[Clinical-demographic characteristics of tracheostomized patients with chronic obstructive pulmonary disease] / Características clínico-demográficas de pacientes traqueostomizados con enfermedad pulmonar obstructiva crónica.

Tracheostomy (TQT) has emerged as a valuable alternative for patients with orotracheal intubation, especially those under prolonged mechanical ventilation (VMP), as in the case of chronic obstructive pulmonary disease (COPD). This population presents additional challenges, and the available information regarding their progression in specialized centers is limited in Argentina.A descriptive, retrospective, and cross-sectional study was conducted at Santa Catalina Neurorehabilitation Clinic between August 2015 and December 2018. Patients with COPD referred to the Intensive Care Unit (ICU), tracheostomized, and subsequently referred to the Center for Ventilation Disconnection and Rehabilitation (CDVMR) were included. Cases with missing data or derived from other CDVMRs were excluded. Clinical records and interviews were employed to collect demographic and progression data.Out of the 27 COPD patients included (4.9% of 555), the majority were males (63%) with an average age of 68.1 years. Most were admitted with AVMi, and 11 (45.8%) were successfully disconnected, while 11 (40.7%) were decannulated. Survival and home discharge were more frequent in decannulated patients (81.8% were discharged) compared to non-decannulated ones (50% deceased, and none were discharged).COPD patients undergoing TQT and VMP, who succeed in being decannulated, seem to have better prospects for survival and home discharge compared to those who do not have the cannula removed. There is a suggestion for the need for additional analytical studies to confirm these findings and improve the understanding of this specific population.

La traqueostomía (TQT) es una una alternativa valiosa para pacientes con intubación orotraqueal, especialmente aquellos bajo ventilación mecánica prolongada (VMP), como en el caso de la enfermedad pulmonar obstructiva crónica (EPOC). Esta población presenta desafíos adicionales,  la información disponible sobre su evolución en centros especializados es limitada en Argentina.Se realizó un estudio descriptivo, retrospectivo y transversal en  Santa Catalina Neurorehabilitación Clínica entre agosto de 2015 y diciembre de 2018. Se incluyeron pacientes EPOC derivados a la unidad de terapia intensiva (UTI), traqueostomizados y posteriormente remitidos al Centro de Desvinculación de Ventilación Mecánica y Rehabilitación (CDVMR). Se excluyeron casos con datos faltantes o derivados de otros CDVMR. Se emplearon registros clínicos y entrevistas para recolectar datos demográficos y de evolución.De los 27 pacientes con EPOC incluidos (4.9% de 555), la mayoría eran hombres (63%) con una edad promedio de 68.1 años. La mayoría ingresó con AVMi, y se logró desvincular a 11 (45.8%) y decanular a 11 (40.7%) pacientes. La sobrevida y el alta domiciliaria fueron más frecuentes en pacientes decanulados (81.8% recibieron el alta) en comparación con los no decanulados (50% fallecieron y ninguno recibió el alta).Los pacientes EPOC sometidos a TQT y VMP, que logran ser decanulados, parecerían tener mejores perspectivas de sobrevida y alta domiciliaria en comparación con aquellos que no se les retira la cánula. Se sugiere la necesidad de estudios analíticos adicionales para confirmar estos hallazgos y mejorar la comprensión de esta población específica.

[Laryngotracheal resection with tracheoesophageal fistula closure in a patient with post-tracheostomy total cicatricial atresia of the larynx and tracheal stenosis combined with cricoid cartilage fracture]. / Laringotrakheal'naya rezektsiya po tipu H. Grillo s razobshcheniem trakheopishchevodnogo svishcha u bol'nogo s posttrakheostomicheskoi total'noi rubtsovoi atreziei gortani i stenozom sheinogo otdela trakhei v sochetanii s perelomom perstnevidnogo khryashcha.

