Unidad de Atención al Paciente Traqueostomizado. Una solución innovadora desde Otorrinolaringología con carácter transversal para el hospital / Tracheostomy Patient Care Unit. An innovative Otorhinolaryngology solution of a transversal nature for the hospital

Antecedentes y objetivo: Los cuidados de los pacientes traqueostomizados son habilidades de alto riesgo y baja incidencia. Las estrategias de mejora de la atención sanitaria en plantas hospitalarias y en especialidades distintas a la Otorrinolaringología (ORL) basadas únicamente en la formación no han sido capaces de ofrecer una solución adecuada. Se presenta un modelo de Unidad de Atención al Paciente Traqueostomizado dirigida por el Servicio de Otorrinolaringología para atender a todos los pacientes traqueostomizados de un hospital en todas las especialidades. Material y métodos Ámbito: hospital universitario público de tercer nivel con 876 camas de hospitalización y 30 camas de UCI para 481.296 habitantes. Modelo de Unidad: unidad transversal para el hospital proporcionando atención a todos los pacientes traqueostomizados, adultos y niños, de todas las especialidades, con dedicación del 50% de una enfermera de ORL de hospitalización que se desplaza hasta la cama de hospitalización de la especialidad de cada paciente y el 50% de otra enfermera de ORL de consultas externas para los pacientes ambulatorios, con la consultoría de un especialista en ORL y coordinación de la supervisora de ORL. Resultados Se atendió en la unidad a 572 pacientes entre 2016 y 2021, el 80% varones, con una media de edad de 63±14 años. Se atendieron 14,7±2 pacientes traqueostomizados diarios y 96±4 consultas por complicaciones anuales, elevándose hasta 19 pacientes traqueostomizados diarios en 2020 y 141±8,4 consultas por complicaciones en los años 2020 y 2021, durante la pandemia por COVID-19. Se redujo la estancia media de las especialidades no ORL en 13 días a lo largo de los 6 años del estudio, aumentando la satisfacción de los profesionales de ORL y de no ORL, y la satisfacción de los usuarios.... (AU)

Background and objective: The care of tracheostomized patients are high risk skills and low incidence. Strategies for improvement of health care in hospital wards and specialties other than otolaryngology based solely on training have not been able to offer an adequate solution. A tracheostomized patient unit is presented directed by the otolaryngology service to attend all tracheostomized hospitalized patients of all specialties. Material and methods Background: Third level public hospital with 876 hospitalization beds and 30 ICU beds for 481,296 inhabitants. Unit model: Transversal unit for the hospital providing attention to all tracheostomized patients, adults, and children, of all specialties, with dedication of 50% of a ENT nurse of hospitalization that moves to the hospitalization bed of the specialty of each patient and 50% of another office ENT nurse for ambulatory patients care, with the consultancy of an ENT specialist and coordinated by the ENT supervisor. Results 572 patients between 2016 and 2021, 80% men, aged 63±14 years, were attended in the unit. 14.7±2 tracheostomized patients daily and 96±4 complication annual consultations were attended, rising up to 19 tracheostomized patients daily by 2020 and 141±8.4 consultations by complications in 2020 and 2021, during the COVID-19 pandemic. The mean stay of the non-ENT specialties was reduced in 13 days, increasing the satisfaction of the ENT and non-ENT professionals and the satisfaction of the users. ... (AU)

Cuffed versus uncuffed tracheal tubes in a rabbit training model for establishing an emergency front-of-neck airway in infants: a prospective trial.

