Objective
Report long‐term tracheostomy outcomes in patients with COVID‐19.
Study Design
Review of prospectively collected data.
Methods
Prospectively collected data were extracted for adults with ...COVID‐19 undergoing percutaneous or open tracheostomy between April 4, 2020 and June 2, 2020 at a major medical center in New York City. The primary endpoint was weaning from mechanical ventilation. Secondary outcomes included sedation weaning, decannulation, and discharge.
Results
One hundred one patients underwent tracheostomy, including 48 percutaneous (48%) and 53 open (52%), after a median intubation time of 24 days (IQR 20, 31). The most common complication was minor bleeding (n = 18, 18%). The all‐cause mortality rate was 15% and no deaths were attributable to the tracheostomy. Eighty‐three patients (82%) were weaned off mechanical ventilation, 88 patients (87%) were weaned off sedation, and 72 patients (71%) were decannulated. Censored median times from tracheostomy to sedation and ventilator weaning were 8 (95% CI 6–11) and 18 (95% CI 14–22) days, respectively (uncensored: 7 and 15 days). Median time from tracheostomy to decannulation was 36 (95% CI 32–47) days (uncensored: 32 days). Of those decannulated, 82% were decannulated during their index admission. There were no differences in outcomes or complication rates between percutaneous and open tracheostomy. Likelihood of discharge from the ICU was inversely related to intubation time, though the clinical relevance of this was small (HR 0.97, 95% CI 0.943–0.998; P = .037).
Conclusion
Tracheostomy by either percutaneous or open technique facilitated sedation and ventilator weaning in patients with COVID‐19 after prolonged intubation. Additional study on the optimal timing of tracheostomy in patients with COVID‐19 is warranted.
Level of Evidence
3 Laryngoscope, 131:E2849–E2856, 2021
Percutaneous tracheostomy is a surgical procedure performed in intensive care units, often at the bedside. It plays a leading role in providing comfort to the patient and discharging patients from ...the intensive care unit in a prolonged period. To examine the relationship between the timing of tracheostomy and mortality, number of days in intensive care unit. To determine the demographic characteristics of the patients who underwent tracheostomy, the reason for the need for intubation, the timing of the tracheostomy, and the complications that developed during and after the tracheostomy procedure. We aimed to compare the characteristics of survivor and deceased patients with tracheotomy.
The data were retrospectively scanned and recorded to evaluate the demographic characteristics, comorbidities, tracheostomy day, reason and course of intubation of the patients who underwent tracheostomy by two intensive care specialists.
Patients under the age of 18 and those who underwent tracheostomy by the otolaryngologists were excluded. Data are given as median (min-max) and %. Mann-Whitney U and Chi-square tests were applied as statistical methods.
The patients were analyzed as survivors and those who deceased. Demographic characteristics were similar between the two groups. No correlation was found between the time of tracheostomy and mortality (p = 0,698)
Mean intubation time was 19 days in survivors group and 15 days in deceased group (p = 0.449). The most important indicator of mortality was the underlying cause of intubation. In patients who underwent tracheostomy due to respiratory failure, mortality was significantly higher than in patients who underwent tracheostomy due to GCS <8.(p = 0.006). Mortality was found to be significantly higher in patients receiving vasopressors (p = 0.045).
While 10 surviving patients were decannulated through tracheostomy, 1 person in the deceased group died after being decannulated (Table1).
In our study, no relationship was found between the timing of tracheostomy and mortality. Although this situation is compatible with the literature, it does not seem logical considering the benefits of tracheostomy to the patient. The presence of patients followed up with Covid 19 may have contributed to this. Since our study is a retrospective evaluation, it is thought that randomized controlled studies will be more guiding for science.
Tracheostomy is one of the most common operations. The two main methods of tracheostomy are open surgical tracheostomy (OST) and percutaneous dilatational tracheostomy (PDT). In critical cases, the ...combination of these two approaches is especially crucial, with the possibility of successful outcomes and low complications. Thus, the purpose of this system is to analyse the effects of both methods on the outcome of postoperative wound. In this research, we performed a systematic review of Cochrane Library, PubMed, Web of Science and Embase, to determine all randomized controlled trials (RCTs) that are comparable in terms of postoperative injury outcomes. Eleven RCTs were found after screening. This study will take the necessary data from the selected trials and evaluate the documentation for RCTs. PDT was associated with a lower incidence of infection at the wound site than OST (OR, 4.46; 95% CI: 2.84–7.02 p < 0.0001), and PDT decreased blood loss (OR, 2.88; 95% CI: 1.62–5.12 p = 0.0003). But the operation time did not differ significantly in both PDT to OST (MD, 4.65; 95% CI: −1.19–10.48 p = 0.12). The meta‐analyses will assist physicians in selecting the best operative procedure for critical cases of tracheostomy. These data can serve as guidelines for clinical management and in the design of future randomized, controlled studies.
