (Issue 3, The Cochrane Library) with previous searches run in December 2010. In this version, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 8); MEDLINE (via PubMed) (1966 to August 2013); EMBASE (via Ovid) (1974 to August 2013); LILACS (1986 to August 2013); PEDro (Physiotherapy Evidence Database) at www.pedro.fhs.usyd.edu.au (1999 to August 2013) and CINAHL (1982 to August 2013). We reran the search in October 2014 and will deal with any studies of interest when we update the review.
Selection criteria
We included all randomized and quasi‐randomized controlled trials (RCTs or QRCTs) comparing early tracheostomy (two to 10 days after intubation) against late tracheostomy (> 10 days after intubation) for critically ill adult patients expected to be on prolonged mechanical ventilation.
Data collection and analysis
Two review authors extracted data and conducted a quality assessment. Meta‐analyses with random‐effects models were conducted for mortality, time spent on mechanical ventilation and time spent in the ICU.
Main results
We included eight RCTs (N = 1977 participants). At the longest follow‐up time available in these studies, evidence of moderate quality from seven RCTs (n = 1903) showed lower mortality rates in the early as compared with the late tracheostomy group (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.70 to 0.98; P value 0.03; number needed to treat for an additional beneficial outcome (NNTB) ≅ 11). Divergent results were reported on the time spent on mechanical ventilation and no differences were noted for pneumonia, but the probability of discharge from the ICU was higher at day 28 in the early tracheostomy group (RR 1.29, 95% CI 1.08 to 1.55; P value 0.006; NNTB ≅ 8).
Authors' conclusions
The whole findings of this systematic review are no more than suggestive of the superiority of early over late tracheostomy because no information of high quality is available for specific subgroups with particular characteristics.
To compare percutaneous with surgical tracheostomy using a meta-analysis of studies published from 1960 to 1996.
Publications obtained through a MEDLINE database search with a Boolean combination ...(tracheostomy or tracheotomy) and complications, with constraints for human studies and English language.
Publications addressing all peri- and postoperative complications. Studies limited to specific tracheostomy complications or containing insufficient details were excluded. Two authors independently selected the publications.
A list of relevant surgical variables and complications was compiled. Complications were divided into peri- and postoperative groups and further subclassified into severe, intermediate, and minor groups. Because most studies of percutaneous tracheostomy were published after 1985, surgical tracheostomy studies were divided into two periods: 1960 to 1984 and 1985 to 1996. The articles were analyzed independently by three investigators, and rare discrepancies were resolved through discussion and data reexamination.
Earlier surgical tracheostomy studies (n = 17; patients, 4185) have the highest rates of both peri- (8.5%) and postoperative (33%) complications. Comparison of recent surgical (n = 21; patients, 3512) and percutaneous (n = 27; patients, 1817) tracheostomy trials shows that perioperative complications are more frequent with the percutaneous technique (10% vs. 3%), whereas postoperative complications occur more often with surgical tracheotomy (10% vs. 7%). The bulk of the differences is in minor complications, except perioperative death (0.44% vs. 0.03%) and serious cardiorespiratory events (0.33% vs. 0.06%), which were higher with the percutaneous technique. Heterogeneity analysis of complication rates shows higher heterogeneity in older and surgical trials.
Percutaneous tracheostomy is associated with a higher prevalence of perioperative complications and, especially, perioperative deaths and cardiorespiratory arrests. Postoperative complication rates are higher with surgical tracheostomy.
The aim of this study is to assess the impact of tracheostomy on radiotherapy in patients with laryngeal cancer.
This is a prospective qualitative study conducted in the year 2022, including 49 ...patients undergoing radiotherapy for laryngeal cancer. Patients were interviewed using a questionnaire with several items during their weekly follow-up consultations. They were required to rate each step of radiotherapy (in the supine position, the application and maintenance of the thermoformed mask, positioning, dosimetric CT scan, and the treatment session) on a scale from 0 to 10, with 0 representing no discomfort and 10 representing extreme discomfort. Patients were also asked to report their level of anxiety during each step. Correlations were explored using the Pearson coefficient.
The age of patients ranged from 42 to 84 years with a median of 63 years. The most common histological type was squamous cell carcinoma. Tracheostomy was performed urgently in 34 patients, accounting for 69.38%, and scheduled in 15 patients, accounting for 30.61%.
According to our surveyed patients, the application and maintenance of the thermoformed mask were the most unpleasant moments, with an average discomfort rating of 8.5/10 and an average anxiety level of 9/10. The averages for other items varied between 3/10 and 8/10. In response to the question “What do you fear the most during the session?”, 11 patients, or 22.44%, believed that the thermoformed mask could cause them asphyxiation. No significant correlations were found.
To ensure the smooth progress of radiotherapy in tracheostomized patients, it is essential to provide prior explanations for all stages of radiotherapy, its benefits, and its side effects. Adequate management of specific situations and a trusting relationship between medical personnel and the patient are also necessary.
Percutaneous Tracheostomy Hashimoto, Daniel A; Axtell, Andrea L; Auchincloss, Hugh G
The New England journal of medicine,
11/2020, Volume:
383, Issue:
20
Journal Article
PDF
