The role of tracheostomy during the coronavirus disease 2019 (COVID-19) pandemic remains unknown. The goal of this consensus statement is to examine the current evidence for performing tracheostomy ...in patients with respiratory failure from COVID-19 and offer guidance to physicians on the preparation, timing, and technique while minimizing the risk of infection to health care workers (HCWs).
A panel including intensivists and interventional pulmonologists from three professional societies representing 13 institutions with experience in managing patients with COVID-19 across a spectrum of health-care environments developed key clinical questions addressing specific topics on tracheostomy in COVID-19. A systematic review of the literature and an established modified Delphi consensus methodology were applied to provide a reliable evidence-based consensus statement and expert panel report.
Eight key questions, corresponding to 14 decision points, were rated by the panel. The results were aggregated, resulting in eight main recommendations and five additional remarks intended to guide health-care providers in the decision-making process pertinent to tracheostomy in patients with COVID-19-related respiratory failure.
This panel suggests performing tracheostomy in patients expected to require prolonged mechanical ventilation. A specific timing of tracheostomy cannot be recommended. There is no evidence for routine repeat reverse transcription polymerase chain reaction testing in patients with confirmed COVID-19 evaluated for tracheostomy. To reduce the risk of infection in HCWs, we recommend performing the procedure using techniques that minimize aerosolization while wearing enhanced personal protective equipment. The recommendations presented in this statement may change as more experience is gained during this pandemic.
The study objective is to identify factors that impact the time to decannulation in pediatric patients ages 0 through 18 years who are tracheostomy-dependent.
This retrospective chart review from ...January 1, 2005 through December 31, 2020 identified pediatric tracheostomy patients at a single pediatric institution. Data extracted included demographic, socioeconomic factors, and clinical characteristics. Multivariate regression and survival analysis were used to identify factors associated with successful decannulation and decreased time with tracheostomy.
Of the 479 tracheostomy-dependent patients identified, 162 (33.8%) were decannulated. Time to decannulation ranged from 0.5 months to 189.2 months with median of 24 months (IQR 12.91–45.71). In the multivariate analysis, patients with bronchopulmonary dysplasia (p = 0.021) and those with Passy-Muir® Valve at discharge (p = 0.015) were significantly associated with decannulation. In contrast, neurologic comorbidities (p = 0.06), presence of gastrostomy tube (p < 0.001), or discharged on a home ventilator (p < 0.001) were associated with indefinite tracheostomy. When adjusting for age, sex, race, ethnicity, and insurance status, for every one month delay in establishment of outpatient otolaryngology care, time to decannulation was delayed by 0.5 months (p = 0.010). For each additional outpatient otolaryngology follow-up visit, time to decannulation increased by 3.36 months (p < 0.001).
Decannulation in pediatric tracheostomy patients is multifactorial. While timely establishment of outpatient care did correlate with quicker decannulation, factors related to medical complexity may have a greater impact on time to decannulation. Our results can help guide institutional decannulation protocols, as well as provide guidance when counseling families regarding tracheostomy expectations.
Currently, due to the spread of the COVID-19 pandemic, the need for long-term mechanical ventilation in many critically ill patients represents the most common situation for which tracheostomy is ...performed. Given the growing number of new procedures, it is possible to expect a future increase in the number of patients who will develop cicatricial tracheal stenosis. This condition should be kept in mind for patients with a history of mechanical ventilation who experience progressive dyspnoea. We present a case of a 64-year-old man who successfully underwent surgical treatment of tracheal stenosis after tracheotomy for COVID-19.
Percutaneous tracheostomy is routinely performed in adult patients but is seldomly used in the pediatric population due to concerns regarding safety and limited available evidence. This study aims to ...consolidate the current literature on percutaneous tracheostomy in the pediatric population.
A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted. MEDLINE, EMBASE, CINAHL, and Web of Science were searched for studies on pediatric percutaneous tracheostomy (age ≤18). The Joanna Briggs Institute and ROBINS-I tools were used for quality appraisal.
