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Tracheal ring fracture and early tracheomalacia following percutaneous dilatational tracheostomy.

ABSTRACT:

Background

Percutaneous dilatational tracheostomy (PDT) is increasingly popular within intensive care units for patients who need prolonged ventilatory support. Significant complications are rare.

Case presentation

Our patient suffered tracheal ring fracture and early tracheomalacia following this procedure. These complications are demonstrated in our accompanying video.

Conclusion

Contrary to common beliefs, tracheal rings are commonly fractured during the PDT procedure. The consequent granulation can lead to tracheal stenosis and tracheomalacia.

SUBMITTER: Ho EC

PROVIDER: S-EPMC1242107 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:INTRODUCTION: Tracheostomy is one of the more commonly performed procedures in critically ill patients yet the optimal method of performing tracheostomies in this population remains to be established. The aim of this study was to systematically review and quantitatively synthesize all randomized clinical trials (RCTs), comparing elective percutaneous dilatational tracheostomy (PDT) and surgical tracheostomy (ST) in adult critically ill patients with regards to major short and long term outcomes. METHODS: MEDLINE, EMBASE, CINAHL and the Cochrane Controlled Clinical Trials Register databases were searched to identify relevant studies. Additionally, bibliographies and selected conference proceedings were reviewed, and experts in the field and manufacturers of two PDT kits were contacted. Randomized clinical trials comparing any method of elective PDT to ST that included critically ill adults and reported at least one clinically relevant outcome were included. Data extracted included trial characteristics, measures of study validity, and clinically relevant outcomes. RESULTS: Seventeen RCTs involving 1,212 patients were included. Most PDTs used a multiple dilator technique and were performed in the intensive care unit (ICU). The pooled odds ratio (OR) for wound infection was 0.28 (95% confidence interval (CI), 0.16 to 0.49, p < 0.0005), indicating a significant reduction with PDT compared to ST. Overall, PDT was equivalent to ST for bleeding, major peri-procedural and long-term complications; however, subgroup analysis suggested PDT resulted in a lower incidence of bleeding (OR = 0.29 (95% CI 0.12 to 0.75, p = 0.01)) and death (OR = 0.71 (95% CI 0.50 to 1.0, p = 0.05)) when the STs were performed in the operating theatre. CONCLUSION: PDT reduces the overall incidence of wound infection and may further reduce clinical relevant bleeding and mortality when compared with ST performed in the operating theatre. PDT, performed in the ICU, should be considered the procedure of choice for performing elective tracheostomies in critically ill adult patients.

Project description:BackgroundBoth single-use and reusable bronchoscopes are suitable for percutaneous dilatational tracheostomy (PDT) to visualise the trachea during the insertion process. To determine the least costly option, the price of single-use bronchoscopes must be weighed against the estimated average cost of a bronchoscopy with reusable equipment. In the latter case, the acquisition cost must be spread over the equipment's useful life and other relevant costs, such as reprocessing and repair, must be included.ObjectiveThis study aimed to calculate the cost of using single-use or reusable bronchoscopes per PDT procedure.MethodsA systematic literature search was conducted to identify studies comparing the costs of reusable and single-use bronchoscopes for PDT. Inclusion criteria were articles assessing the cost of single-use or reusable bronchoscopes, and where costs were divided into acquisition, reprocessing, and repair costs. A questionnaire regarding repair rates and costs for reusable bronchoscopes was sent to 366 hospitals in the US, UK, and Germany to supplement the identified literature.ResultsEleven studies met the inclusion criteria. Ninety-nine completed responses were received, of which 31 hospitals used reusable equipment for PDT. Literature research revealed an average acquisition cost of $US135 (SD 152) and reprocessing cost of $US123 (SD 128). Additionally, a combination of data from the literature and the questionnaires gave a repair cost per use of $US148 (SD 242), resulting in a total average cost of $US406 for reusable bronchoscopes and $US249 (SD 36) for single-use bronchoscopes per PDT procedure. Thus, the incremental cost per use of a reusable bronchoscope compared with a single-use bronchoscope was $US157.ConclusionsWe conclude that significant savings can be made by using single-use bronchoscopes to guide PDT in preference to reusable bronchoscopes. Results depend on hospital setting, the reprocessing procedures, annual bronchoscope procedures, individual repair cost, and repair rates.

Project description:BackgroundTeaching and assessing clinical procedures requires a clear delineation of the individual steps required to successfully complete the procedure. For decades, human reliability analysis (HRA) has been used to identify the steps required to complete technical procedures in higher risk industries. However, the use of HRA is uncommon in healthcare. HRA has great potential supporting simulation-based education (SBE) in two ways: (1) to support training through the identification of the steps required to complete a clinical procedure; and (2) to support assessment by providing a framework for evaluating performance of a clinical procedure. The goal of this study was to use HRA to identify the steps (and the risk associated with each of these steps) required to complete a bronchoscope-assisted percutaneous dilatational tracheostomy (BPDT). BPDT is a potentially high-risk minimally invasive procedure used to facilitate tracheostomy placement at the bedside or in the operating theatre.MethodsThe subgoals, or steps, required to complete the BPDT procedure were identified using hierarchical task analysis. The Systematic Human Error Reduction and Prediction Approach (SHERPA) was then used to identify potential human errors at each subgoal, the level of risk and how these potential errors could be prevented.ResultsThe BPDT procedure was broken down into 395 subgoals, of which 18% were determined to be of high-risk. The most commonly identified remediation strategies for reducing the risk of the procedure included: checklist implementation and audit, statutory and mandatory training modules, simulation training, consultant involvement in all procedures, and fostering a safety-focused hospital culture.ConclusionThis study provides an approach for how to systematically identify the steps required to complete a clinical procedure for both training and assessment. An understanding of these steps is the foundation of SBE. HRA can identify 'a correct way' for teaching learners how to complete a technical procedure, and support teachers to give systematic and structured feedback on performance.

