An Interdisciplinary Approach to the Management of Individuals With Tracheostomy.

BACKGROUND: Study objectives were to identify the proportion of tracheostomy subjects with successful decannulation, time to decannulation after ICU discharge, and predictors of long-term tracheostomy based on an interdisciplinary team approach. METHODS: This retrospective cohort study recruited all adult tracheostomy patients admitted between January 2016 and December 2018. Long-term tracheostomy patients with recurrent admissions and compromised airway and patients with neck tumors obstructing the airway were excluded. Data regarding subjects' demographics, comorbidities, Glasgow coma score (GCS), feeding, ICU discharge date, decannulation date, and outcome were collected. The interdisciplinary team members included tracheostomy resource nurse; respiratory therapist; speech clinician; ear, nose, and throat specialist; and rehab medicine specialist. RESULTS: Of the 221 subjects followed during the study period, 16% (36/221) were excluded, and the remaining 84% (185/221) underwent the decannulation protocol. Subjects who failed capping multiple times 114/185 (62%) were labeled long term and did not progress to decannulation. We successfully decannulated 71/185 subjects (38%), and none developed decannulation failure. Forty deaths occurred during hospitalization, but none was due to tracheostomy complications. The median time to decannulation after ICU discharge was 47 d. Predictors of long-term tracheostomy were GCS < 11 (odds ratio [OR] 5.6 [95% CI 2.7-12.0]), age ≥ 65 y (OR 4.5 [95% CI (2.1-10.0]), comorbidities ≥ 2 (OR 4.0 [95% CI 1.5-11.2]), and female sex (OR 3.0 [95% CI 1.3-7.4]). The proportion of subjects with long-term tracheostomy significantly increased with the total number of predictors (Fisher exact test, P < .001). CONCLUSIONS: Long-term tracheostomy was a common outcome among subjects with a tracheostomy. Older age, low GCS, female gender, and the number of comorbidities were significant long-term tracheostomy predictors. Further studies to assess outcomes and predictors of tracheostomy are needed.

Improving access to school based education for South African children in rural areas who have a tracheostomy: A case series and recommendations.

OBJECTIVES: Currently few children with tracheostomies attend rural mainstreams schools in South Africa limiting their ability to gain an education. We sought to document the current school experience for the few children attending school who have tracheostomies and devise educational tools for teachers and administrators that will facilitate greater acceptance and safety in classrooms for this population. METHODS: The four patients that are currently attending school with a tracheostomy were identified from the patient records of a tertiary hospital with a pediatric tracheostomy home based care service. With the aid of a Zulu language translator, the mothers and classroom teachers completed a semi structured interview and closed item questionnaire in their home and school, respectively. Schools were visited to understand and describe the settings in which the children and their teachers were being asked to function. Tools for education were developed in conjunction with key stakeholders at schools already hosting such children. RESULTS: The key teacher-identified barriers to enrollment were: teacher unfamiliarity with tracheostomies, uncertainty about the school's liability, and concerns about the response of other children. The safety barriers identified were: greater than 60 children per classroom - limiting teacher's ability to attend to the child with a tracheostomy, lack of running water, pit latrines separate from school threatening hygiene and isolating the child when they leave to use the latrines & sandy classrooms which can result in sand entering the airway. Identified needs for successful school placement include providing tracheostomy supplies and suctioning equipment, hand hygiene materials and training teachers in: identification of respiratory distress, performance of emergency tracheostomy changes, CPR. CONCLUSIONS: Children with tracheostomies could likely successfully attend South African rural mainstream public schools with a training program for teachers. As a first step, an introductory booklet for teachers that explains tracheostomies and provides educational and safety suggestions was created. A list of recommendations for successful inclusion of students in the school system was developed together with and delivered to key stakeholders.