Tracheostomy before and during COVID-19 pandemic.

BACKGROUND: The aim of the study was to provide insight into the influence of the COVID-19 on the frequency and characteristics of urgent and emergent tracheostomies (TS), comparing data collected both before and during the pandemic. Our two hypotheses were that during COVID-19, more TS were performed in the emergent setting and that during COVID-19 more TS were performed under general anaesthesia. PATIENTS AND METHODS: The research was retrospective. The study period included the two years before and after the COVID-19 outbreak in Slovenia. Forty-one patients in each period met the inclusion criteria. Their medical charts were reviewed. The anamnestic, clinical, surgical and anaesthesiological data were collected. The two groups of patients from corresponding time periods were statistically compared. RESULTS: Predominantly men required the surgical resolution of acute upper airway obstruction (76% of patients). The causes for acute respiratory distress included head and neck cancer (62%), infections (20%), vocal cord paralysis (16%), and stenosis (2%). There were no statistically significant differences either in the (emergent/urgent) setting of TS or in the type of anaesthesia used. Both hypotheses were rejected. A statistically significant rise in use of the C-MAC laryngoscope during COVID-19 (from 3% to 15%) was reported. CONCLUSIONS: The outbreak of COVID-19 did not have a statistically significant effect on the frequency of performing emergent and urgent tracheostomies nor on the use of general or local anaesthesia. It did, however, require a change of intubation technique. Consequently, a significant rise in the use of the C-MAC laryngoscope was noted.

Systematic review and meta-analysis of surgical approaches for improving airway stability in infants with Robin sequence: Evaluating complications and outcomes.

The purpose of this systematic review and meta-analysis was to determine the most effective and least morbid surgical technique for relieving retroglossal airway obstruction in infants with Robin sequence (RS). The study adhered to PRISMA guidelines and included 25 studies (24 cohorts and one case series) that investigated interventions for airway improvement, including conservative measures, tongue-lip adhesion (TLA), mandibular distraction osteogenesis (MDO), and tracheostomy. The primary outcome variable was complication rate, while predictor variable was the use of interventions for airway improvement. Results showed that conservative measures were the preferred initial management strategy in most studies, while TLA was recommended for infants with mild obstruction, and MDO or tracheostomy was reserved for severe cases. Only complications could be analysed via meta-analysis due to data heterogeneity, revealing that tracheostomy had a summary odds ratio of 5.39 in favour of TLA, while MDO had a ratio of 2.8 over TLA, and the complication rates were similar between MDO and tracheostomy. If conservative measures fail, the study recommends mandibular distraction as the preferable technique for stable airway improvement. If the infant is unsuitable for distraction, tongue-lip adhesion may serve as an alternative, while tracheostomy should be reserved for cases of severe multi-level obstruction. The authors propose that large-scale, multicentre trials comparing long-term outcomes are required to establish definitive guidelines.

Tracheostomy Incidence and Complications: A National Database Analysis.

OBJECTIVE: To describe the incidence of tracheostomy-related complications and identify prognostic risk factors. STUDY DESIGN: Administrative database analysis. SETTING: Outpatient and inpatient insurance claims records obtained from a national database. METHODS: PearlDiver, a private analytics database of insurance claims from Medicare, Medicaid, and commercial insurance companies, was used to identify patients who underwent tracheostomies and associated complications between January 2010 and October 2021 by CPT and ICD-9/ICD-10 codes. RESULTS: A total of 198,143 tracheostomies were identified from PearlDiver, and at least 1 tracheostomy-related complication occurred within 90 days of the procedure in 22,802 (10.3%) of these cases. The proportion of tracheostomy-related complications was 2.3 times higher in 2019 compared to 2010 (95% confidence interval [CI]: 2.18-2.52). The risk of developing tracheostomy-complications was associated with the hospital region (highest in the Midwest as compared to the West [odds ratio [OR] = 1.32; 95% CI: 1.25-1.39]), provider specialty (highest for otolaryngologists as compared to nonsurgical physicians [OR = 2.22; 95% CI: 2.10-2.34]), insurance plan type (lowest for cash payment compared to Medicaid [OR = 0.70, 95% CI: 0.50-0.94]), and Elixhauser Comorbidity Index (ECI) (highest in patients with ECI of 7+ compared to 0-1 [OR = 2.96; 95% CI: 2.17-3.24]), but was not significantly associated with patient age (OR = 0.99; 95% CI: 0.99-0.99), or gender (OR = 1.04; 95% CI: 1.01-1.07). CONCLUSIONS: Complications after tracheostomy are common and sicker patients are at higher risk for complications. Identifying factors associated with increased risk for complications could help to improve patient and family counseling, guide quality improvement initiatives, and inform future studies on tracheostomy outcomes.