BACKGROUND: There is a paucity of evidence regarding the optimal type of tracheal tube to be advanced over a Frova catheter when performing a 'bougie' emergency front-of-neck airway (eFONA) technique in infants during a 'cannot intubate, cannot oxygenate' situation. METHODS: A prospective non-inferiority trial in a rabbit cadaver surgical tracheotomy model to assess the performance of the eFONA technique with an uncuffed 3.5 mm ID tracheal tube vs a cuffed 3.0 mm ID tracheal tube. Queried outcomes include success rate, performance time, and severe secondary airway injuries among tracheal tube types. RESULTS: In 60 tracheostomies performed by 30 participants, the overall success rate was 98%. Performance time was independent from tracheal tube choice (uncuffed: 61 s [95% confidence interval (CI), 52-76], cuffed: 64 s [95% CI, 55-79]; P = 0.82). No tracheal tube type was preferred in terms of usability by participants. The cuffed tracheal tube required increased force to be advanced over the Frova catheter and was associated with a risk ratio of 2.5 (95% CI, 0.53-11.9; number needed to harm, 10) for severe secondary airway injuries when compared with the uncuffed tracheal tube. CONCLUSION: In performing eFONA in the rabbit cadaver model, an ID 3.5 uncuffed is non-inferior to an ID 3.0 cuffed tracheal tube regarding performance time and preference by the operator. Greater force application to advance the cuffed tube over the Frova catheter and more severe airway injuries may argue for the standardised performance of the eFONA technique with a uncuffed tracheal tube in infants.

Navigation system for percutaneous tracheotomy.

BACKGROUND: Percutaneous dilatational tracheotomy (PDT) is a well-established method. The prerequisite is to identify anatomical landmarks of the neck. We introduce a three-dimensional navigation system - SafeTrach. AIMS/OBJECTIVES: We present an alternative technique using internal landmarks that can be used in patients with difficult anatomy. MATERIAL AND METHODS: The device is a forceps-like instrument with an outer and an inner shank. The later serves as a ventilation lumen and stabilizes the orotracheal tube in the midline of trachea. The outer shank acts as a three-dimensional guide for the puncturing needle. RESULTS: Out of 48 patients we have determined the level of puncture in 20 patients by using intraoperative measurements. The distance from the vocal cords to the puncture site was about 50 mm for men and 40 mm for women. In 13 of the patients who had had CT scans, we studied the distance between the vocal cords and the optimal puncture site and found the median distance for men 45 mm and for women 42 mm. CONCLUSIONS AND SIGNIFICANCE: With the studied navigation system one may use external or internal landmarks to indicate the puncture level in PDT. The device may minimize the risk of injuring the posterior tracheal wall.

Effectiveness and safety of a newly designed partially covered tracheal metallic Y-shaped stent for the treatment of high cervical gastro-tracheal or tracheo-esophageal fistula: A retrospective observational study.

ABSTRACT: The aim of this study was to evaluate the effectiveness and safety of a partially covered metallic tracheal Y-shaped stent for the treatment of high cervical gastro-tracheal fistula (GTF) and tracheo-esophageal fistula (TEF). From January 2017 to January 2019, 16 patients with high cervical GTF and TEF received partially covered metallic Y-shaped stent placement under fluoroscopic guidance. The technical and clinical success rates, incidence of major complications, and survival outcomes were analyzed. Eastern Cooperative Oncology Group (ECOG) score and quality of life (SF-36 questionnaire) were compared pre and post stent placement. Technical and clinical success rates were 100% and 81.3%, respectively. Major complications (severe tumor ingrowth, mucostasis, hyperplastic granulation tissue) occurred in 7/16 (43.8%) patients. ECOG score and 5 of the 8 domains of the SF-36 (physical function, role physical, general health, vitality, social function) were significantly improved at 1 month after treatment (P < .01). During the median follow-up period of 8.3 months, 9 patients were alive. Median overall survival was 10.3 months (95% CI, 8.0-12.6). The newly designed partially covered tracheal Y-shaped stent appears to be effective and safe for treatment of high cervical GTF and TEF.

Safety of percutaneous dilatational tracheotomy (PDT) with the rigid tracheotomy endoscope (TED): a 6-month follow-up multicenter investigation.

