Is routine chest X-ray after surgical and percutaneous tracheostomy necessary in adults: a systemic review of the current literature.

BACKGROUND: For many years, routine post-tracheostomy chest X-ray has been the standard of care for patients in many countries. However, recent evidence suggests that this is unnecessary and cost-ineffective. OBJECTIVE: To review the current literature and examine the role of routine post-tracheostomy chest X-ray in adult patients. TYPE OF REVIEW: Systemic review. SEARCH STRATEGY: Electronic databases (PubMed, EMBASE, Cochrane) were searched using the keywords 'chest X-ray/radiography/radiograph' and 'tracheostomy/tracheotomy' in various permutations. Search period ranged from 1960 to 2012. Inclusion criteria included systematic reviews, meta-analyses, randomised control trials, prospective and retrospective case series. Paediatric and non-English articles were excluded. Abstracts and subsequently full text articles were screened by two of the authors independently. References from obtained articles were also examined. EVALUATION METHOD: Specific outcome measures were collated to evaluate the usefulness of post-tracheostomy chest X-ray: Chest X-ray detected (tracheostomy-related) complication rates Proportion of cases requiring significant intervention Potential predictors of complications RESULTS: Routine post-tracheostomy chest X-ray is of a low yield, and its findings had limited impact on patient management. Complication detection rates for surgical and percutaneous tracheostomy are 2.2% and 3.2%, respectively. Only 0.7% and 1.8% of chest X-rays performed in surgical and percutaneous tracheostomy cases, respectively, required intervention. Certain groups of patients, however, are at higher risks of complications, and may benefit from post-tracheostomy chest X-ray. For surgical tracheostomy, these groups include those with post-operative signs and symptoms of complications or had emergent or 'difficult' tracheostomies. For percutaneous tracheostomy, high-risk patients include trauma cases (unspecified), patients with post-procedural signs and symptoms of complications, patients who have high ventilatory requirements, difficult tracheostomy cases or tracheostomy cases performed without bronchoscopic guidance. CONCLUSION: The practice of routine post-tracheostomy chest X-ray is debatable owing to its low yield and minimal impact on clinical management. However, certain groups of patients appear to be at higher risks of post-tracheostomy complications; currently, there is insufficient evidence to conclude the absolute need for routine chest X-ray in these groups of patients, although it may be prudent to do so based on available evidence in the literature and logical clinical reasoning.

Should mild obstructive sleep apnoea be treated? A systematic review from the standpoint of disease progression.

OBJECTIVE: This study was a systematic review to investigate the progression of untreated obstructive sleep apnoea in order to evaluate whether mild obstructive sleep apnoea should be treated from the standpoint of disease progression. METHOD: The database search study outcomes that were collected included Apnea Hypopnea Index and Respiratory Disturbance Index. A meta-analysis of obstructive sleep apnoea severity over time intervals was performed. RESULTS: A total of 17 longitudinal studies and 1 randomised, controlled trial were included for review. For patients with mild obstructive sleep apnoea, mean pre-study and post-study Apnea Hypopnea Index was 5.21 and 8.03, respectively, over a median interval of 53.1 months. In patients with moderate to severe obstructive sleep apnoea, mean pre-study and post-study Apnea Hypopnea Index was 28.9 and 30.3, respectively, over a median interval of 57.8 months. Predictors for disease progression in mild obstructive sleep apnoea are patients aged less than 60 years and those with a baseline body mass index less than 25. CONCLUSION: Mild obstructive sleep apnoea progression is observed, but it does not appear to reach any clinically significant progression to moderate or severe obstructive sleep apnoea.

Multi-level obstruction in obstructive sleep apnoea: prevalence, severity and predictive factors.

OBJECTIVES: To characterise multi-level obstruction in terms of prevalence, obstructive sleep apnoea severity and predictive factors, and to collect epidemiological data on upper airway morphology in obstructive sleep apnoea patients. METHODS: Retrospective review of 250 obstructive sleep apnoea patients. RESULTS: On clinical examination, 171 patients (68.4 per cent) had multi-level obstruction, 49 (19.6 per cent) had single-level obstruction and 30 (12 per cent) showed no obstruction. Within each category of obstructive sleep apnoea severity, multi-level obstruction was more prevalent. Multi-level obstruction was associated with severe obstructive sleep apnoea (more than 30 events per hour) (p = 0.001). Obstructive sleep apnoea severity increased with the number of obstruction sites (correlation coefficient = 0.303, p < 0.001). Multi-level obstruction was more likely in younger (p = 0.042), male (p = 0.045) patients, with high body mass index (more than 30 kg/m2) (p < 0.001). Palatal (p = 0.004), tongue (p = 0.026) and lateral pharyngeal wall obstructions (p = 0.006) were associated with severe obstructive sleep apnoea. CONCLUSION: Multi-level obstruction is more prevalent in obstructive sleep apnoea and is associated with increased severity. Obstruction at certain anatomical levels contributes more towards obstructive sleep apnoea severity.

Sequential cohort study comparing chlorine dioxide wipes with automated washing for decontamination of flexible nasendoscopes.

INTRODUCTION: Flexible nasoendoscope is an important tool in otorhinolaryngology practice. The endoscope needs to be decontaminated prior to use in the next patient. The 2005 ENT-UK guidance for cleaning fibre-optic laryngoscopes stated that the ideal disinfecting agent and process should be effective and have low capital and maintenance costs. OBJECTIVE: To compare the efficacy and cost-effectiveness of chlorine dioxide wipes versus automated washer, for decontamination of flexible nasendoscopes. METHODS: A sequential cohort, in vitro study was performed to test the efficacy of chlorine dioxide wipes and automated washer. Costs were also calculated. RESULTS: After deliberate bacterial contamination of the nasendoscope and subsequent decontamination, swab samples from the endoscope showed Staphylococcus epidermidis growth in 2 per cent (1/50 swabs) of the chlorine dioxide wipe group and in 28 per cent (14/50 swabs) of the automated washer group (p = 0.00). Based on a projected 10-year cost calculation, the automated washer was cheaper. CONCLUSION: Further studies are required to test whether these results are replicable. A similar study should be performed using real patients, to check the significance of improper decontamination.

Hoarseness secondary to haemodialysis: case report and literature review.

INTRODUCTION: Hoarseness is common and can have a major impact on patients' quality of life. We report a rare case of hoarseness secondary to haemodialysis. CASE REPORT: A 62-year-old man described developing transient hoarseness after haemodialysis sessions, which he underwent three times weekly. Fibre-optic nasendoscopy showed incomplete glottis closure due to bowing of the vocal folds. A computed tomography scan of the neck and thorax was unremarkable. Speech therapy was unhelpful. The renal physicians concluded that no change could be made to his dialysis regime. The patient subsequently underwent injection laryngoplasty with calcium hydroxylapatite, with marked improvement of his symptoms. DISCUSSION: A literature search found one relevant article reporting that 60 per cent of patients suffered post-dialysis hoarseness and decreased vocal fold thickness. It is postulated that dialysis causes dehydration of Reinke's space, affecting vocal fold thickness and the patient's voice. CONCLUSION: Hoarseness caused by haemodialysis is uncharted territory. Further research is required to determine its prevalence and contributing factors.