Treatment of patients with post-intubation (post-tracheostomy) stenotic laryngotracheal lesions combined with tracheoesophageal fistula is the most difficult problem for various specialists. A 20-year-old patient received a severe concomitant injury with necessary prolonged mechanical ventilation and tracheostomy. Decannulation was followed by shortness of breath and cough with discharge of sputum mixed with liquid and food. Post-tracheostomy total cicatricial atresia of the larynx and cervical trachea combined with cricoid cartilage fracture, as well as tracheoesophageal fistula of cervical trachea was diagnosed. Tracheostomy and gastrostomy were performed. After 3-month rehabilitation, the patient admitted to the Vishnevsky National Medical Research Center of Surgery. After additional examination, the patient underwent circular laryngotracheal resection, closure of tracheoesophageal fistula, laryngotracheal reconstruction (laryngotracheal anastomosis by Grillo with thyroid cartilage repair), re-tracheostomy. A favorable outcome was obtained. In such patients, treatment strategy cannot be standardized and require a personalized approach.

[Epidemiology of tracheostomized children living at home in Argentina]. / Epidemiología de niños traqueostomizados que viven en sus hogares en Argentina.

INTRODUCTION: Although extensive research exists on the morbidity and mortality associated with tracheostomy in pediatrics, scarse work has been done to analyze the outcomes after hospital discharge of tracheostomized children. In our country there are no publications referring to the follow-up of this population. The general objective of this study was to describe and analyze the situation of tracheostomized children living at home in Argentina. MATERIALS AND METHODS: Descriptive, cross-sectional study through a survey with convenience sampling. Surveys sent between January and July 2023 were collected and analyzed. RESULTS: We obtained 193 surveys during the study period. One hundred eighteen children (61%) underwent tracheostomies before one year of age. The majority (n=183) have a Single Disability Certificate (94.8%). Regarding health coverage, 113 children have social insurance (58.5%), 42 have prepaid coverage (21.8%) and 38 depend on public insurance (19.7%). Almost all of the families (n=184) received some training to care for their children (95.3%). In their homes, 152 families (78.7%) had to resolve some adverse event related to the tracheostomy, and 128 families (66%) had to abandon some paid job. Although 118 children are not in school (61%), 170 (88%) receive rehabilitation therapy. DISCUSSION: Our research, the first of its kind, provides a crucial epidemiologic analysis of the situation of tracheostomized children living at home in Argentina. These findings are significant as they shed light on a previously unexplored area, emphasizing the need for further studies to confirm and expand these data.

Introducción: Si bien existe investigación sobre la morbimortalidad asociada a la traqueostomía en pediatría, pocos trabajos analizan los resultados luego del alta hospitalaria. En nuestro país no existen publicaciones referidas al seguimiento de esta población. El objetivo general de este trabajo fue describir y analizar la situación de niños traqueostomizados que viven en su hogar en Argentina. Materiales y métodos: Estudio descriptivo, transversal a través de una encuesta con muestreo por conveniencia. Se recolectaron y analizaron las encuestas remitidas entre enero y julio de 2023. Resultados: Se obtuvieron 193 encuestas durante el período de estudio. Fueron traqueostomizados antes del año de vida 118 niños (61%). La mayoría (n=183) posee Certificado Único de Discapacidad (94.8%). En relación a la cobertura de salud, 113 niños cuentan con Obra Social (58.5%), 42 con cobertura prepaga (21.8%) y 38 dependen del sector público (19.7%). Casi la totalidad de las familias (n=184) recibió capacitación para el cuidado de su hijo (95.3%). En sus hogares, 152 familias (78.7%) debieron resolver algún evento adverso relacionado con la traqueostomía y 128 familias (66%) abandonaron algún trabajo remunerado. Si bien 118 niños no se encuentran escolarizados (61%), 170 (88%) reciben terapia de rehabilitación. Discusión: Nuestra investigación, la primera de su tipo, proporciona un análisis epidemiológico crucial de la situación de los niños traqueostomizados que viven en sus hogares en Argentina. Hallazgos importantes, ya que arrojan luz sobre un área previamente inexplorada, enfatizando la necesidad de más estudios para confirmar y ampliar estos datos.