BACKGROUND: The rigid tracheotomy endoscope (TED) was recently introduced to improve the fiberoptic technique during percutaneous dilatational tracheotomy (PDT) in critically ill patients. The aim was to evaluate the long-term complications of PDT using TED equipment in a prospective multicenter investigation. METHODS: One hundred eighty adult patients underwent PDT using TED in four German hospitals. Patients who were alive or their guardians were contacted via telephone and interviewed using a structured questionnaire 6 months following the tracheostomy procedure. Patients with airway complaints were invited for outpatient clinical ENT examination. The incidence of adverse events related to PDT was registered. RESULTS: Of 180 patients who received tracheostomy, 137 (76.1%) were alive at the time of follow-up. None of the 43 lethal events was related to the PDT. Fifty-three (38.7%) patients were available for follow-up examination, whereas 14 (10.2%) were able to visit ENT physicians. Two (3.8%) out of 53 patients developed tracheocutaneous fistula with required surgical closure of tracheostoma. Dyspnea (7.5%), hoarseness (5.7%), stridor and swallowing difficulties (both with 3.8%) were the most common complaints. Tracheal stenosis was confirmed in 1 patient (1.88% [95% CI: 0.33; 9.93]). CONCLUSION: The use of TED for PDT in the clinical setting is safe regarding adverse events at 6-month follow-up. The incidence of tracheal stenosis after PDT with TED is comparable with that of flexible bronchoscopy; however, its role for PDT at the intensive care unit should be clarified in further investigations.

Respuesta a Documento de consenso de la traqueotomía en pacientes con COVID 19 / Reply to Consensus document on tracheotomy in patients with COVID 19

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Front-of-neck airway rescue with impalpable anatomy during a simulated cannot intubate, cannot oxygenate scenario: scalpel-finger-cannula versus scalpel-finger-bougie in a sheep model.

BACKGROUND: Front-of-neck airway rescue in a cannot intubate, cannot oxygenate (CICO) scenario with impalpable anatomy is particularly challenging. Several techniques have been described based on a midline vertical neck incision with subsequent finger dissection, followed by either a cannula or scalpel puncture of the now palpated airway. We explored whether the speed of rescue oxygenation differs between these techniques. METHODS: In a high-fidelity simulation of a CICO scenario in anaesthetised Merino sheep with impalpable front-of-neck anatomy, 35 consecutive eligible participants undergoing airway training performed scalpel-finger-cannula and scalpel-finger-bougie in a random order. The primary outcome was time from airway palpation to first oxygen delivery. Data, were analysed with Cox proportional hazards. RESULTS: Scalpel-finger-cannula was associated with shorter time to first oxygen delivery on univariate (hazard ratio [HR]=11.37; 95% confidence interval [CI], 5.14-25.13; P<0.001) and multivariate (HR=8.87; 95% CI, 4.31-18.18; P<0.001) analyses. In the multivariable model, consultant grade was also associated with quicker first oxygen delivery compared with registrar grade (HR=3.28; 95% CI, 1.36-7.95; P=0.008). With scalpel-finger-cannula, successful oxygen delivery within 3 min of CICO declaration and ≤2 attempts was more frequent; 97% vs 63%, P<0.001. In analyses of successful cases only, scalpel-finger-cannula resulted in earlier improvement in arterial oxygen saturations (-25 s; 95% CI, -35 to -15; P<0.001), but a longer time to first capnography reading (+89 s; 95% CI, 69 to 110; P<0.001). No major complications occurred in either arm. CONCLUSIONS: The scalpel-finger-cannula technique was associated with superior oxygen delivery performance during a simulated CICO scenario in sheep with impalpable front-of-neck anatomy.

Barrier device prototype for open tracheotomy during COVID-19 pandemic.

OBJECTIVE: To present a low-cost prototype for a barrier enclosure device which can be used during open surgeries such as tracheotomy. METHODS: We provide detailed description of a novel device called COVID-Box, developed by The Surgical Airway Team for COVID-19 Pandemic, a temporary task force formed by Walter Cantídio University Hospital. Safety guidelines for performing tracheotomies in COVID-19 patients are also stated. RESULTS: Our prototype device provides greater hand mobility than previous barrier devices reported, making it more suitable for airway surgical procedures, such as tracheotomy. The curved shaped format and the customizable access ports provides ergonomics, without compromising safety. CONCLUSION: The COVID-Box appears to be an efficient, reproduceable, low-cost barrier enclosure device that can be used for open tracheotomies in ICU patients during the COVID-19 pandemic.

Survival analysis and decannulation outcomes of infants with tracheotomies.

