Retrospective review of acute post-tracheostomy complications and contributing risk factors.

OBJECTIVE: Tracheostomy is performed for various indications ranging from prolonged ventilation to airway obstruction. Many factors may play a role in the incidence of complications in the immediate post-operative period including patient-related factors. Chronic obstructive pulmonary disease and asthma are some of the most common pulmonary pathologies in the United States. The relationship between obstructive pulmonary diseases and acute post-tracheostomy complications has been incompletely studied. DESIGN: A retrospective chart review was designed in order to answer these objectives. Medical records were reviewed for the technique used, complications, and contributing patient factors. Post-operative complications were defined as any tracheostomy-related adverse event occurring within 14 days. SETTING: The study took place at an academic comprehensive cancer. PARTICIPANTS: Inclusion criteria included patients from January 2017 through December 2018 who underwent a tracheostomy. Exclusion criteria included presence of stomaplasty, total laryngectomy, and tracheostomies performed at outside hospitals. MAIN OUTCOME MEASURES: Patient factors examined included demographics, comorbidities, and body mass index with the primary outcome measured being the rate of tracheostomy complications. RESULTS: The most common indication for tracheostomy among the 321 patients that met inclusion criteria was airway obstruction or a head and neck cancer surgical procedure. Obstructive sleep apnea was associated with acute complications in bivariate analysis (29.4% complications, p = .003). Chronic obstructive pulmonary disease and asthma were not associated with acute complications in bivariate analysis (11.6% complications, p = .302). Among the secondary outcomes measured, radiation was associated with early complications occurring in post-operative days 0-6 (1.1%, p = .029). CONCLUSION: Patients with obstructive sleep apnea may have a higher risk of acute post-tracheostomy complications that might be due to the patient population at risk for obstructive sleep apnea. Patients with obstructive pulmonary pathologies such as asthma or chronic obstructive pulmonary disorder did not have an elevated risk of complications which is clinically significant when considering the utility of ventilation and tracheostomy in the management of acute respiratory failure secondary to these conditions.

[Recommendations for the management and rehabilitation of patients with a tracheostomy].

Tracheostomy is a common procedure in critically ill patients who require mechanical ventilation. Tracheostomies have several advantages over endotracheal tubes, including less sinusitis or pharyngeal injuries, fewer sedative drugs, improved oropharyngeal hygiene, easier communication, more comfort, preservation of vocal cord function, and so on. However, patients with a tracheostomy require high quality care and often suffer from dysphagia, dysphonia, tracheal stenosis, or excessive airway secretions, etc. In China, there are currently no comprehensive evidence-based clinical guidelines or consensus documents on the management and rehabilitation of patients with a tracheostomy. Approaches to tracheostomy care are inconsistent among different institutions and clinicians. Therefore, a group of top experts specialized in this field in China were gathered to draft this document to reduce variations in practice in the management of patients with a tracheostomy and to minimize complications. Panel members were asked to complete surveys on various aspects of adult tracheostomy care, followed by a conference at which the results were presented and a number of themes outlined for a formal literature review and a preliminary draft. Several conferences were then held to discuss the differences of opinion among the panel members. In general, the panel reached a consensus and a total of 9 issues were covered in the document. At first, the importance of a standardized management protocol, pathophysiological characteristics, indications, complications, contradictions, and techniques used for tracheostomies were discussed. Then, more emphasis was placed on post-operative care such as airway clearance therapy, tube changes, and decannulation criteria, etc. In addition, the most important topic was elaborated, namely the methods used to promote the rehabilitation and decannulation of patients with a tracheostomy, including respiratory and other skeletal muscle training, dysphagia and verbal communication intervention, ventilation support, chest physiotherapy, and specifically the traditional Chinese medical therapies that were excellent in this area, such as acupuncture, moxibustion, and herbal medicine, etc. Finally, a flow chart was created to summarize the suggestions for managing and promoting rehabilitation or decannulation of patients with a tracheostomy. Proposed by Respiratory Equipment Committee of China Association of Medical Equipment, Young and Middle-Aged Pulmonary Rehabilitation Group of Pulmonary Rehabilitation Committee of China Association of Rehabilitation of Disabled Person, and Critical Illness Rehabilitation Group of China Association of Rehabilitation Medicine, and sponsored by several national or provincial natural science research projects, this work is expected to provide clear guidance for the general treatment of adult patients with a tracheostomy in China in the future.

Tubeless tracheal resection and reconstruction for management of benign stenosis.