Mapping health-related quality of life of children and families receiving pediatric invasive home mechanical ventilation: a scoping review protocol.

BACKGROUND: Children utilizing invasive home mechanical ventilation (administered via tracheostomy tube) receive intensive care at home without the support of trained staff typically present in an intensive care unit; within the context of worsening home nursing shortages, much of the 24/7 care burden falls to families which are likely under supported. Prior reviews have explored the quality of life of children receiving various forms of mechanical ventilation, without addressing the impact on the family. Additionally, the literature inconsistently differentiates the unique experience of families with children using invasive home mechanical ventilation from non-invasive, which has lower morbidity and mortality and requires less nursing care in the home. Therefore, our study aims to explore and map the existing literature regarding the impact of invasive home mechanical ventilation on the child and family's quality of life. Identified gaps will inform future research focused on improving the family quality of life of children with invasive home mechanical ventilation. METHODS: Five databases will be searched using keywords and controlled vocabulary to identify relevant studies: Ovid Medline, Embase, Scopus, and Cochrane Library. English language studies will meet inclusion criteria if they include primary research studies of children or families of children utilizing invasive home mechanical ventilation at home and assess quality of life. Children and young adults aged 0-25 years will be included. We exclude studies of hospitalized children, studies focused solely on healthcare professional experiences or clinical outcomes, and those focused on the period surrounding discharge from admission for tracheostomy placement. Two independent reviewers will screen studies at the title/abstract and full-text levels. Two independent reviewers will extract data from relevant studies. Disagreements will be resolved by an independent third reviewer. A targeted grey literature search will be performed utilizing ProQuest, clinicaltrials.gov, WHO trial registry, Google Scholar, and professional societies. Findings will be presented in tables and figures along with a narrative summary. DISCUSSION: This scoping review seeks to map the literature and provide a descriptive report of the health-related quality of life of children using invasive home mechanical ventilation and their families. REGISTRATION: Open Science Framework https://doi.org/10.17605/OSF.IO/6GB84 Date of Registration: November 29, 2023.

An eight-year follow-up study of Home Invasive Mechanical Ventilation in Finland.

BACKGROUND: Studies on long-term invasive mechanical ventilation (IMV) via tracheostomy in chronic respiratory insufficiency are limited. The aim of this study was to clarify the use of HIMV (home invasive mechanical ventilation) within the Finnish population and to analyze the characteristics and survival rate of HIMV patients from 2015 to 2022. METHODS: Data on HIMV patients was collected annually from all Finnish Hospital District patient registries between January 1, 2015, and December 31, 2022. Data included basic demographic data of the patients, underlying diagnosis, time from diagnosis to HIMV initiation, treatment duration, and mortality. RESULTS: This study included 179 patients. In 2015, there were 107 HIMV patients, and as of December 31, 2022, there were 95 patients. During the eight-year follow-up period, 84 patients (46.9%) died and there were 67 new patients between 2015 and2022. The prevalence of HIMV treatment in Finland was 2.4/100,000 on January 1,2015, and 1.8/ 100 000 on December 31, 2022. The average number of years living with HIMV for deceased patients at death was 10.1 ± 10.5 years largely depending on the underlying diagnosis. Of all the HIMV treatments, 32% were elective. CONCLUSIONS: HIMV is a rare treatment in Finland, and based on our 8-year follow-up, prevalence of HIMV is diminishing. Given the high demands, and significant costs associated with HIMV, it is essential to prepare for long treatment, when planning HIMV. It is also advisable to prolong non-invasive ventilation (NIV) treatments for as long as possible.

Decannulation protocol in pediatric patients: case series study.

