Comparison of Clinical Outcomes of Tracheostomy between COVID-19 and Non-COVID-19 Patients.

BACKGROUND AND OBJECTIVES: We compared decannulation-related factors between COVID-19 and non-COVID-19 patients who underwent tracheostomy. SUBJECTS AND METHODS: We conducted a retrospective study of patients who underwent a tracheostomy. The clinical factors were compared between the successful (decannulation within 3 months) and failed decannulation (decannulation over 3 months) groups in COVID-19 and non-COVID-19 patients. RESULTS: The successful decannulation rates were 41.1% in COVID-19 and 45.1% in non-COVID-19 patients, with no significant differences in demographic and clinical factors between the two groups. In the non-COVID-19 patients, the failed decannulation group had a higher proportion of cerebrovascular and pulmonary diseases. Ventilator dependency or increased oxygen demand was the primary cause of decannulation failure in both groups, with no significant differences except for a higher prevalence of swallowing problems in the COVID-19 group (42.4% vs. 20.0%). CONCLUSIONS: The predominant cause of decannulation failure was ventilator and oxygen demand in both the non-COVID-19 and COVID-19 patients. In the non-COVID-19 patients, underlying cerebrovascular diseases were considered to have a significant impact on the decannulation process. On the other hand, swallowing problems significantly influenced decannulation among the COVID-19 patients. Therefore, we should consider early and active respiratory and swallowing rehabilitation to facilitate successful decannulation in COVID-19 patients.

Tracheostoma Closure Technique Using Three Local Flaps.

When a tracheostoma is no longer needed, the opening normally closes spontaneously after cannula removal, but some cases require tracheostoma closure. This procedure has been well described, but must be performed in such a way as to minimize its invasiveness and complications while securing a high closure rate. Our procedure for conducting tracheostoma closure technique involves the creation of two hinge flaps and one cover flap to close the tracheostomy opening. We reviewed the medical records of 23 patients (12 men, 11 women; mean age 60.0 SD19.7 years) who underwent tracheostoma closure technique between 2001 and 2019. Surgery was indicated for patients in whom closure had not occurred after conservative monitoring for ≥ 2 months following cannula removal. The surgical procedure began by raising two hinge flaps on either side of the tracheostomy opening, turning the skin surface to the luminal side to form the anterior tracheal wall. Rather than a single layer of skin, multiple skin layers were sutured together to prevent air leakage from between hinge flaps. A further cover flap was produced to cover the anterior tracheal wall, closing the tracheostomy opening. Postoperatively, the tracheal lumen was observed via fiberscopy. No stenosis of the tracheal lumen occurred in any patients, and the tracheocutaneous fistula was successfully closed in all cases. Tracheostoma closure technique using hinge flaps to reconstruct the anterior tracheal wall and a cover flap as a skin flap to cover the skin defect appears useful for patients with failure of spontaneous tracheocutaneous fistula closure.

[Role of anthropometric parameters in percutaneous tracheostomies performed on cadavers]. / Az antropometriai paraméterek szerepe a cadaveren végzett percutan tracheostomás módszerekben.

INTRODUCTION AND OBJECTIVE: For patients requiring prolonged mechanical ventilation, tracheostomy becomes necessary, which may be performed through surgical or percutaneous methods. In this study, we used three different methods of percutaneous dilatational tracheostomy. Our goal was to identify anthropometric parameters relevant for the correct position of the tracheostomy tube. MATERIAL AND METHODS: Randomized, controlled observational study was performed on 118 cadavers. Three different tracheostomy methods were used: the Griggs (n = 37), the Griggs modified by Élo (n = 45), and the Ciaglia's Blue Rhino (n = 36). The neck circumference, jugulomental distance, and mid-upper arm circumference were measured on each cadaver. We assessed whether the aforementioned parameters related with the appropriate positioning of the tracheostomy tube Results: Significant correlation was found (p = 0.0287) between mid-upper arm circumference and incorrect tracheostomy tube position (below the fourth tracheal cartilage ring). We identified the value of 30 cm of mid-upper arm circumference as the ideal cut-off for predicting tube malposition (sensitivity: 63.63%, specificity: 60.22%). CONCLUSION: When planning percutaneous tracheostomy, it is important to measure the anthropometric parameters. If mid-upper arm circumference is 30 cm or higher we recommend other tests and/or ENT (ear, nose, and throat) consultation. Orv Hetil. 2023; 164(16): 630-635.

A simple widening technique of postlaryngectomy tracheostomal stenosis: Anchoring to the medial clavicle.