BACKGROUND: We reported a tubeless tracheal resection and reconstruction for the management of benign posttracheostomy tracheal stenosis. METHODS: A 34-year-old man with stridor, severe respiratory distress, and recurrent pneumonia was referred to our attention for treatment of benign posttracheostomy tracheal stenosis. As he refused general anesthesia, the procedure was performed while he was under local anesthesia and spontaneous ventilation. RESULTS: Sedation was started with infusion of dexmedetomidine 0.7 mg/kg/min and of remifentanil 0.5 mg/kg/h; also, 40%-50% oxygen was delivered using a laryngeal mask at a rate of 3.5 mL/min. An additional dose of 2% lidocaine was injected into the surgical site during the operation to achieve an adequate level of anesthesia. A standard resection and reconstruction of trachea was carried out and no recurrence was found in the follow-up of 41 months. CONCLUSION: Tubeless tracheal surgery seems to be a feasible and safe procedure. Larger prospective series should validate our results.

The complex spectrum of forensic issues arising from obesity.

The increasing numbers of obese and morbidly obese individuals in the community are having a direct effect on forensic facilities. In addition to having to install more robust equipment for handling large bodies, the quality of autopsy examinations may be reduced by the physical difficulties that arise in trying to position bodies correctly so that normal examinations can proceed. Accelerated putrefaction is often an added complication. Metabolic disturbances resulting from obesity increase susceptibility to a range of conditions that are associated with sudden and unexpected death, and surgery may have increased complications. The rates of a number of different malignancies, including lymphoma, leukemia, melanoma and multiple myeloma, and carcinomas of the esophagus, stomach, colon, gallbladder, thyroid, prostate, breast and endometrium, are increased. In addition, obese individuals have higher rates of diabetes mellitus, and sepsis. The unexpected collapse of an obese individual should raise the possibility of a wide range of conditions, many of which may be more difficult to demonstrate at autopsy than in an individual with a normal body mass index. Although sudden cardiac death due to cardiomegaly, pulmonary thromboembolism, or ischemic heart disease may be the most probable diagnosis in an unexpected collapse, the range of possible underlying conditions is extensive and often only determinable after full postmortem examination.

A new technique for T tube insertion in severe subglottic stenosis.

T tube insertion for subglottic stenosis is often difficult due to bending of the T tube itself. A T tube could be inserted safely and consistently in a patient with severe subglottic stenosis employing a method that we newly devised. Our method can be performed under local anesthesia without special instruments and is technically straightforward. And also, our method is considered to be applicable to marked stenosis and stenosis with a complex morphology. Herein we present an improved method for inserting a silicone T tube through a tracheostomy stoma in patients with severe subglottic stenosis.

CO2 laser repair of permanent tracheostomy stricture.

We present our experience in treating postlaryngectomy patients with respiratory disturbance caused by stricture of the permanent stoma by CO2 laser surgery. Laser surgery is a simple procedure that can be performed with the patient under local anesthesia without bleeding and with minimal damage to the adjacent strictures resulting in a minimal postoperative edema and contracture. In our opinion the CO2 laser is a useful surgical tool for enlargement of the airway lumen and for improvement of respiratory disturbance in postlaryngectomy patients with stomal stricture, and this procedure should be considered for treatment of selected patients.

A case of fibrin sealant application for closing benign trachea-esophageal fistula (TEF).

Surgical treatment of upper airway-esophageal communications are frequently lead to failure. Having previous experience of thoracic administration of Tissucol fibrin glue authors attempted the local application in a case of TEF. A young lady suffering from myasthenia gravis required longstanding artificial ventilation. Not surprisingly a TEP developed in the area of the tracheostomy. There was no room for surgical repair of the TEF. Two administrations of rapid acting form of Tissucol was needed following local astringent therapy and enzymatic debridement to achieve a complete and permanent closure of a tracheobronchial sinus in a diameter of 5 mm. In addition of meticulous technique and of general supporting therapy special attention was paid to the followings: 1/healthy wound edges 2/ local infection control 3/dry environment 4/patient building up strategy.

Excellent functional outcome in patients with squamous cell carcinoma of the base of tongue treated with external irradiation and interstitial iodine 125 boost.