Project description:BackgroundApart from conventional reusable bronchoscopes, single-use bronchoscopes (SUB) were recently introduced. Data suggest that SUB might prevent from the risk of cross contamination (i.e. multiresistant pathogens, SARS CoV-2) and save costs. We aimed to investigate visualization, ventilation, handling characteristics, changes in patients' gas exchange, and costs associated with both types of bronchoscopes during percutaneous dilatational tracheostomy (PDT).MethodsIn this prospective, randomized, noninferiority study, 46 patients undergoing PDT were randomized 1:1 to PDT with SUB (Ambu aScope) or reusable bronchoscopes (CONV, Olympus BF-P60). Visualization of tracheal structures rated on 4-point Likert scales was the primary end-point. Furthermore, quality of ventilation, device handling characteristics, changes in the patients' gas exchange, pH values, and costs were assessed.ResultsNoninferiority for visualization (the primary endpoint) was demonstrated for the SUB group. Mean visualization scores (lower values better) were 4.1 (95% confidence intervals: 3.9;4.3) for SUB vs. 4.1 (4.0;4.2) for CONV. Noninferiority of ventilation (estimated by minute volume and SpO2) during the procedure could be shown as well. Mean score was 2.6 (2.0;3.1) for SUB vs. 2.4 (2.1;2.7) for CONV (lower values better). No significant differences regarding handling (SUB: 1.2 (1.0;1.4), CONV: 1.3 (1.1;1.6)), blood gas analyses and respiratory variables were found. Cost analysis in our institution revealed 93 € per conventional bronchoscopy versus 232.50 € with SUB, not considering an estimate for possible infection due to cross-contamination with the reusable device.ConclusionIn our study, visualization and overall performance of the SUB during PDT were noninferior to reusable bronchoscopes. Therefore, PDT with SUB is feasible and should be considered if favored by individual institution's cost analysis.Trial registrationClinicalTrials.gov, NCT03952247 . Submitted for registration on 28/04/2019 and first posted on 16/05/2019.

Project description:BACKGROUND:We evaluated severe pain-related adverse events (SAE) during the percutaneous dilatational tracheostomy (PDT) procedure performed by a neurointensivist and compared the outcomes with that of conventional surgical tracheostomy in neurocritically ill patients. METHODS:This was a retrospective and observational study of adult patients who were admitted to the neurosurgical intensive care unit between January 2014 and March 2018 and underwent tracheostomy. In this study, primary endpoints were incidence of SAE: cardiac arrest, arrhythmias, hypertension, hypotension, desaturation, bradypnea, or ventilatory distress. The secondary endpoint was procedure-induced complications. RESULTS:A total of 156 patients underwent tracheostomy during the study. Elective surgery of brain tumors (34.0%) and intracranial hemorrhage (20.5%) were the most common reasons for admission. The most common reasons for tracheostomy were difficult ventilator weaning or prolonged intubation (42.9%) and sedative reduction (23.7%). Tachycardia (30.1%) and hypertension (30.1%) were the most common SAE. Incidence of SAE was more common in conventional tracheostomy compared to PDT (67.1% vs. 42.3%, P?=?0.002). The total duration of SAE (19.8?±?23.0?min vs. 3.4?±?5.3?min, P?<?0.001) and procedural time (42.2?±?21.8?min vs. 17.7?±?9.2?min, P?<?0.001) were longer in conventional tracheostomy compared to PDT. Multivariable adjustment revealed that only PDT by a neurointensivist significantly reduced the incidence of SAE by one third (adjusted odds ratio [OR]: 0.36, 95% confidence interval [CI]: 0.187-0.691). In addition, PDT by a neurointensivist deceased the duration of SAE by 8.64?min (?: -8.64, 95% CI: -?15.070 - -2.205, P?=?0.009) and prolonging the procedure time by every one minute significantly increased the duration of SAE by 6.38?min (?: 6.38, 95% CI: 0.166-0.470, P?<?0.001). Procedure-induced complications were more common in conventional tracheostomy compared to PDT (23.5% vs. 11.3%, P?=?0.047). CONCLUSIONS:This retrospective and exploratory study of our single-center limited cohort of tracheostomy patients revealed that decreased SAE may be associated with short procedural time during the PDT procedure performed by a neurointensivist. It is proposed that PDT by a neurointensivist may be safe and feasible in neurocritically ill patients.