Tracheostomal stenosis is a common distressing problem for surgeons and patients after laryngectomy. The stenosis occurs in up to 44% of laryngectomized patients, according to different contributing factors. Various surgical techniques have been introduced to treat tracheostomal stenosis, showing no clear advantages over the other methods. Only a few studies have reported stomal widening techniques with the preservation of tracheoesophageal puncture (TEP). Tracheostomal restenosis may occur after the stomaplasty, often requiring revision surgery. A new surgical method was developed to preserve TEP and avoid stomal restenosis, including the bilateral vertical incisions of tracheostoma stenosis and anchoring to the clavicle. This operative technique is relatively safe, simple, less invasive and time-consuming, and preserves the TEP and voice prosthesis. Therefore, this article presents the surgical procedure, potential indications, and pros and cons of the new widening method of tracheostomal stenosis.

Themistocles Gluck and the premises of modern total laryngectomy.

The aim of this historical vignette is to recall the importance of the German surgeon Themistocles Gluck in the development of total laryngectomy with primary closure of the pharyngeal orifice, a technique proposed a few years after Theodor Billroth's first total laryngectomy in 1873.

Redo Aortic Valve Replacement With Perceval Prosthesis via Minithoracotomy in a Patient With Permanent Tracheostoma and Tracheoesophageal Shunt.

A 76-year-old male patient had undergone aortic valve replacement with a 19-mm Carpentier-Edwards Perimount valve 12 years prior and underwent laryngopharyngo-esophagectomy for hypopharyngeal carcinoma followed by permanent tracheostomy and tracheoesophageal shunt creation 2 years later. Echocardiography showed exacerbated structural valve deterioration of the bioprosthesis, necessitating redo surgery. A permanent tracheostoma, located just above the upper edge of the sternum, seemed to be at high risk of serious infections when median resternotomy was performed. To minimize the risk of infection, we performed implantation of a Perceval prosthesis via the right anterior minithoracotomy after sufficient anatomical assessments. There was no evidence of mediastinitis or wound infection during the follow-up period. This report highlights that the less invasive Perceval implantation strategically allowed reduction in the resternotomy-associated infection risks in this patient.

Coronary artery bypass grafting via manubrium-sparing sternotomy in a patient with total laryngectomy and a permanent tracheostoma.

For patients who have previously undergone total laryngectomy and a permanent tracheostomy, median full sternotomy is not the ideal surgical approach because of the substantially increased risk of sternal wound complications and tracheal injuries. We present a case in which conventional coronary artery bypass grafting using bilateral internal thoracic arteries was performed safely via a manubrium-sparing sternotomy in a patient who had undergone total laryngectomy and a permanent tracheostoma. We also discuss the appropriate surgical approach for patients with total laryngectomy and a permanent tracheostoma. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-021-01309-8.

Total arch replacement with both frozen elephant trunk and transthoracic aorto-axillary extra-anatomical bypass through partial sternotomy for acute aortic dissection in a tracheostomy patient.

Median sternotomy near an existing tracheostoma risks deep sternal wound infection after cardiac surgery. We present herein a case of acute type A aortic dissection in a patient with a permanent tracheostoma after laryngectomy. Total arch replacement with both frozen elephant trunk and extra-anatomical bypass for supra-aortic trunks was performed through T-shaped partial sternotomy, resulting in recovery without deep sternal wound infection.

Changes in hormones of the thyroid axis after tracheostomy and their influence on regeneration in patients with head and neck cancer: A prospective study.

This prospective study aimed to compare and evaluate changes in hormones of the thyroid axis affected by tracheostomy due to surgical treatment in patients with oral cancer. The patients were evaluated with regard to serum levels of the thyroid axis - free T3/triiodothyronine (fT3) and free T4/thyroxine (fT4), as well as thyroid-stimulating hormone (TSH) - at fixed perioperative time points: during the tumor staging about 1 week before operation, immediately before and within 6 h after operation, 2 days after operation, and about 10 days after operation. Additionally, data on the patients' characteristics (age, gender), relevant secondary diagnoses, duration of ventilation in the intensive care unit, and perioperative complications were obtained and analyzed. In total, 51 patients with an average age of 68.29 years (±11.82) were included. Analyses of thyroid hormones directly before and after tracheostomy showed a significant postoperative decrease in circulating TSH (p = 0.005) and fT3 (p < 0.001), whilst a significant increase in fT4 values (p < 0.001) was found. Nine patients showed perioperative complications, such as infection, emphysema, or requiring a revision operation. Eleven patients were diagnosed with a cardiac problem or suffered from agitation after operation. Within the limitations of the study it seems that hormonal changes following tracheostomy in critically ill patients should be monitored and thyroid hormone adjustment should be taken into account because the latter might lead to lower mortality and morbidity during hospitalization in these patients. CLINICAL TRIAL REGISTRATION NUMBER: DRKS00023942.

A safe procedure? The unusual case of a fatal airway obstruction by silicone during the production process of a tracheostomal epithesis in a 13-year-old boy.