Tracheostomy tubes Hess, Dean R; Altobelli, Neila P
Respiratory care,
06/2014, Volume:
59, Issue:
6
Journal Article
Peer reviewed
Open access
Tracheostomy tubes are used to administer positive-pressure ventilation, to provide a patent airway, and to provide access to the lower respiratory tract for airway clearance. They are available in a ...variety of sizes and styles from several manufacturers. The dimensions of tracheostomy tubes are given by their inner diameter, outer diameter, length, and curvature. Differences in dimensions between tubes with the same inner diameter from different manufacturers are not commonly appreciated but may have important clinical implications. Tracheostomy tubes can be cuffed or uncuffed and may be fenestrated. Some tracheostomy tubes are designed with an inner cannula. It is important for clinicians caring for patients with a tracheostomy tube to appreciate the nuances of various tracheostomy tube designs and to select a tube that appropriately fits the patient. The optimal frequency of changing a chronic tracheostomy tube is controversial. Specialized teams may be useful in managing patients with a tracheostomy. Speech can be facilitated with a speaking valve in patients with a tracheostomy tube who are breathing spontaneously. In mechanically ventilated patients with a tracheostomy, a talking tracheostomy tube, a deflated cuff technique with a speaking valve, or a deflated cuff technique without a speaking valve can be used to facilitate speech.
Background
Tracheostomy is a frequently performed procedure that allows for definitive airway access in critically ill patients. Complications associated with tracheostomy have been well documented ...in the literature. This study aims to examine if different tracheostomy techniques were associated with specific complications. Secondary objectives were to determine the rate and commonality of post-tracheostomy complications.
Methods
This was a descriptive retrospective study of patients who underwent tracheostomy between June 2009 and June 2019. Patients included in the study were ≥18 years and were admitted to a rural tertiary care hospital system.
Results
Overall procedure complication rate was 34.3% with pneumonia (18.6%), obstruction (6.2%), bleeding (4.0%), and accidental tube decannulation (3.8%) being the most common. Rate of complications was not associated with the timing of the tracheostomy, the incision type, tube location, tracheostomy technique, and securing technique. However, tube size significantly differed between patients with or without complications (P = .016). Tube size 8 Shiley was most commonly used in both groups and was significantly associated with reduced complication rate (72.0% vs 78.8%, P = .002).
Conclusion
Tracheostomy technique should be guided by proceduralist experience and patient clinical picture to determine the best approach. However, the association of post-tracheostomy complication with tube size perhaps will guide clinicians with tube size selection.
Background
The COVID-19 pandemic overwhelmed New York City hospitals early in the pandemic. Shortages of ventilators and sedatives prompted tracheostomy earlier than recommended by professional ...societies. This study evaluates the impact of percutaneous dilational tracheostomy (PDT) in COVID+ patients on critical care capacity.
Methods
This is a single-institution prospective case series of mechanically ventilated COVID-19 patients undergoing PDT from April 1 to June 4, 2020 at a public tertiary care center.
Results
Fifty-five patients met PDT criteria and underwent PDT at a median of 13 days (IQR 10, 18) from intubation. Patient characteristics are found in Table 1. Intravenous midazolam, fentanyl, and cisatracurium equivalents were significantly reduced 48 hours post-PDT (Table 2). Thirty-five patients were transferred from the ICU and liberated from the ventilator. Median time from PDT to ventilator liberation and ICU discharge was 10 (IQR 4, 14) and 12 (IQR 8, 17) days, respectively. Decannulation occurred in 45.5% and 52.7% were discharged from acute inpatient care (Figure 1). Median follow-up for the study was 62 days. Four patients had bleeding complications postoperatively and 11 died during the study period. Older age was associated with increased odds of complication (OR 1.12, 95% CI 1.04, 1.23) and death (OR=1.15, 95% CI 1.05, 1.30). All operators tested negative for COVID-19 during the study period.
Conclusion
These findings suggest COVID-19 patients undergoing tracheostomy within the standard time frame can improve critical care capacity in areas strained by the pandemic with low risk to operators. Long-term outcomes after PDT deserve further study.
Pediatric patients undergoing tracheostomy placement are often medically fragile with multiple comorbidities. The complexity of these patients partnered with the risks of a newly placed tracheostomy ...necessitates a clear understanding of patient management and clinical competence. At our institution, a quality improvement initiative was formed with a focus on increasing the safety of these patients by developing a postoperative care guideline.
Background
A significant proportion of Coronavirus Disease 2019 (COVID-19) patients require admission to the intensive care unit (ICU) and invasive mechanical ventilation (IMV). Tracheostomy is ...increasingly performed when a prolonged course of IMV is anticipated.
Objectives
To determine clinical and resource utilization benefits of early versus late tracheostomy among COVID-19 patients.
Methods
Pubmed, Cochrane Library, Scopus, and Embase were used to identify relevant studies comparing outcomes of COVID-19 patients undergoing early and late tracheostomy from January 1, 2020, to December 1, 2021.