Supporting Direct Breastfeeding for a Tracheostomy-Dependent Extremely Premature Infant: A Case Study.

INTRODUCTION: The benefits of human milk for preterm infants are well documented. Complex medical conditions can limit the extremely premature infant's ability to breastfeed and to receive human milk directly, yet these vulnerable infants may benefit most from receiving it. MAIN ISSUE: Extremely preterm infants are at risk for infections, digestive challenges, and chronic lung disease, and occasionally require a tracheostomy to facilitate weaning from mechanical ventilation. There is a risk of aspiration when orally feeding a child with a tracheostomy. This case study describes a tertiary neonatal team supporting a family's direct breastfeeding goal in an extremely premature infant with a diagnosis of bronchopulmonary dysplasia requiring a tracheostomy. MANAGEMENT: Initially, the infant participant (born at 24 weeks and 3 days of gestation, with a birthweight of 540 g) was gavage fed with human milk. The interdisciplinary team collaborated with the family to guide the infant's feeding goals, providing positive oral stimulation with soothers, oral immune therapy, and frequent skin-to-skin contact to prepare for future oral feeding. Within a month of the tracheotomy procedure, oral feeding was initiated, and direct breastfeeding with the tracheostomy tubing in place was achieved at 50 weeks and 1 day of age as a primary source of nutrition. CONCLUSION: The open dialogue between the family and healthcare team was the foundation for trialing direct breastfeeding for an extremely premature infant with a tracheostomy. While direct breastfeeding of full-term infants with tracheostomies has been previously described in the literature, this is the first case study of an extremely premature infant with a tracheostomy transitioning to direct breastfeeding.

Practical guide to building machine learning-based clinical prediction models using imbalanced datasets.

Clinical prediction models often aim to predict rare, high-risk events, but building such models requires robust understanding of imbalance datasets and their unique study design considerations. This practical guide highlights foundational prediction model principles for surgeon-data scientists and readers who encounter clinical prediction models, from feature engineering and algorithm selection strategies to model evaluation and design techniques specific to imbalanced datasets. We walk through a clinical example using readable code to highlight important considerations and common pitfalls in developing machine learning-based prediction models. We hope this practical guide facilitates developing and critically appraising robust clinical prediction models for the surgical community.

Arterial Blood Gas Analysis in Patients with Stridor, and the Impact of Emergency Tracheostomy on It: A Tertiary Care Center Experience.

Comparative evaluation of arterial blood gas in patients with stridor, before and after emergency tracheostomy. The present prospective study was conducted in tertiary care Centre from February 2022 to June 2023 on 42 patients who presented with stridor and underwent emergency tracheostomy in our department. After proper history taking and clinical examination, nonsurgical cause of stridor was ruled out. Patients were then classified on the basis of location of cause of stridor (whether oropharyngeal, hypo-pharyngeal, supra-glottic, glottic or sub-glottic). Immediately an arterial blood gas (ABG) analysis was done, and emergency tracheostomy was performed. Following tracheostomy, ABG analysis was done immediately, after 12 h and after 24 h. The mean age of presentation of stridor in our study was 65.02 ± 3.23 years, with male preponderance (Male: female ratio being 3.66:1). Most common etiology of stridor in our study was glottic carcinoma comprising 50%, and least common etiology of stridor was hypopharyngeal carcinoma, and subglottic stenosis comprising 2.4% each. There was statistically significant normalization of ABG in terms of pH, PO2, PCO2, HCO3. Mean pH, PO2, PCO2, and HCO3 before tracheostomy were 7.31, 74.8, 60.6, and 29.8 respectively. Mean pH, PO2, PCO2, HCO3, immediately after tracheostomy were7.38, 91.3, 48.4, and 27.4 respectively. After 12 h of tracheostomy, mean pH, PO2, PCO2, HCO3 were 7.41, 95.4, 42.7, 25.3 respectively. Mean pH, PO2, PCO2, HCO3 24 h after emergency tracheostomy were 7.441, 95.5, 42.8, 24.6 respectively. Emergency tracheostomy in stridor patients improves the acid base and ventilatory status, by relieving the obstruction as evidenced by statistically significant improvement in arterial blood gas values, and can be used as a diagnostic tool in upper airway obstruction.