OBJECTIVE: The aim of this study was to describe the phases of a decannulation protocol and the results from its application in hospitalized children. METHODS: This is a retrospective, observational study. Data were collected from medical records of decannulated patients followed up in a pediatric hospital in Belo Horizonte, Minas Gerais between 2011 and 2021. RESULTS: Among the children followed up in the service (n=526), 23% (n=120) were successfully decannulated. Children aged between 2 months and 16 years, with a mean age of 4 years, 69% of whom were male, were evaluated. About 75% of the patients have tracheostomy due to upper airway obstruction and 60% of these due to acquired subglottic stenosis. At the beginning of the decannulation protocol, 5.5% of the patients had moderate oropharyngeal dysphagia, while 80.4% had normal swallowing. Correction in the upper airway pre-decannulation was performed in 39.5% of the patients, dilation in 63.8%, and endoscopic correction was performed in 55.3%. After performing the decannulation, none of the patients had complications. CONCLUSIONS: The described decannulation protocol is safe, since no complications such as death and need for recannulation happened.

Percutaneous dilational tracheostomy following anterior cervical spine fixation - a retrospective propensity-matched cohort study.

PURPOSE: In patients with traumatic, infectious, degenerative, and neoplastic surgical indications in the cervical spine, commonly the anterior approach is used. Often these patients require a tracheostomy necessary due to prolonged mechanical ventilation. The limited spinal mobility and proximity to the surgical site of anterior cervical spine fixation (ACSF) could pose an increased risk for complications of percutaneous dilational tracheostomy (PDT.) Importantly, PDT might raise wound infection rates of the cervical spine approach. The aim of this study is to prove safety of PDT after ACSF. METHODS: We performed a retrospective, single-center study comparing patients with and without ACSF who underwent Ciaglia-single step PDT. After propensity score matching using logistic regression, we compared intra- and postprocedural complication rates. Furthermore, surgical site infections were evaluated. Putensen's definitions of complications and Clavien-Dindo's classification were used. RESULTS: A total of 1175 patients underwent PDT between 2009 and 2021. Fifty-seven patients underwent PDT following ACSF and were matched to fifty-seven patients without ACSF. The mean interval between ACSF and PDT was 11.3 days. The overall complication rate was 19.3% in the ACSF group and 21.1% in the non-ACSF group. The mean follow-up was 388 days (± 791) in the ACSF group and 424 days (± 819) in the non-ACSF group. Life-threatening complications (Clavien-Dindo IV to V) were found in 1.8% of ACSF patients and 3.5% of non-ACSF patients. There were no significant differences in complication rates. No surgical site infection of the anterior spine access was detected. CONCLUSION: PDT is a feasible and safe procedure in patients after ACSF. Complication rates are comparable to patients without ACSF. Surgical site infections of ACSF are very rare.

Hyperbaric oxygen treatment (HBOT) in a case of traumatic chondronecrosis of the cricoid cartilage.

Cricoid chondronecrosis is a rare entity and is scarcely reported in the literature. Its prevalence is increasing in the form of chondroradionecrosis among the survivorship of head and neck carcinoma patients treated with radiotherapy. We have reported a case of cricoid chondronecroisis caused by trauma from repeated tracheostomy. The patient presented with hoarseness and dyspnoea. Radiological findings in multidetector computed tomography showed disintegration of the cricoid and confirmed the diagnosis. Conservative treatment was given in the form of antibiotics, steroids and nebulised anticholinergics and bronchodilators. However, the patient did not improve and his condition worsened throughout two months of hospitalisation. He was referred for hyperbaric oxygen treatment, which was given over 30 sessions. This was associated with improvement in his condition and he was able to be decannulated from tracheostomy. Six monthly follow up of the patient showed a well-healed tracheostomy scar.

Awake Tracheostomy in a Pediatric Patient.

Awake tracheostomy is rare in the pediatric population. We describe the case of a 10-year-old male who underwent awake tracheostomy due to airway obstruction from an oropharyngeal rhabdomyosarcoma. Given the varying medical understanding and communication skills in children, advanced planning and interdisciplinary collaboration are essential to keep the patient calm and safe during awake tracheostomy.

