Acquired Tracheomalacia Requiring Urgent Tracheostomy Exchange in Patients With COVID-19.

Tracheostomy for prolonged ventilation of patients with COVID-19 was often delayed due to high viral loads and persistent high ventilatory requirements. With prolonged intubation and significant dose corticosteroid use, patients with COVID-19 are at risk for tracheomalacia, and urgent tube exchange may be required to address persistent cuff leak and to maintain adequate mechanical ventilation. We sought to describe our single center experience with COVID-19 patients requiring tracheostomy and the tracheal complications that followed. We performed a review of patients with COVID-19 who underwent tracheostomy from June 2020 to October 2021. 45 patients were identified; 82.2% survived their index hospitalization. Tracheostomy was performed after 16.4 days of mechanical ventilation. 22.2% required urgent exchange to an extended length tracheostomy tube after 7.2 days from initial tracheostomy. Placement of an extended length tracheostomy tube can reduce cuff leak in ventilated COVID-19 patients and may be considered during initial tracheostomy placement.

Acquired Tracheomegaly in Critically Ill Patients With COVID-19: A Literature Review.

Tracheomegaly is defined as an abnormally dilated trachea and is seen in patients requiring long-standing mechanical ventilation and/or significant hyperinflation of their endotracheal or tracheostomy tube cuffs can occur in adults with severe COVID-19. Tracheomegaly is linked with inadequate nutrition, pneumonia, diabetes, hypotension, steroids, and protracted mechanical ventilation, which are common in COVID-19 patients. Findings include cuff leaks that necessitate cuff overinflation to maintain adequate tidal volumes. Tracheomegaly can be diagnosed with chest radiographs, chest computed tomography, bronchoscopy, or diagnostic laryngoscopy or tracheoscopy. This condition leads to a concern for obstruction, airway collapse, aspiration pneumonia, and iatrogenic tracheal injuries.

Surgical outcomes and complications of bedside tracheostomy in the ICU for patients on ECMO.

OBJECTIVE: Extracorporeal membrane oxygenation (ECMO) is increasingly employed in the management of patients with severe cardiac and pulmonary dysfunction. Patients commonly require tracheostomy for ventilator liberation. Though bedside percutaneous tracheostomy is commonly performed, it has the potential for increased complications, both surgical and with the ECMO circuit. We examined surgical outcomes of bedside percutaneous tracheostomy in the ECMO population. METHODS: Patients were identified from an institutional database for bedside procedures. Demographics and data on complications were recorded. Descriptive statistics were calculated. RESULTS: 37 patients on ECMO at the time of tracheostomy were identified. Median age and BMI were 43.2 and 28.0, respectively. 33 patients (89%) were on VV ECMO, and 4 (11%) were on VA ECMO. All were on anticoagulation prior to tracheostomy, which was held for 4 h before and after the procedure in all cases. There were no procedure-related deaths or airway losses. No patients experienced periprocedural clotting events of their ECMO circuit or oxygenator within 24 h. 3 patients (8%) required reintervention (re-exploration or bronchoscopy) for bleeding. Four other patients (10%) had minor bleeding controlled with packing. One patient had pneumomediastinum which resolved without intervention, and one had an occlusion of their tracheostomy which was treated with tracheostomy exchange. CONCLUSIONS: Bedside percutaneous tracheostomy is feasible for patients on ECMO. Further study is needed to determine specific risk factors for complications and means to mitigate these. Bedside percutaneous tracheostomy may be considered as part of the management of patients on ECMO to help facilitate liberation from mechanical support.

Sympathetic Nervous System and Exercise Affects Cognition in Youth (SNEACY): study protocol for a randomized crossover trial.

BACKGROUND: There is an increasing prevalence of physical inactivity during childhood, which is associated with a variety of health problems. However, the mechanisms by which acute exercise benefits cognition in childhood remains unknown. Here we describe the protocol for a randomized crossover trial called SNEACY (Sympathetic Nervous System & Exercise Affects Cognition in Youth), a study designed to better understand mechanisms linking acute exercise and cognition in 9-10-year-old healthy, cognitively normal children. METHODS: Children from the Greater Boston, MA region will be recruited to participate in this single center study. A randomized crossover design will be utilized, such that participants will act as their own controls, through initial randomization to condition assignment and condition counterbalancing across participants. One hundred three children will participate in three randomized acute interventions: moderate intensity treadmill exercise (20 min, 70-75% of their maximal heart rate), seated rest (20 min), and a Trier Social Stress Test for Children (14 min). These visits will occur on 3 three separate days, approximately 5-8 days apart. Before and after each intervention, children complete a variety of cognitive tasks measuring attentional inhibition while their neuroelectric activity is recorded. Variables of interest include EEG data, accuracy and reaction time, academic achievement, and salivary alpha amylase. Academic achievement is also assessed following interventions. In addition, children provide passive drool samples throughout the interventions to measure various biomarkers that may explain the acute exercise benefit on cognition. DISCUSSION: The results from this study could influence educational and public health recommendations to enhance cognition and learning in pre-adolescent children. TRIAL REGISTRATION: ClinicalTrials.gov NCT03592238 . Registered on 19 July 2018.