A Clinical Study on Microbiological Profile in Tracheostomy Wounds.

Tracheostomy is a surgical procedure in an emergency setting to relieve the upper airway obstruction by creating an opening in the anterior part of trachea. It can also be done electively to wean off from a ventilator, during an elective surgery and clearance of pulmonary secretions. This study was a retrospective analysis of microbiological profile, antibiotic sensitivity & resistance pattern in patients with a tracheostomized wound. A retrospective review of the microbiological profiles of all adult patients who underwent a tracheostomy was conducted between May 2022 and May 2023 at our hospital. Based on the tracheostomy indications, patients were allocated under obstructed and non-obstructed group. Any patient with at least one positive sample was followed up quarterly for a year. The first culture result obtained was recorded at least one month following the last antibiotic dose in each quarter. Out of the 65 tracheal aspirate results obtained from 58 patients (mean age, 57.5 ± 16.48 years), the most common procedure and indications were surgical tracheostomy (72.4%) and non-obstructed causes (74.1%), respectively. Moreover, 47.7% of the culture results indicated Pseudomonas aeruginosa, which showed significantly different proportions across the quarters (p = 0.006). Among obstructed patients, P. aeruginosa was the most common (35%), followed by methicillin-resistant Staphylococcus aureus (MRSA; 23.5%). The colonization was predominantly by gram negative bacteria Acinetobacter species, P. aeruginosa & Klebsiella pneumoniae and fungal species like Candida albicans followed by Aspergillus niger and non-Albicans candida.

The Role of a 'Tracheostomy Care Training Module' in Improving the Knowledge, Attitude and Practices Among Nurses in High Dependency Units.

Background: The occurrence of life-threatening events in hospitalized patients with tracheostomies are often preventable. Nurses have a vital role in providing consistent tracheostomy care to patients, thereby avoiding complications. This study was conducted to assess the knowledge of nurses in high dependency areas at a tertiary care hospital with regards to tracheostomy care, to train them and to assess the impact of a tracheostomy care teaching module. Methods: Purposive sampling techniques were used to recruit 65 nurses from high dependency areas in Father Muller Medical College Hospital. With appropriate informed, a detailed evaluation was conducted with a pre-validated questionnaire that assesses the knowledge, attitude and practices with regards to tracheostomy care. The nurses then underwent a tracheostomy training programme with a teaching module that emphasizes on tracheostomy care, a demonstration and hands on experience in the simulation lab, followed by an OSCE and a post-test. Statistical analysis was done using SPSS version 28 for paired T test and crosstabulation. Results: There was a mean increase in test scores, from 7.74 in pretest to 10.66 in post-test which was statistically significant. The comfort and confidence level of nurses after the module, increased by 80% and the OSCE scores were averaged around 73% giving a satisfactory outcome. Conclusion: This module significantly increased the quality of tracheostomy tube care provided by nurses thereby improving patient outcome. Small modifications to existing training programs can have a significant impact on overall health care as demonstrated by our study. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-024-04489-y.

Cholesteatoma in the pediatric aerodigestive population.