BACKGROUND: Local control, functional outcome, and complications in patients with carcinoma of the base of tongue (BOT) were analyzed to assess the impact of interstitial implant boost with I-125 seeds. METHODS: Between December 1986 and May 1995, 16 patients with squamous cell carcinoma of the BOT received treatment at the William Beaumont Hospital and 4 received treatment at the Northern Virginia Cancer Center. The primary tumor classification for this group consisted of T1/T2-11 patients, T3/T4-9 patients. All patients initially received 50.4-66.6 Gray (Gy) (median: 54 Gy) external beam irradiation to the primary site and regional lymph nodes followed by an interstitial implant boost 2 to 3 weeks later. Implant dose ranged from 20 to 32 Gy (median: 27 Gy). The implanted volume included the tumor and glossotonsillar sulcus in all patients and the pharyngeal wall or tonsil in select cases. RESULTS: Median follow-up was 47 months (range, 6-88 mos). Two patients have failed within the tumor bed (T2 and T4) for a 5-year actuarial local control rate of 88%. The T2 patient was salvaged surgically, for an overall 5-year actuarial local control rate of 93%. No patients have relapsed within the neck as the only or first site of failure. The 5-year actuarial overall survival rate was 72%. Complications included three cases of exposed bone and one case of cranial nerve XII palsy. All complications were managed conservatively. Excellent to good functional outcome, including speech and swallowing, was preserved in 18 of the 20 patients. CONCLUSIONS: Patients with cancer of the BOT can be treated effectively with an interstitial boost utilizing I-125 seeds. Overall, local control is excellent and complications are minimal. Of greatest significance, organ preservation with excellent understandability of speech and diet tolerance was achieved in 90% of the patients.

Effect of artificial airway on ear complications from hyperbaric oxygen.

Hyperbaric oxygen treatment is associated with an increased risk of barotrauma to the tympanic membrane and middle ear. An artificial airway may compromise normal eustachian tube function and equilibration of middle ear pressures. This retrospective study was designed to evaluate the risk of middle ear complications in 267 patients receiving hyperbaric oxygen (HBO) therapy and to compare those with and without artificial airways. Charts of all patients were reviewed for middle ear and tympanic membrane complications and myringotomy tube placement. Eighteen of the 267 patients had artificial airways. Seventeen (94%) of these 18 patients developed middle ear or tympanic membrane complications, and 11 (61%) required tympanostomy tubes for pain, hemotympanum, or serous otitis. In contrast, 114 (45.8%) of the 249 patients without airways developed ear complications, and 53 (21.3%) required tympanostomy tubes. These results suggest that patients with an artificial airway who are receiving HBO therapy are at greater risk for developing tympanic membrane and middle ear complications than nonintubated patients. Similarly, patients with artificial airways receiving HBO frequently require placement of tympanostomy tubes.

Percutaneous tracheostomy: ready or not?

A novel approach to tracheostomy has recently been introduced, based on the Seldinger guide-wire technique. A well-packaged percutaneous tracheostomy kit promises a rapid and safe alternative to the traditional surgical tracheostomy. At the National Defence Medical Centre, this percutaneous approach was tried on four patients. Deficiencies in the kit instruments were discovered which, with the expected "learning curve," led to unexpected difficulties. Thus, the promise of percutaneous tracheostomy remains as yet unfulfilled.

New approaches in the rehabilitation of the traumatic high level quadriplegic.

The use of noninvasive alternatives to tracheostomy for ventilatory support have been described in the patient management of various neuromuscular disorders. The use of these techniques for patients with traumatic high level quadriplegia, however, is hampered by the resort to tracheostomy in the acute hospital setting. Twenty traumatic high level quadriplegic patients on intermittent positive pressure ventilation (IPPV) via tracheostomy with little or no ability for unassisted breathing were converted to noninvasive ventilatory support methods and had their tracheostomy sites closed. Four additional patients were ventilated by noninvasive methods without tracheostomy. These methods included the use of body ventilators and the noninvasive intermittent positive airway pressure alternatives of IPPV via the mouth, nose, or custom acrylic strapless oral-nasal interface (SONI). Overnight end-tidal pCO2 studies and monitoring of oxyhemoglobin saturation (SaO2) were used to adjust ventilator volumes and to document effective ventilation during sleep. No significant complications have resulted from the use of these methods over a period of 45 patient-years. Elimination of the tracheostomy permitted significant free time by glossopharyngeal breathing for four patients, two of whom had no measurable vital capacity. We conclude that noninvasive ventilatory support alternatives can be effective and deserve further study in this patient population.

Electrophrenic ventilation: a different perspective.

Since 1972, radio-frequency electrophrenic nerve pacing (EPP) has been an option for assisting the ventilation of patients with chronic paralytic respiratory insufficiency. Most of the medical literature has been favorable regarding its continued application. We reviewed the literature to determine how "successful" application of EPP was defined. Our studies indicated that long-term follow-up of EPP patients has been generally inadequate with little emphasis placed on incidence and severity of complications. There was no standardization in defining successful experiences with EPP. Upper airway instability during pacing, lack of internal pacemaker alarms, and the risk of sudden pacemaker failure necessitate permanent tracheostomy in the great majority of patients but complications of the presence of a tracheostomy were not considered in evaluating the desirability of EPP. Some EPP patients became independent of any ventilatory support thus benefiting minimally from the time commitment, effort, and extreme expense needed for EPP placement and training. We conclude that EPP is a valid option for the properly screened patient but that expense, failure rate, morbidity and mortality remain excessive and that alternative methods of ventilatory support should be explored.