Patient factors associated with positive respiratory cultures following tracheostomy in pediatric patients.

OBJECTIVES: An increasing number of pediatric patients undergo tracheostomy placement annually. Despite advances in care, these patients remain at high risk for postoperative complications, including respiratory infections. The risk factors for positive respiratory cultures and the impact of culture positivity on overall morbidity and mortality in this population is not fully characterized. STUDY DESIGN AND SETTING: Retrospective cross-sectional analysis of all patients within a single tertiary care institution who underwent tracheostomy placement from January 1, 2019 to 12/31/2021. METHODS: We collected patient demographic information, comorbidities, primary indication for tracheostomy placement, and respiratory culture information preoperatively and postoperatively. The primary outcome measure was positive bacterial respiratory culture with speciation within 1, 3, or 6 months of tracheostomy placement. The secondary outcome measure was all-cause mortality within the study period. RESULTS: A total of 180 patients with median (IQR) age of 5.2 (3.4-31.0) months at time of tracheostomy placement were included in the study. Nearly half of patients had a positive culture within 1 month (n = 81,47.4 %) while 63.7 % of patients were positive within 6 months of tracheostomy placement (n = 109). Risk factors included respiratory and/or cardiac comorbidities. Positive respiratory cultures within 6 months of surgery and cardiac and/or neurologic comorbidities were associated with increased all-cause mortality following tracheostomy placement. CONCLUSIONS: Positive respiratory cultures are common following tracheostomy placement, more so in patients with cardiac and pulmonary comorbid conditions. Positive cultures are associated with increased all-cause mortality. More work is necessary to determine optimal screening frequency and treatment protocols for positive cultures in this population.

Preventing pediatric accidental decannulation events: A quality improvement initiative.

OBJECTIVE: To describe a quality improvement (QI) method to decrease pediatric accidental decannulation (AD) in the early postoperative period for children under age 3. METHODS: A retrospective chart review was conducted on children under age 3 who underwent tracheostomy at Duke University Health System from August 1, 2013 to May 1, 2023 (n = 104). A root cause analysis was used to assess factors associated with AD following pediatric tracheostomy. Based on the factors identified by the research team, retrospective data was collected before (8/1/13 - 1/31/22) and after (2/1/22 - 5/1/23) a single practice change was implemented: using twill neck ties, rather than foam neck ties, to secure newly-placed tracheostomy tubes. Twill ties were applied intraoperatively as a visual cue to signal a recent tracheostomy for the interdisciplinary care team. The primary outcome in the pre-intervention and post-intervention period was measured as 30-day incidence of AD per 10 tracheostomy cases. RESULTS: Prior to the intervention, a total of 11 ADs occurred in 9 patients across 93 pediatric tracheostomies (1.18 AD per 10 cases). Afterward, 0 ADs occurred across 11 pediatric tracheostomies (0 AD per 10 cases). CONCLUSION: This data suggests that the twill tie intervention may prevent AD and the associated morbidity. With the twill tie initiative, we describe 11 ADs and associated risk factors and present a QI intervention that may help prevent AD and improve patient safety in the early postoperative period.

The Shared Airway: Tracheal Mass Excision.

ABSTRACT: We report a case of successful airway management of a 26-year-old male patient who was posted for tracheal mass excision. The main challenge in such a case is to formulate a plan to provide maximum surgical access to the trachea for mass excision through an intraoral approach while ensuring adequate oxygenation and airway management. The patient presented with acute respiratory distress in the emergency ward. On computed tomography (CT), the patient was diagnosed with a polypoidal tracheal tumor occluding more than 90% of the tracheal lumen and 5.8 cm away from the carina. The case was successfully managed using a peripheral bypass for airway management. After the removal of the tumor, a tracheostomy tube was placed through the tracheotomy hole used for tumor excision. The whole process was uneventful.

Spinal muscular atrophy in an upper-middle-income nation before the advent of reimbursed disease-modifying therapies.