OBJECTIVES: To report the prevalence of cholesteatoma and related comorbidities in pediatric aerodigestive patients requiring tracheostomy or airway reconstruction procedures. To use study findings to inform clinical management of these complex patients. METHODS: A repository of clinical data drawn from our institution's electronic medical records was queried to identify airway reconstruction (airway) and complex hospital control (control) patient cohorts. Retrospective chart review was then performed to investigate the occurrence of cholesteatoma and related pathologies in these patients, as well as clinical management. RESULTS: The prevalence of cholesteatoma in airway and control patients was 6/374 (1.60 %) and 35/30,565 (0.11 %), respectively. The relative risk of cholesteatoma diagnosis in airway patients was 14.01 (95 % CI 6.06-32.14). Airway patients were more likely than control patients to have pressure equalization tube history (relative risk 3.25, 95 % CI 2.73-3.82). Age at cholesteatoma diagnosis and first surgical intervention was younger in airway compared to control patients (5.43 vs. 8.33, p = 0.0182, and 6.07 vs. 8.82, p = 0.0236). However, time from diagnosis to intervention and extent of surgery were similar between the groups. CONCLUSION: This is the first study to investigate the prevalence of cholesteatoma in the pediatric aerodigestive population. The relative risk of cholesteatoma diagnosis was found to be 14 times higher in patients with tracheostomy or airway reconstruction history. Underlying eustachian tube and palatal dysfunction are likely contributing factors to the elevated risk. Additionally, cholesteatoma in this population was diagnosed and required surgical intervention at a younger age, which may suggest a more aggressive disease course. Providers should maintain a high degree of suspicion for cholesteatoma in this complex population.

Executive Summary of the Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR) Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management.

The Airway section of the Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) present the Guidelines for the integral management of difficult airway in adult patients. This document provides recommendations based on current scientific evidence, theoretical-educational tools and implementation tools, mainly cognitive aids, applicable to the treatment of the airway in the field of anesthesiology, critical care, emergencies and prehospital medicine. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations and optimization in the progression of the application of strategies to preserve adequate alveolar oxygenation in order to improve safety and quality of care.

A rare case of straight-back syndrome causing airway obstruction.

Straight-back syndrome is a rare congenital condition involving the loss of the normal dorsal curvature of the upper thoracic spine. This leads to flattening of the upper thoracic cavity, resulting in compression of the underlying vasculature and airways. In this case report, we discuss the management of an 18-year-old male with straight-back syndrome who was referred to our interventional pulmonary clinic for further management of his stridor and apneic events. A trial of airway stenting was done which resolved the patient's respiratory symptoms. Definitive surgical correction was not applicable due to other significant medical conditions, but tracheostomy provided a sustainable alternative treatment. Tracheostomy tube placement and airway stenting are reasonable alternatives to surgery for patients who experience airway obstruction due to straight-back syndrome. Stent placement may also relieve respiratory symptoms but is associated with a higher rate of complications.

Clinical Conundrum: Unveiling a Unique Presentation of Hypopharyngeal Carcinoma.

Dysphagia is a common symptom encountered in clinical practice, typically associated with a wide range of etiologies, including structural abnormalities, inflammatory conditions, neoplasms, and neurological disorders. However, the combination of subcutaneous emphysema, vocal cord palsy, enlarged arytenoids, and pooling of saliva in a dysphagic patient represents a rare and intriguing presentation. A 33-year-old female presented at a tertiary care hospital in Western India with hoarseness of voice, difficulty in swallowing, productive cough, and neck pain for two months with an abrupt increase in the severity of all symptoms in two days. A history of chewable tobacco use for six years was disclosed. Clinical evaluation revealed a thin build with platynychia and conjunctival pallor, dental staining, drooling of saliva, the presence of extensive subcutaneous emphysema on palpation of the neck, and absent laryngeal crepitus. Endoscopic evaluation was suggestive of right vocal cord palsy and enlarged, congested arytenoid cartilages, post-cricoid growth with pooling of saliva in bilateral pyriform fossae. A CT scan of the neck showed a 2x3 cm neoplastic growth in the hypopharynx, with subcutaneous emphysema and free air foci in the head and neck region, prompting an immediate tracheostomy and biopsy of the hypopharyngeal growth with Ryle's tube insertion. Squamous cell carcinoma was confirmed on the biopsy report. Due to its rarity, the possible underlying cause of idiopathic subcutaneous emphysema should be sought whenever encountered in clinical practice since these patients are potentially misdiagnosed. A high index of suspicion among clinicians, along with a consideration of the constellation of other symptoms and clinical features of a possible underlying hypopharyngeal cancer whenever encountering such patients is of key importance for prompting further investigations and treatment.

Tracheostomy is associated with decreased vasoactive-inotropic score in postoperative cardiac surgery patients on prolonged mechanical ventilation.