The Experience With Smoke-Free Policies in Affordable Multiunit Housing in North Carolina: A Statewide Survey.

PURPOSE: Previous surveys of housing operators have identified concerns about enforcement, legal issues, and loss of market share as the main barriers to implementing smoke-free policies in multiunit housing. The purpose of this study was to examine enforcement practices as well as economic and legal outcomes in smoke-free affordable multiunit housing. DESIGN: Cross-sectional. SETTING: Affordable multiunit housing in North Carolina. SUBJECTS: Affordable multiunit housing properties (n = 1063, 57% response rate). MEASURES: Property representatives completed a written survey with questions regarding the existence of smoke-free policies, smoke-free policy implementation and enforcement practices, and smoking-related costs. ANALYSIS: Descriptive statistics, χ(2) goodness-of-fit test, and t-test. RESULTS: A total of 16.5% of properties had policies that prohibited smoking in all residential units. Half (49.8%) of smoke-free properties reported no violations to their policies in the past 12 months. Legal actions to enforce policies were rarely needed and were successful when they did occur. Compared to smoking-allowed properties, smoke-free properties did not experience a loss of market share in terms of occupancy rate (t = .09; p = .93) or residents moving away (χ(2) =. 5; p = .48). CONCLUSION: Housing operators' concerns about enforcement, legal issues, and loss of market share associated with smoke-free policies are largely unfounded among affordable housing properties in North Carolina. Public health professionals should use messaging strategies that refute these concerns to encourage more properties to adopt smoke-free policies.

Outcomes of adding acute care nurse practitioners to a Level I trauma service with the goal of decreased length of stay and improved physician and nursing satisfaction.

BACKGROUND: The trauma service experienced preventable delays caused by an Accreditation Council for Graduate Medical Education work restrictions and a 16% increase in patient census. Furthermore, nurses needed a consistently accessible provider for the coordination of care. We hypothesized that using experienced acute care nurse practitioners (ACNPs) on the stepdown unit would improve throughput and decrease length of stay (LOS) and hospital charges. Moreover, we hypothesized that adding ACNPs would improve staff satisfaction. On December 1, 2011, the Vanderbilt University Medical Center Division of Trauma reassigned ACNPs to the stepdown area 5 days a week for a pilot program. METHODS: LOS data from December 1, 2011 through December 1, 2012 was compared with data from the same months from the previous two years and estimated hospital charges and patient days were extrapolated. Physician and nursing surveys were performed. Data from 2010 (n = 2,559) and 2011 (n= 2,671) were averaged and the mean LOS for the entire trauma service was 7.2 days. After adding an experienced ACNP, the average LOS decreased to 6.4 days, a 0.8 day reduction. Per patient, there was a $ 9,111.50 savings in hospital charges, for a reduction of $27.8 million dollars in hospital charges over the 12 month pilot program. RESULTS: A confidential survey administered to attending physicians showed that 100% agreed that a nurse practitioner in the stepdown area was beneficial and helped throughput. Dayshift nurses were surveyed, and 100% agreed or strongly agreed that the ACNPs were knowledgeable about the patient's plan of care, experienced in the care of trauma patients, and improved patient care overall. CONCLUSION: The addition of experienced ACNPs resulted in the decrease of overall trauma service LOS, saving almost $9 million in hospital charges. LEVEL OF EVIDENCE: Economic/decision study, level III.

A cross-section of readability of Health Information Portability and Accountability Act authorizations required with health care research.

The Health Information Portability and Accountability Act (HIPAA) regulations require that agencies provide authorizations that can be read and understood. Agencies are responsible to comply with this regulation. It is estimated that half of Americans read at an eighth-grade reading level. All institutional review boards (IRBs) listed on the website of the U.S. Department of Health and Human Services were contacted by investigators in this study. Fifty-one IRBs returned HIPAA templates on which readability tests could be completed. Three readability tests were used on all templates, including the Flesch Reading Ease formula, the Dale-Chall formula, and the Fry formula. For the returned templates, the mean of the Dale-Chall readability formula gave a ninth-grade level; the mean scores for the Flesch Reading Ease and Fry formulas were at a high-school reading level or above. The readability scores ranged from sixth-grade to college graduate. This study demonstrates that HIPAA authorization forms are written at too high a level for most of the population. Based on the results of this study and other similar studies, it can be concluded that consumers/patients are currently being asked to read important health-related documents that may be beyond their reading level.