Results
Twelve studies were selected, and 2222 critically ill COVID-19 patients hospitalized between January to December 2020 were included. Among the included patients, 34.5% and 65.5% underwent early and late tracheostomy, respectively. Among the included studies, 58.3% and 41.7% defined early tracheostomy using cutoffs of 14 and 10 days, respectively. All-cause in-hospital mortality was not different between the early and late tracheostomy groups (32.9% vs. 33.1%; OR = 1.00; P = 0.98). Sensitivity analysis demonstrated a similar mortality rate in studies using a cutoff of 10 days (34.6% vs. 35.5%; OR = 0.97; P = 0.89) or 14 days (31.2% vs. 27.7%; OR = 1.05; P = 0.78). The early tracheostomy group had shorter ICU length of stay (LOS) (mean: 23.18 vs. 30.51 days; P < 0.001) and IMV duration (mean: 20.49 vs. 28.94 days; P < 0.001) than the late tracheostomy group. The time from tracheostomy to decannulation was longer (mean: 23.36 vs. 16.24 days; P = 0.02) in the early tracheostomy group than in the late tracheostomy group, but the time from tracheostomy to IMV weaning was similar in both groups. Other clinical characteristics, including age, were similar in both groups.
Conclusions
Early tracheostomy reduced the ICU LOS and IMV duration among COVID-19 patients compared with late tracheostomy, but the mortality rate was similar in both groups. The findings have important implications for the treatment of COVID-19 patients, especially in a resource-limited setting.
The performance of tracheotomy is a common procedural request by critical care departments to the surgical services of general surgery, thoracic surgery and otolaryngology - head & neck surgery. A ...Canadian Society of Otolaryngology - Head & Neck Surgery (CSO-HNS) task force was convened with multi-specialty involvement from otolaryngology-head & neck surgery, general surgery, critical care and anesthesiology to develop a set of recommendations for the performance of tracheotomies during the COVID-19 pandemic.
The tracheotomy procedure is highly aerosol generating and directly exposes the entire surgical team to the viral aerosol plume and secretions, thereby increasing the risk of transmission to healthcare providers. As such, we believe extended endotracheal intubation should be the standard of care for the entire duration of ventilation in the vast majority of patients. Pre-operative COVID-19 testing is highly recommended for any non-emergent procedure.
The set of recommendations in this document highlight the importance of avoiding tracheotomy procedures in patients who are COVID-19 positive if at all possible. Recommendations for appropriate PPE and environment are made for COVID-19 positive, negative and unknown patients requiring consideration of tracheotomy. The safety of healthcare professionals who care for ill patients and who keep critical infrastructure operating is paramount.
Objective
The purpose of this study was to identify risk factors for perioperative complications and long‐term morbidity in infants from the neonatal intensive care unit (NICU) presenting for a ...tracheostomy.
Methods
This single‐center retrospective cohort study included infants in the NICU presenting for a tracheostomy from August 2011 to December 2019. Primary outcomes were categorized as either a perioperative complication or long‐term morbidity. A severe perioperative complication was defined as having either (1) an intraoperative cardiopulmonary arrest, (2) an intraoperative death, (3) a postoperative cardiopulmonary arrest within 30 days of the procedure, or (4) a postoperative death within 30 days of the procedure. Long‐term morbidities included (1) the need for gastrostomy tube placement within the tracheostomy hospitalization and (2) the need for diuretic therapy, pulmonary hypertensive therapy, oxygen, or mechanical ventilation at 12 and 24 months following the tracheostomy.
Results
One‐hundred eighty‐three children underwent a tracheostomy. The mean age at tracheostomy was 16.9 weeks while the mean post‐conceptual age at tracheostomy was 49.7 weeks. The incidence of severe perioperative complications was 4.4% (n = 8) with the number of pulmonary hypertension medication classes preoperatively (OR: 3.64, 95% CI: (1.44–8.94), p = 0.005) as a significant risk factor. Approximately 81% of children additionally had a gastrostomy tube placed at the time of the tracheostomy, and 62% were ventilator‐dependent 2 years following their tracheostomy.
Conclusion
Our study provides critical perioperative complications and long‐term morbidity data to neonatologists, pediatricians, surgeons, anesthesiologists, and families in the expected course of infants from the NICU presenting for a tracheostomy.
Level of Evidence
3 Laryngoscope, 134:1945–1954, 2024
The purpose of this study was to identify risk factors for perioperative complications and long‐term morbidity in infants from the neonatal intensive care unit (NICU) presenting for a tracheostomy. This single‐center retrospective cohort study found an incidence of severe perioperative complications of 4.4%, including perioperative cardiac arrest and death, with the number of pulmonary hypertension medication classes preoperatively as a significant risk factor. Furthermore, approximately 81% of patients had a gastrostomy tube placement at the time of the tracheostomy and 62% of patients were ventilator dependent 2 years following the tracheostomy. Our study provides critical perioperative and long‐term data to neonatologists, pediatricians, surgeons, anesthesiologists, and families about the expected course of infants from the NICU presenting for a tracheostomy.
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