Objective: We sought to quantify the influence that tracheostomy placement has on the hemodynamic stability of postoperative cardiac surgery patients with persistent ventilatory requirements. Methods: A retrospective, single-center, and observational analysis of postoperative cardiac surgery patients with prolonged mechanical ventilation who underwent tracheostomy placement from 2018 to 2022 was conducted. Patients were excluded if receiving mechanical circulatory support or if they had an unrelated significant complication 3 days surrounding tracheostomy placement. Vasoactive and inotropic requirements were quantified using the Vasoactive-Inotrope Score. Results: Sixty-one patients were identified, of whom 58 met inclusion criteria. The median vasoactive-inotrope score over the 3 days before tracheostomy compared with 3 days after decreased from 3.35 days (interquartile range, 0-8.79) to 0 days (interquartile range, 0-7.79 days) (P = .027). Graphic representation of this trend demonstrates a clear inflection point at the time of tracheostomy. Also, after tracheostomy placement, fewer patients were on vasoactive/inotropic infusions (67.2% [n = 39] pre vs 24.1% [n = 14] post; P < .001) and sedative infusions (62.1% [n = 36] pre vs 27.6% [n = 16] post; P < .001). The percent of patients on active mechanical ventilation did not differ. Conclusions: The median vasoactive-inotrope score in cardiac surgery patients with prolonged mechanical ventilation was significantly reduced after tracheostomy placement. There was also a significant reduction in the number of patients on vasoactive/inotropic and sedative infusions 3 days after tracheostomy. These data suggest that tracheostomy has a positive effect on the hemodynamic stability of patients after cardiac surgery and should be considered to facilitate postoperative recovery.

Characteristics of tracheostomized patients followed up by a Palliative Care and Complex Chronic Patient Service.

INTRODUCTION AND OBJECTIVES: In recent years, there has been an increase in the number of children with tracheostomies. The objective was to describe the characteristics of paediatric patients with a tracheostomy followed up by the Department of Palliative Care and Chronic Medically Complex Illness (DPCCMCI) of a tertiary care hospital. METHODS: Single-centre retrospective observational study in patients aged less than 18 years with a tracheostomy followed up by the PCCCPS of a tertiary care hospital (November 2020-June 2022). We analysed epidemiological, clinical, microbiological and social data by reviewing the health records. RESULTS: The sample included 44 tracheostomized patients. The most frequent underlying disease was acquired upper airway disease (20.5%). The most common indication for tracheostomy was upper airway obstruction (66%). Bacterial isolates were detected in 84% of the tracheal aspirates, among which P. aeruginosa was the most frequent (56.8%). The most frequently prescribed antibiotic was ciprofloxacin (84%). In addition, 18.1% of the patients received at least 1 course of intravenous antibiotherapy and 29.5% received more than 3 systemic antibiotic regimens in the past 20 months. Fifty-nine percent of the children were schooled: 38.6% attended a regular school, 15.9% a special needs school and 4.5% were home-schooled. We identified social difficulties in 53.7%. Also, 22.7% of the families received financial support to care for a child with severe illness. CONCLUSIONS: Because of the complexity of caring for tracheostomized children, integral and coordinated management is essential. Schooling is possible and safe if caregivers are trained.

Effects of Preoperative Glucocorticoid Use on Patients Undergoing Single-Level Lumbar Fusions: A Retrospective Propensity Score-Matched Registry Study.