A tracheostomal epithesis is a plastic prosthesis that serves for sealing a tracheostoma and ensuring the position of the tracheostomy tube. The production of a tracheostomal epithesis requires an impression of the tracheostoma. To this end, silicone impression material is applied by an anaplastologist in and around the tracheostomal region, including the trachea. The blocked cuff of the tracheostomy tube serves to prevent aspiration of the material. We report on a 13-year-old boy who died during this procedure because the lower airways were obstructed with cured silicone. Forensic autopsy confirmed asphyctic suffocation as cause of death. Forensic physical investigation of the tracheostomy tube and its cuff revealed no structural or functional defects. Yet, the investigation results prove that the viscous silicone must have passed the cuff. To conclude, this case report demonstrates that the production of an impression of a tracheostoma is a procedure with a potentially lethal outcome. Hence, professional guidelines, including clear safety precautions, are urgently needed.

Efficacy of Sirolimus in Patients Requiring Tracheostomy for Life-Threatening Lymphatic Malformation of the Head and Neck: A Report From the European Reference Network.

Extensive lymphatic malformations (LMs) of the head and neck region may require tracheostomy to secure the airway. Treatment of these life-threatening LMs is usually multimodal and includes sclerotherapy and surgery, among others. Recently, systemic therapy with sirolimus has been introduced as an effective treatment for venous and lymphatic malformations; its efficacy and safety profile in patients with extensive LM requiring tracheostomy are, however, as yet not fully known. We performed a retrospective, multicenter review and identified 13 patients with an extensive LM of the head and neck region, who previously underwent placement of tracheostomy and subsequently received sirolimus treatment with the aim to improve the local respiratory situation and remove the tracheostomy. Under sirolimus therapy, tracheostomy could be reversed in 8/13 (62%) patients, a further 2/13 (15%) patients improved markedly, and removal of the tracheostomy was planned at the time of writing, while 3/13 (23%) patients showed insufficient or absent response to sirolimus, rendering tracheostomy reversal not feasible. The median duration of sirolimus treatment until removal of tracheostomy was 18 months (range, 8 months to 5.6 years). Adverse events of sirolimus therapy were common [10/13 (77%) patients], yet the majority of these were mild [9/10 (90%) patients] and only one severe adverse event was recorded, with ulceration and necrosis at a catheter insertion site. In conclusion, sirolimus can be considered an effective and safe salvage treatment in patients with extensive LM even after placement of a tracheostomy, as closure of the latter was possible in the majority of patients (62%) of our retrospective cohort. A better understanding of when to start sirolimus therapy, of the duration of treatment, and of factors allowing the prediction of treatment response will require further investigation.

Swallowing problems in children with a tracheostomy.

Children with a tracheostomy often present with swallowing disorders. Assessing the impact the presence of the tracheostomy tube has on swallowing function next to the underlying pathology can be very challenging. This article gives an overview of normal swallowing physiology and development, swallowing difficulties as encountered in various airway pathologies and addresses the mechanism by which the tracheostomy tube impacts swallowing. We discuss methods of investigating swallowing disorders and offer tools for management in everyday practice.

Improving Hands-free Speech Rehabilitation in Patients With a Laryngectomy: Proof-of-Concept of an Intratracheal Fixation Device.

Permanent hands-free speech with the use of an automatic speaking valve (ASV) is regarded as the optimal voice rehabilitation after total laryngectomy. Due to fixation problems, regular ASV use in patients with a laryngectomy is limited. We have developed an intratracheal fixation device (ITFD) composed of an intratracheal button augmented by hydrophilic foam around its shaft. This study evaluates the short-term effectiveness and experienced comfort of this ITFD during hands-free speech in 7 participants with a laryngectomy. We found that 4 of 7 participants had secure ASV fixation inside the tracheostoma during hands-free speech for at least 30 minutes with the ITFD. The ITFD's comfort was perceived positively overall. The insertion was perceived as being mildly uncomfortable but not painful. This proof-of-concept study demonstrates the feasibility of the ITFD that might improve stomal attachment of ASVs, and it provides the basis for further development toward a prototype suitable for long-term daily use.

Off-pump coronary artery bypass grafting via left anterior thoracotomy from the 4th costal space in a patient with total laryngectomy and a permanent tracheostoma.

Median sternotomy is the standard approach for coronary artery bypass grafting. Herein, we performed off-pump coronary artery bypass grafting via left anterior thoracotomy from the 4th costal space in an unstable angina pectoris patient with total laryngectomy and a permanent tracheostoma. In this patient, median sternotomy had high risks of surgical-site infection and tracheal injury. To avoid these risks, we selected left anterior thoracotomy. Initially, it was difficult to expose the ascending aorta and postdescending branch. With extension of the skin incision to the median area and division of the 5th and 6th ribs and costal arch, we could expose the anastomotic sites, including the ascending aorta and postdescending branch, without median sternotomy conversion. We performed multiple coronary artery bypass graft procedures safely. This approach might be an additional surgical option in patients with total laryngectomy and a permanent tracheostoma.