OBJECTIVE: To elucidate the clinical characteristics and standard of care (SoC) of spinal muscular atrophy (SMA) patients in Thailand, focusing on primary endpoints: age at death and a composite of death or tracheostomy need. DESIGN: Retrospective observational study. SETTING: Seven tertiary centres across Thailand. PATIENTS: Records of 110 patients with genetically confirmed SMA, spanning 2012-2021. INTERVENTIONS: Historical data review; no active interventions. MAIN OUTCOME MEASURES: Age at death and a composite measure of death or tracheostomy necessity. RESULTS: The cohort included 1 SMA0, 50 SMA1, 40 SMA2 and 19 SMA3 cases. Median ages at the onset and diagnosis of SMA1 were 3 and 6.2 months. Of SMA1 patients, 63% required ventilators, and eight received dimethyltryptamines (DMTs) at a median of 15 months (range 6.4-24.5 months). The median time from onset to DMT was 11 months (range 4.2-20.5 months). Among SMA1 patients, 73% died by the study's end. SMA2 and SMA3 patients' median onset ages were 11 and 24 months, respectively, with diagnosis at 24.8 and 68.7 months. Half of all types received physical therapy. CONCLUSIONS: Significant delays in diagnosis and SoC access, including DMTs, were observed, underscoring urgent needs for improved diagnostic and care strategies to enhance SMA patient outcomes in Thailand.

[Puncture dilatation tracheostomy in children during transoral neurosurgical interventions]. / Punktsionnaya dilatatsionnaya trakheostomiya u detei pri transoral'nykh neirokhirurgicheskikh vmeshatel'stvakh.

Neurosurgical interventions within the ventral surface of the clivus and upper cervical vertebrae in childhood are sometimes carried out through transoral approach. In this situation, tracheostomy is safer for airway protection and mechanical ventilation compared to prolonged intubation. The world experience of percutaneous dilation tracheostomy in pediatric patients is limited due to anatomical and physiological features, such as difficult orientation in anatomical landmarks, high mobility of the trachea and small tracheal lumen. Also, the trachea easily collapses when pressed in pediatric patients that complicates safe puncture of anterior wall and can lead to perforation of posterior tracheal wall. OBJECTIVE: To describe a modified technique of video-assisted percutaneous dilation tracheostomy using additional thin guide and dilator in children of primary school age. MATERIAL AND METHODS: We considered 11 patients aged 6-12 years who underwent video-assisted percutaneous dilation tracheostomy. RESULTS: There were no perioperative complications (bleeding, false course, perforation of posterior tracheal wall). Infection of tracheostomy, fistulas or tracheal stenosis was absent. CONCLUSION: Percutaneous dilation tracheostomy may be alternative to classical surgical tracheostomy for pediatric patients. Endoscopic control and certain technical changes of percutaneous tracheostomy are necessary and provide safe manipulation. Surgery time, less trauma and minimal cosmetic defect after tracheostomy are significant advantages of this technique compared to surgical tracheostomy.

Tracheostomy care for adults and the elderly in the home environment: a scoping review.

OBJECTIVE: To map out scientific knowledge regarding tracheostomy care for adults and the elderly carried out by individuals, famies or caregivers in home environments. METHOD: Scoping review, conducted in February 2023, according to the methodology of the Joanna Briggs Institute. The guiding question was: what and how should adult/elderly tracheostomy care be carried out by the individual/family/caregiver in the home environment? Studies published in Portuguese, English and Spanish were considered. The databases consulted were: Lilacs; Medline, via PubMed; Cinahl; Cochrane Library; PEDro; Embase; Scopus and Web of Science. RESULTS: 2158 articles were identified, of which 81 were read in full and 14 included in the review. The main types of care identified included psychobiological needs: airway suction, changing the tracheostomy attachment, cleaning the endocannula and sanitizing the peristomal skin. As for psychosocial needs, incentives for communication and autonomy were identified. There were no recommendations for care related to psychospiritual needs. CONCLUSION: The findings prioritize biological care, few studies have detailed how to carry out such care at home.