Objective Spinal fusions are gaining popularity as a means of treating spinal deformity and instability from a range of pathologies. The prevalence of glucocorticoid use has also increased in recent decades, and their systemic effects are well-documented. Although commonly used in the preoperative period, the effects of steroids on outcomes among patients undergoing spinal fusions are inadequately described. This study compares the odds of developing complications among patients who underwent single-level lumbar fusions with and without preoperative glucocorticoid use in hopes of establishing more evidence-based parameters for guiding preoperative steroid use. Methods The TriNetX multi-institutional electronic health record database was used to perform a retrospective, propensity score-matched analysis of clinical outcomes of two cohorts of patients who underwent posterior or posterolateral single-level lumbar fusions with and without interbody fusion, those who used glucocorticoids for at least one week within a year of fusion and those who did not. The outcomes of interest were examined within 30 days of the operation and included death, reoperation, deep or superficial surgical site infection (SSI), pneumonia, reintubation, ventilator dependence, tracheostomy, acute kidney injury (AKI), renal insufficiency, pulmonary embolism (PE) or deep venous thrombosis (DVT), urinary tract infection (UTI), emergency department (ED) visit, sepsis, and myocardial infarction (MI). Results The odds of developing pneumonia within 30 days of spinal fusion in the cohort that used glucocorticoids within one year of operation compared to the cohort without glucocorticoid use was 0.67 (p≤0.001, 95% CI: 0.59-0.69). The odds of requiring a tracheostomy within 30 days of spinal fusion in the cohort that used glucocorticoids within one year of operation compared to the cohort without glucocorticoid use was 0.39 (p≤0.001, 95% CI: 0.26-0.60). The odds of reoperation, deep and superficial SSI, and ED visits within 30 days of operation were significantly higher for the same glucocorticoid-receiving cohort, with odds ratios of 1.4 (p=0.003, 95% CI: 1.11-1.65), 1.86 (p≤0.001, 95% CI: 1.31-2.63), 2.28 (p≤0.001, 95% CI: 1.57-3.31), and 1.25 (p≤0.001, 95% CI: 1.17-1.33), respectively. After propensity score-matching, there was no significant difference between the odds of death, DVT, PE, MI, UTI, AKI, sepsis, reintubation, and ventilator dependence between the two cohorts. Conclusion In support of much of the current literature regarding preoperative glucocorticoid use and rates of complications, patients who underwent a single-level lumbar fusion and have used glucocorticoids for at least a week within a year of operation experienced significantly higher odds of reoperation, deep and superficial SSI, and ED visits. However, these patients using glucocorticoids were also found to have lower odds of developing pneumonia, renal insufficiency, and tracheostomy requirement than those who did not use steroids within a year of surgery.

The Effect of Delay Following the Clinical Decision to Perform Tracheostomy in the Critical Care Setting.

BACKGROUND: Tracheostomy in patients who are critically ill is generally performed due to prolonged mechanical ventilation and expected extubation failure. However, tracheostomy criteria and ideal timing are poorly defined, including equivocal data from randomized controlled trials and median intubation to tracheostomy times that range from 7-21 d. However, a consistent finding is that only ∼50% of late tracheostomy groups actually undergo tracheostomy, with non-performance due to recovery or clinical deterioration. Unlike in many jurisdictions, elective surgical procedures in our institution require a court-appointed guardian, which necessitates an approximately 1-week delay between the decision to perform tracheostomy and surgery. This offers a unique opportunity to observe patients with potential tracheostomy during a delay between the decision and the performance. METHODS: ICU patients who were ventilated were identified for inclusion retrospectively by an application for guardianship relating to tracheostomy, the intention-to-treat point. The main outcomes of tracheostomy, extubation, or death/palliative care after inclusion were noted. Demographics, outcomes, and event timing were compared for the 3 outcome groups. RESULTS: Tracheostomy-related guardianship requests were made for 388 subjects. Of these, 195 (50%) underwent tracheostomy, whereas 127 (33%) were extubated and 66 (17%) either died before tracheostomy (46 [12%]) or were transitioned to palliative care (20 [5%]). The median time (interquartile range) from guardianship request until a defining event was the following: 6.2 (4.0-11) d for tracheostomy, 5.0 (2.9-8.2) d for extubation (P < .001 as compared to tracheostomy group), and 6.5 (2.5-11) d for death/palliative care (P = .55 as compared to tracheostomy). Neurological admissions were more common in the tracheostomy group and less common in the palliative group. Other admission demographics and hospitalization characteristics were similar. Hospital mortality was higher for subjects undergoing tracheostomy (58/195 [30%]) versus extubation (24/127 [19%]) (P = .03). CONCLUSIONS: Delay in performing tracheostomy due to legal requirements was associated with a 50% decrease in the need for tracheostomy. This suggests that decision-making with regard to ideal tracheostomy timing could be improved, saving unnecessary procedures.

A 5-Year Review of a Tracheostomy Quality Improvement Initiative: Reducing Adverse Event Frequency and Severity.