Swallowing problems in children with a tracheostomy tube.

INTRODUCTION: Swallowing problems in children with a tracheostomy tube seem to be a common problem, although exact prevalence is not known. The aim of this study is to identify the prevalence and type of swallowing problems in children with a tracheostomy tube. METHODS: We retrospectively included 44 children having a tracheostomy tube at Erasmus MC-Sophia Children's hospital. Assessment by a specialized speech and language therapist, the Modified Evans Blue Dye test, Video Fluoroscopic Swallowing Study and a Fiber-optic Endoscopic Evaluation of Swallowing were reviewed with regard to the different phases of swallowing, in particular signs of aspiration. RESULTS: In our cohort, 31 (70%) children with a tracheostomy tube presented with problems in the oral and/or the pharyngeal phase of swallowing. Overall 19 (43%) children aspirated. CONCLUSIONS: The majority of children with a tracheostomy tube have swallowing problems in the different swallowing phases with a high risk for aspiration.

Frontiers in Clinical Practice of Long-Term Care of Chronic Ventilatory Failure.

Home mechanical ventilation (HMV) is an effective long-term treatment for chronic hypercapnic respiratory failure. In addition to the established practice of providing HMV for the treatment of chronic ventilatory failure in slowly progressive neuromuscular and chest wall disease, there is accumulating evidence for improvement of quality of life and prolongation of survival by HMV in highly prevalent diseases like chronic obstructive pulmonary disease and ever-increasing obesity hypoventilation syndrome as well as rapidly progressive neuromuscular disease. The key concepts for successful HMV are an experienced team selecting the right patients, timely initiation of adequate ventilation via an appropriate interface, and monitoring effectiveness during regular long-term follow-up. Coaching of patients with chronic respiratory failure on long-term HMV within a dedicated service and collaborations with community services for home care are essential. The current review describes various important practical aspects of HMV that remain frontiers in the implementation of the current knowledge in clinical practice and may help in providing effective HMV to all those in need.

Multicenter randomized crossover trial evaluating the provox luna in laryngectomized subjects.

OBJECTIVES: The aim of this study was to compare the relative compliance and the dermatological and pulmonary outcomes when the Provox Luna system (Atos Medical, Malmö, Sweden) is added during the night to the usual tracheastoma care of laryngectomized subjects. METHODS: This was a multicenter randomized crossover trial conducted in the Netherlands Cancer Institute, Erasmus Medical Center, and Maastricht University Medical Center in The Netherlands. The study included 46 laryngectomized subjects with prior heat and moisture exchanger (HME) and adhesive experience. RESULTS: A significant improvement in the number of compliant individuals was found: Luna: n = 43 of 45 (96%); usual care: n = 35 of 46 (76%), P = 0.02. The Luna period was associated with longer intervals of daily HME use (Luna 23.2 hours [range: 15.6-24.0 hours], usual care [UC]: 21.5 hours [range: 6.0-24.0 hours], P = 0.003) and an increased frequency of skin improvement overnight (Luna 3.9 days [standard deviation (SD)]: 7.0 days), Usual Care: 8.1 days ([SD: 10.8 days], P = 0.008). Fifty-six percent (n = 26) of participants wanted to continue using the Provox Luna system at the conclusion of the study. CONCLUSION: An improvement in compliance and skin recovery overnight was observed when the Provox Luna was added to the usual adhesive and HME use. Therefore, there is utility in supplementing the usual post-total laryngectomy care with the Provox Luna system at night, particularly in the setting of compliance concerns and in subjects who desire dermatological relief overnight. LEVEL OF EVIDENCE: 1b Laryngoscope, 129:2354-2360, 2019.

Off-pump coronary artery bypass grafting in a tracheostomy patient.

In patients who have undergone laryngectomy and have a tracheal stoma, a full median sternotomy substantially increases the risk of wound infection, osteomyelitis, mediastinitis, bleeding, tracheal injury, and poor wound healing. Several reports have been published on sternotomies and skin incisions in tracheostoma patients. Transverse bilateral thoracosternotomy, T-shaped partial sternotomy (manubrium-sparing sternotomy) with transverse skin flaps and anterolateral thoracotomy with partial sternotomy are described as successful approaches to the mediastinum for cardiac surgery. We present a successful case in which off-pump coronary artery bypass grafting (CABG) was performed in a tracheostoma patient using a low T-shaped partial sternotomy and the PAS-Port system. Good long-term results were achieved.