Outcomes of delayed tracheostomy among intubated patients during the coronavirus disease pandemic.

BACKGROUND: Respiratory distress and failure is a complication of the coronavirus disease (COVID-19) and tracheostomy may be necessary in cases of prolonged intubation in order to reduce mechanical ventilation duration. However, according to the Canadian Society of Otolaryngology-Head and Neck Surgery guidelines, which our institution applies, patients should not undergo tracheostomy unless cleared of the virus to reduce its spread among healthcare workers because tracheostomy is an aerosolized procedure. This study aimed to identify the outcomes of prolonged intubation in patients with and without COVID-19 who underwent tracheostomy and to determine the morbidity and mortality rates in both groups. METHODS: This retrospective cohort study included adult patients admitted to the intensive care unit of King Fahad Hospital of the University, Alkhobar, Saudi Arabia, between March 1 and October 31, 2020. This study compared and analyzed the outcomes of delayed tracheostomy in patients with and without COVID-19 in terms of complication, morbidity, and mortality rates. RESULTS: Of the 228 study participants, 111 (48.68%) had COVID-19. The mean age of the study participants was 58.67 years (SD = 17.36, max.=93, min.=20), and the majority were males (n = 149, 65.35%). Regarding tracheostomy in patients with COVID-19, 11 (9.91%) patients underwent tracheostomy; however, four (36.36%) of them had prolonged intubation. The mean intensive care unit admission length of stay for tracheostomy patients was 37.17 days, while it was 12.09 days for patients without tracheostomy (t(226)=-9.32, p < 0.001). Regarding prolonged intubation among patients with COVID-19 (n = 7, 6.31%), the complications were as follows: six people (85.71%) had dysphonia, one (14.29%) had vocal cord granuloma, and two (28.57%) had subglottic tracheal stenosis. The mortality rate among our study participants was 51.32%, and the risk was significantly higher in older people (Odds ratio = 1.04, 95% Confidence Interval [CI] = 1.02-1.06) and in delayed tracheostomy cases (OR = 2.95, 95% CI = 1.31-6.63). However, COVID-19 status was not significantly related to the risk of mortality. CONCLUSIONS: Delaying tracheostomy increases the risk of mortality. Therefore, we recommend weighing the risks and benefits for each patient to benefit both healthcare workers and patients with COVID-19.

Dilemma in patients with amyotrophic lateral sclerosis and expectations from brain-machine interfaces.

OBJECTIVE: We hypothesized that patients with amyotrophic lateral sclerosis (ALS) face a dilemma between motivation to live and difficulty in living, and brain-machine interfaces (BMIs) can reduce this dilemma. This study aimed to investigate the present situation of patients with ALS and their expectations from BMIs. MATERIALS AND METHODS: Our survey design consisted of an anonymous mail-in questionnaire comprising questions regarding the use of tracheostomy positive pressure ventilation (TPPV), motivation to live, anxiety about the totally locked-in state (TLS), anxiety about caregiver burden, and expectations regarding the use of BMI. Primary outcomes were scores for motivation to live and anxiety about caregiver burden and the TLS. Outcomes were evaluated using the visual analogue scale. RESULTS: Among 460 participants, 286 (62.6%) were already supported by or had decided to use TPPV. The median scores for motivation to live, anxiety about TLS, and anxiety about caregiver burden were 8.0, 9.0, and 7.0, respectively. Overall, 49% of patients intended to use BMI. Among patients who had refused TPPV, 15.9% intended to use BMI and TPPV. Significant factors for the use of BMI were motivation to live (p = .003), anxiety about TLS (p < .001), younger age (p < .001), and advanced disease stage (p < .001). CONCLUSIONS: These results clearly revealed a serious dilemma among patients with ALS between motivation to live and their anxiety about TLS and caregiver burden. Patients expected BMI to reduce this dilemma. Thus, the development of better BMIs may meet these expectations.

