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Tracheostomy: from insertion to decannulation.

ABSTRACT: Tracheostomy is a common surgical procedure, and is increasingly performed in the intensive care unit (ICU) as opposed to the operating room. Procedural knowledge is essential and is therefore outlined in this review. We also review several high-quality studies comparing percutaneous dilational tracheostomy and open surgical tracheostomy. The percutaneous method has a comparable, if not superior, safety profile and lower cost compared with the open surgical approach; therefore the percutaneous method is increasingly chosen. Studies comparing early versus late tracheostomy suggest morbidity benefits that include less nosocomial pneumonia, shorter mechanical ventilation and shorter stay in the ICU. However, we discuss the questions that remain regarding the optimal timing of tracheostomy. We outline the potential acute and chronic complications of tracheostomy and their management, and we review the different tracheostomy tubes, their indications and when to remove them.

SUBMITTER: Engels PT

PROVIDER: S-EPMC2769112 | biostudies-other | 2009 Oct

REPOSITORIES: biostudies-other

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Tracheostomy: from insertion to decannulation.

Engels Paul T PT Bagshaw Sean M SM Meier Michael M Brindley Peter G PG

Canadian journal of surgery. Journal canadien de chirurgie 20091001 5

Tracheostomy is a common surgical procedure, and is increasingly performed in the intensive care unit (ICU) as opposed to the operating room. Procedural knowledge is essential and is therefore outlined in this review. We also review several high-quality studies comparing percutaneous dilational tracheostomy and open surgical tracheostomy. The percutaneous method has a comparable, if not superior, safety profile and lower cost compared with the open surgical approach; therefore the percutaneous m ...[more]

PMID: 19865580

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Project description:ImportanceDuring respiratory disease outbreaks such as the COVID-19 pandemic, aerosol-generating procedures, including tracheostomy, are associated with the risk of viral transmission to health care workers.ObjectiveTo quantify particle aerosolization during tracheostomy surgery and tracheostomy care and to evaluate interventions that minimize the risk of viral particle exposure.Design, setting, and participantsThis comparative effectiveness study was conducted from August 2020 to January 2021 at a tertiary care academic institution. Aerosol generation was measured in real time with an optical particle counter during simulated (manikin) tracheostomy surgical and clinical conditions, including cough, airway nebulization, open suctioning, and electrocautery. Aerosol sampling was also performed during in vivo swine tracheostomy procedures (n = 4), with or without electrocautery. Fluorescent dye was used to visualize cough spread onto the surgical field during swine tracheostomy. Finally, 6 tracheostomy coverings were compared with no tracheostomy covering to quantify reduction in particle aerosolization.Main outcomes and measuresRespirable aerosolized particle concentration.ResultsCough, airway humidification, open suctioning, and electrocautery produced aerosol particles substantially above baseline. Compared with uncovered tracheostomy, decreased aerosolization was found with the use of tracheostomy coverings, including a cotton mask (73.8% [(95% CI, 63.0%-84.5%]; d = 3.8), polyester gaiter 79.5% [95% CI, 68.7%-90.3%]; d = 7.2), humidification mask (82.8% [95% CI, 72.0%-93.7%]; d = 8.6), heat moisture exchanger (HME) (91.0% [95% CI, 80.2%-101.7%]; d = 19.0), and surgical mask (89.9% [95% CI, 79.3%-100.6%]; d = 12.8). Simultaneous use of a surgical mask and HME decreased the particle concentration compared with either the HME (95% CI, 1.6%-12.3%; Cohen d = 1.2) or surgical mask (95% CI, 2.7%-13.2%; d = 1.9) used independently. Procedures performed with electrocautery increased total aerosolized particles by 1500 particles/m3 per 5-second interval (95% CI, 1380-1610 particles/m3 per 5-second interval; d = 1.8).Conclusions and relevanceThe findings of this laboratory and animal comparative effectiveness study indicate that tracheostomy surgery and tracheostomy care are associated with significant aerosol generation, putting health care workers at risk for viral transmission of airborne diseases. Combined HME and surgical mask coverage of the tracheostomy was associated with decreased aerosolization, thereby reducing the risk of viral transmission to health care workers.

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:IntroductionSince the start of the COVID-19 pandemic 2019, quite a few patients became critical and needed ICU admission with ventilator assistance. Tracheostomy, which was initially performed late during the course of patient on ventilator, has now been considered a procedure that can be performed relatively early as this leads to early weaning of patients and overcomes the shortage of critical beds.ObjectiveThis study aims to focus on the outcomes of tracheotomised COVID-19 patients in terms of survival and any tracheostomy related morbidity.MethodsA prospective study was performed on COVID-19 patients undergoing tracheostomy at this tertiary care teaching hospital, which also was a dedicated centre for treating COVID-19 patients. The duration of this study was from April 2020 to September 2021. Following tracheostomy, all patients were followed up regularly and clinical changes were recorded. Points that were specifically noted were timing of the tracheostomy, change in ventilator settings, tracheostomy related complications, requirement of oxygen, days needed to wean the patient, decanulation, and, if death, the cause of death.ResultsA total of 136 surgical open tracheostomies were performed on COVID-19 patients over the study period. The mean duration of intubation (timing of tracheostomy) was 12 days. A total of 73 out of 136 (53.6%) patients survived. 51 patients (37.5%) got decannulated during the course of the hospital stay. 9 patients were decanulated during the follow up visits and 13 patients were lost to follow up. 63 out of 136 (46.3%) patients died due to COVID pneumonia. Most of the patients who died had gone into multi-organ failure. Air leak syndromes (pneumothorax and pneumomediastinum) were common findings. 10 patients already had surgical emphysema before taking up for tracheostomy and 6 developed 2-3 days after tracheostomy. The most common complication was bleeding, which was seen in 28 out of 136 patients. The Median weaning of period of patients who survived was 5 days.ConclusionPerforming tracheostomy early in COVID-19 patients helps in early weaning of the patient from the ventilator and makes nursing care easier and increases the availability of ICU beds. The mortality rate was 46% amongst the 136 tracheostomies done in COVID-19 patients. Local site bleeding was the most common complication and surgical emphysema was also seen more than routine tracheostomies.Supplementary informationThe online version contains supplementary material available at 10.1007/s12070-022-03248-1.

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Tracheostomy: from insertion to decannulation.

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Tracheostomy: from insertion to decannulation.

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