OBJECTIVE: The number of tracheostomies performed annually in resource-rich countries is estimated at 250,000. While an essential procedure, approximately 20% to 30% of patients will experience at least 1 tracheostomy-related adverse event. Within tracheostomy care and across wider health care environments, quality improvement (QI) programs have been shown to reduce patient harm and improve outcomes. Herein we report on a 5-year long, tracheostomy QI initiative aimed at improving patient experience and reducing the frequency and severity of adverse events. METHODS: A 5-year (ongoing) QI initiative led by the Cardiff and Vale University Health Board tracheostomy team, within a tertiary, 1000-bedded hospital in South Wales, United Kingdom. The QI initiative has focused on 3 main themes: (1) Education and training; (2) Clinical oversight and decision making; and (3) improved data collection. Data were collected from existing tracheostomy databases. RESULTS: Over the past 5 years, we have observed a sustained reduction in both the frequency and severity of adverse events, with less than 1 patient per 100 experiencing a moderate or severe adverse event. This has resulted in improvements in patient experience and a cost reduction of £GBP364,726 per annum. DISCUSSION: Our 5-year ongoing tracheostomy QI initiative has resulted in improved outcomes with increased achievement of tracheostomy weaning markers and sustained reductions in both the frequency and severity of adverse events. IMPLICATIONS FOR PRACTICE: A continuous focus on QI is associated with improved patient and service outcomes. These improvements can be spread and scaled to benefit more patients and organizations.

Tracheostomy for the pediatric patient with fibrodysplasia ossificans progressiva: a case report.

BACKGROUND: Fibrodysplasia ossificans progressiva (FOP) is an extremely rare connective tissue disease characterized by subsequent ossification of skeletal muscles, tendons, ligaments, and other fibrous tissues. The ossification of these tissues progresses during childhood and leads to limb and trunk deformities. Since any surgery may trigger subsequent ossification, it is relatively contraindicated for patients with FOP. In this report, we describe our experience in performing tracheostomy in a pediatric patient with FOP who developed a restrictive respiratory disorder due to progressive deformity of the trunk. CASE PRESENTATION: A 12-year-old boy, diagnosed with FOP at the age of one, was referred for a tracheotomy after requiring 2 months of oral intubation and mechanical ventilation due to severe deformity-induced dyspnea. After changing from oral intubation to nasal intubation, we carefully considered the indications and benefits of tracheostomy in patients with FOP. Eventually, tracheostomy was successfully performed using our surgical design: creating a skin incision at the level of the cricoid cartilage that can always be identified, creating inverted U-shaped incision on the anterior tracheal wall to make a flap, and suturing the entire circumference of the tracheotomy and skin. One month after the surgery, he regained normal breathing and pronunciation and returned to school. The patient showed no unfavorable postoperative outcomes over a 4-year follow-up period. CONCLUSIONS: Tracheostomy in our pediatric case of FOP required careful perioperative management. However, it could effectively improve the patient's quality of life.

Emergency Tracheostomy: Complications, Anesthetic Techniques, and Outcomes.

Objectives: Acute upper airway obstruction is a critical medical condition that presents considerable challenges to anesthesiologists. This study aims to provide a formal report on the incidence and outcomes of perioperative complications, as well as the factors that influence unstable intraoperative hemodynamics. Methods: This retrospective study reviewed patients aged 18 years and older who underwent emergency tracheostomy between January 2013 and October 2021. Data on perioperative complications and outcomes within the first 24 hours and 7 days after surgery were subjected to analysis. Descriptive and multivariate analyses were used to examine the results. Results: A total of 253 patients were included in the study. The mean age was 61.5 ± 12.9 years. Malignancy was detected in 78.3% of the patients. General anesthesia was administered to 43.9% of the patients. The incidence of intraoperative complications was 51.8%, with hypotension and hypertension occurring in 30.4% and 22.5% of the cases, respectively. Desaturation and cardiac arrest were observed in 4.7% and 0.8% of the patients, respectively. The mortality rate at 7 days after surgery was 1.6%. Multivariate analysis revealed that monitored anesthesia care [adjusted odds ratio (OR) = 1.80; 95% confidence interval (CI): 1.08-3.00] and hypertensive patients (adjusted OR = 1.70, 95% CI: 1.01-2.86) were associated with unstable intraoperative hemodynamics. Conclusions: Cardiovascular instability represented the majority of the complications observed. Monitoring anesthesia care and hypertension were significant prognostic factors for unstable intraoperative hemodynamics. We recommend extensive communication between ear, nose, and throat surgeons and anesthesiologists to determine the appropriate choice of anesthesia.