Effect of Early Versus Delayed Tracheostomy Strategy on Functional Outcome of Patients With Severe Traumatic Brain Injury: A Target Trial Emulation.

OBJECTIVES: Optimal timing of tracheostomy in severe traumatic brain injury (TBI) is unknown due to lack of clinical trials. We emulated a target trial to estimate the effect of early vs. delayed tracheostomy strategy on functional outcome of patients with severe TBI. DESIGN: Target trial emulation using 1:1 balanced risk-set matching. SETTING: North American hospitals participating in the TBI Hypertonic Saline randomized controlled trial of the Resuscitation Outcomes Consortium. PATIENTS: The prematching population consisted of patients with TBI and admission Glasgow Coma Scale less than or equal to 8, who were alive and on mechanical ventilation on the fourth day following trial enrollment, and stayed in the ICU for at least 5 days. Patients with absolute indication for tracheostomy and patients who died during the first 28 days with a decision to withdraw care were excluded. INTERVENTIONS: We matched patients who received tracheostomy at a certain timepoint (early group) with patients who had not received tracheostomy at the same timepoint but were at-risk of tracheostomy in the future (delayed group). The primary outcome was a poor 6-month functional outcome, defined as Glasgow Outcome Scale-Extended less than or equal to 4. MEASUREMENTS AND MAIN RESULTS: Out of 1282 patients available for analysis, 275 comprised the prematching population, with 75 pairs being created postmatching. Median time of tracheostomy differed significantly in the early vs. the delayed group (7.0 d [6.0-10.0 d] vs. 12.0 d [9.8-18.3 d]; p < 0.001). Only 40% of patients in the delayed group received tracheostomy. There was no statistically significant difference between groups regarding poor 6-month functional outcome (early: 68.0% vs. delayed: 72.0%; p = 0.593). CONCLUSIONS: In a target trial emulation, early as opposed to delayed tracheostomy strategy was not associated with differences in 6-month functional outcome following severe TBI. Considering the limitations of target trial emulations, delaying tracheostomy through a "watchful waiting" approach may be appropriate.

Low-Resource Hospital Days for Children Following New Tracheostomy.

BACKGROUND AND OBJECTIVES: Children with new tracheostomy and invasive mechanical ventilation (IMV) require transitional care involving caregiver education and nursing support. To better understand hospital resource use during this transition, our study aimed to: (1) define and characterize low-resource days (LRDs) for this population and (2) identify factors associated with LRD occurrence. METHODS: This retrospective cohort analysis included children ≤21 years with new tracheostomy and IMV dependence admitted to an ICU from 2017 to 2022 using the Pediatric Health Information System database. A LRD was defined as a post tracheostomy day that accrued nonroom charges <10% of each patient's accrued nonroom charges on postoperative day 1. Factors associated with LRDs were analyzed using negative binomial regression. RESULTS: Among 4048 children, median post tracheostomy stay was 69 days (interquartile range 34-127.5). LRDs were common: 38.6% and 16.4% experienced ≥1 and ≥7 LRDs, respectively. Younger age at tracheostomy (0-7 days rate ratio [RR] 2.42 [1.67-3.51]; 8-28 days RR 1.8 (1.2-2.69) versus 29-365 days; Asian race (RR 1.5 [1.04-2.16]); early tracheostomy (0-7 days RR 1.56 [1.2-2.04]), and longer post tracheostomy hospitalizations (31-60 days RR 1.85 [1.44-2.36]; 61-90 days RR 2.14 [1.58-2.91]; >90 days RR 2.21 [1.71-2.86]) were associated with more LRDs. CONCLUSIONS: Approximately 1 in 6 children experienced ≥7 LRDs. Younger age, early tracheostomy, Asian race, and longer hospital stays were associated with increased risk of LRDs. Understanding the postacute phase, including bed utilization, serves as an archetype to explore care models for children with IMV dependence.