Twenty-one articles were included resulting in 143 patients. Patient age ranged from 2 days to 17 years, with the largest subpopulation of patients (n = 57, 40 %) being adolescents (age between 12 and 17 years old). Main indications for percutaneous tracheostomy included prolonged ventilation (n = 6), respiratory insufficiency (n = 5), and upper airway obstruction (n = 5). One-third (n = 47) of percutaneous tracheostomies were completed at the bedside in an intensive care unit. Select studies reported on surgical time and time from intubation to tracheostomy with a mean of 13.8 (SD = 7.8) minutes (n = 27) and 8.9 (SD = 2.8) days (n = 35), respectively. Major postoperative complications included tracheoesophageal fistula (n = 4, 2.8 %) and pneumothorax (n = 3, 2.1 %). There were four conversions to open tracheostomy.
Percutaneous tracheostomy had a similar risk of complications to open surgical tracheostomy in children and adolescents and can be performed at the bedside in a select group of patients if necessary. However, we feel that consideration must be given to the varying anatomical considerations in children and adolescents compared with adults, and therefore suggest that this procedure be reserved for adolescent patients with a thin body habitus and clearly demarcated and palpable anatomical landmarks who require a tracheostomy. When performed, we strongly support using endoscopic guidance and a surgeon who has the ability to convert to an open tracheostomy if required.
•Pediatric percutaneous tracheostomy has a low complication rate and procedure time.•Risk profiles for percutaneous versus open tracheostomy are similar in children.•Percutaneous tracheostomy may be suitable for adolescents with thin body habitus and clearly demarcated anatomical landmarks.•Current data on pediatric percutaneous tracheostomy are heterogeneous and limited.•Future studies should employ more rigorous designs to explore the safety and feasibility of the percutaneous approach in children.
Tracheostomy is one of the most frequent procedures performed in the intensive care unit (ICU), with over 100,000 performed annually in the United States.1 First described by Ciaglia in 1985,2 ...percutaneous dilatational tracheostomy (PDT) has become the standard of care for tracheostomy placement performed at the bedside. The addition of video bronchoscopy during PDT, which allows for direct visualization during tracheal cannulation and dilation, has further increased the safety of the procedure.3 Despite this, accidental extubation remains a rare but feared complication of PDT, with reported occurrence rates of 0.1–3.3%.4–6 Typically, the tip of the endotracheal tube (ETT) is withdrawn into the subglottic space at the commencement of the procedure. Maintaining airway access via the guidewire is especially critical in patients where emergent orotracheal re-intubation may be difficult e.g. high body-mass-index (BMI), small inter-incisor gap, presence of cervical spine external fixator, history of difficult intubations.
Background
Children with tracheostomy are frequently admitted to the hospital for tracheostomy‐associated respiratory infections (TRAINs). However, there remains a paucity of evidence to direct the ...diagnosis, treatment, and prevention of TRAINs. An important first step to addressing this knowledge gap is to synthesize existing data regarding TRAINs to inform current practice and facilitate innovation.
Data Sources
We searched PubMed, Embase, Cochrane Library, CINAHL, and Web of Science from inception to October 2020. Original research articles and published s including children and young adults 0–21 years of age with tracheostomy were included. Included studies assessed the clinical definitions of and risk factors for TRAINs, microbiologic epidemiology and colonization of tracheostomies, and treatment and outcomes of TRAINs.
Data Synthesis
Out of 5755 studies identified in the search, 78 full‐text studies were included in the final review. A substantial number of studies focused on the detection of specific pathogens in respiratory cultures including Pseudomonas aeruginosa. Several different definitions of TRAIN including clinical, microbiologic, and laboratory testing results were utilized; however, no uniform set of criteria were identified. The few studies focused on treatment and prevention of TRAIN emphasized the role of empiric antimicrobial therapy and the use of inhaled antibiotics.
Conclusions
Despite a growing number of research articles studying TRAINs, there is a paucity of prospective interventional trials to guide the diagnosis, treatment, and prevention of respiratory disease in this vulnerable population. Future research should include studies of interventions designed to improve short‐ and long‐term respiratory‐related outcomes of children with tracheostomy.
Abstract
Background
Some patients on extracorporeal membrane oxygenation (ECMO) require prolonged mechanical ventilation. An early tracheostomy strategy while on ECMO has appeared to be beneficial ...for these patients. This study aims to explore the safety of tracheostomy in ECMO patients.
Methods
This is a retrospective observational single‐center study.
Results
Hundred and nine patients underwent tracheostomy (76 percutaneous and 33 surgical) during V‐V ECMO support over an 8‐year period. Patients with a percutaneous tracheostomy showed a significantly shorter ECMO duration 25.5 (17.3–40.1) vs 37.2 (26.5–53.2) days,
p
= 0.013 and a shorter ECMO‐to‐tracheostomy time 13.3 (8.5–19.7) vs 27.8 (16.3–36.9) days,
p
< 0.001 compared to those who underwent a surgical approach. There was no difference between the two strategies regarding both major and minor/no bleeding (
p
= 0.756). There was no difference in survival rate between patients who underwent percutaneous or surgical tracheostomy (
p
= 0.173). Patients who underwent an early tracheostomy (within 10 days from ECMO insertion) showed a significantly shorter hospital stay (
p
< 0.001) and a shorter duration of V‐V ECMO support (
p
< 0.001). Our series includes 24 patients affected by COVID‐19, who did not show significantly higher rates of major bleeding when compared to non‐COVID‐19 patients (
p
= 0.297). Within the COVID‐19 subgroup, there was no difference in major bleeding rates between surgical and percutaneous approach (
p
= 1.0).
Conclusions
Percutaneous and surgical tracheostomy during ECMO have a similar safety profile in terms of bleeding risk and mortality. Percutaneous tracheostomy may favor a shorter duration of ECMO support and hospital stay and can be considered a safe alternative to surgical tracheostomy, even in COVID‐19 patients, if relevant clinical expertise is available.
Objective
Tracheostomy is performed for various indications ranging from prolonged ventilation to airway obstruction. Many factors may play a role in the incidence of complications in the immediate ...post‐operative period including patient‐related factors. Chronic obstructive pulmonary disease and asthma are some of the most common pulmonary pathologies in the United States. The relationship between obstructive pulmonary diseases and acute post‐tracheostomy complications has been incompletely studied.
Design
A retrospective chart review was designed in order to answer these objectives. Medical records were reviewed for the technique used, complications, and contributing patient factors. Post‐operative complications were defined as any tracheostomy‐related adverse event occurring within 14 days.
Setting
The study took place at an academic comprehensive cancer.
Participants
Inclusion criteria included patients from January 2017 through December 2018 who underwent a tracheostomy. Exclusion criteria included presence of stomaplasty, total laryngectomy, and tracheostomies performed at outside hospitals.
Main outcome measures
Patient factors examined included demographics, comorbidities, and body mass index with the primary outcome measured being the rate of tracheostomy complications.
Results
The most common indication for tracheostomy among the 321 patients that met inclusion criteria was airway obstruction or a head and neck cancer surgical procedure. Obstructive sleep apnea was associated with acute complications in bivariate analysis (29.4% complications, p = .003). Chronic obstructive pulmonary disease and asthma were not associated with acute complications in bivariate analysis (11.6% complications, p = .302). Among the secondary outcomes measured, radiation was associated with early complications occurring in post‐operative days 0–6 (1.1%, p = .029).
Conclusion
Patients with obstructive sleep apnea may have a higher risk of acute post‐tracheostomy complications that might be due to the patient population at risk for obstructive sleep apnea. Patients with obstructive pulmonary pathologies such as asthma or chronic obstructive pulmonary disorder did not have an elevated risk of complications which is clinically significant when considering the utility of ventilation and tracheostomy in the management of acute respiratory failure secondary to these conditions.
Tracheostomy remains one of the most commonly performed surgical procedures in the setting of acute respiratory failure. Tracheostomy literature focuses on 2 aspects of this procedure: when (timing) ...and how (technique). Recent trials have failed to demonstrate an effect of tracheostomy timing on most clinically important endpoints. Nonetheless, relative to continued translaryngeal intubation, studies suggest that tracheostomy use is associated with less need for sedation and enhanced patient comfort. Evidence likewise suggests that percutaneous dilational tracheostomy is advantageous with respect to cost and complication profile and should be considered the preferred approach in appropriately selected patients.
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