OBJECTIVE: To evaluate for differences in time to decannulation and survival rates for pediatric tracheotomy patients based on ventilator status upon discharge. STUDY DESIGN: Retrospective longitudinal cohort study. METHODS: A single-institution longitudinal study of pediatric tracheostomy patients was conducted. Patients were categorized based on mechanical ventilation status on discharge and principal reason for tracheostomy. Survival rates were determined using the Kaplan-Meier method. The Wilcoxon's Rank Sum test and Cox regression analysis evaluated differences in survival times and time to decannulation based on primary indication for tracheotomy and ventilation status. RESULTS: Chart review identified 305 patients who required a tracheostomy under the age of 3. The median age at the time of tracheotomy was 5.2 months. The indications for tracheotomy in these patients were airway obstruction in 145 (48%), respiratory failure in 214 (70%), and pulmonary toilet in 10 (3.3%). Seventy-nine percent of patients were ventilator dependent at discharge. At the conclusion of the study period, 55% of patients were alive with tracheostomy in place, 30% patients were decannulated, and 15% patients were deceased. Patients with ventilator dependence at initial discharge, bronchopulmonary dysplasia, or airway obstruction were more likely to be decannulated. Hispanic patients were less likely to be decannulated. Patients had an equal probability of death regardless of ventilator status at discharge. CONCLUSIONS: This study demonstrated that the time to decannulation and likelihood of decannulation varies based on the indication for the tracheostomy. The majority of patients with a tracheostomy were not decannulated at the conclusion of this study. Median time to decannulation was 2.5 years for patients with a median death time of 6 months. LEVEL OF EVIDENCE: 2b Laryngoscope, 130:2319-2324, 2020.

Nonintubated Tracheal Surgery.

The article describes an anesthetic management strategy for resection of the cervical trachea due to benign stenosis without using an endotracheal tube. The strategy includes: (1) insertion of an airway stent in the stenotic area, (2) insertion of a supraglottic airway device (SGAD), and (3) advancing a jet ventilation catheter through the SGAD. The stent is removed during surgery together with the resected part of the trachea. The technique of nonintubated tracheal resection allows the surgeon to work most comfortably and helps the anesthesiologist properly maintain the patient's vital functions in the operating room.

Time to oxygenation for cannula- and scalpel-based techniques for emergency front-of-neck access: a wet lab simulation using an ovine model.

Emergency front-of-neck access to achieve a percutaneous airway can be a life-saving intervention, but there is debate about the preferred technique. This prospective, observational study was designed to compare the two most common emergency surgical airway techniques in a wet lab simulation using an ovine model. Forty-three doctors participated. After providing standardised reading, a lecture and dry lab benchtop training, participants progressed to a high-fidelity wet lab simulation. Participants entered an operating theatre where a 'cannot intubate, cannot oxygenate' situation had been declared and were directed to perform emergency front-of-neck access: first with a cannula technique (14-gauge cannula insertion with ventilation using a Rapid-O2® cricothyroidotomy insufflation device); and subsequently, a scalpel-bougie technique (surgical incision, bougie insertion into trachea and then tracheal tube passed over bougie, with ventilation using a self-inflating bag). The primary end-point was time from declaration of 'cannot intubate, cannot oxygenate' to delivery of oxygen via a correctly placed percutaneous device. If a cannula or tracheal tube was not placed within 240 s, the attempt was marked as a failure. There was one failure for the cannula approach and 15 for the scalpel-bougie technique (OR 0.07 (95%CI 0.00-0.43); p <0.001). Median (IQR [range]) time to oxygenation, if successful, was 65 (57-78 [28-160]) s for the cannula approach and 90 (74-115 [40-265]) s for the scalpel-bougie technique (p=0.005). In this ovine model, emergency front-of-neck access using a cannula had a lower chance of failure and (when successful) shorter time to first oxygen delivery compared with a scalpel-bougie technique.

Glottic Stenosis: An Anatomic Analysis and New Treatment With a Self-Retaining Interarytenoid Spring.

INTRODUCTION:: Endotracheal (ET) intubation is a common cause of acquired glottic stenosis. Severe cases often require an irreversible arytenoidectomy/cordectomy, which typically results in poor voice quality. Adult human cadaver larynges were studied to gain insights about ET tube-induced posterior glottic injuries, hoping to create a less invasive remedy. STUDY DESIGN:: Human cadaver investigation and case reports. METHODS:: Microlaryngeal assessments were done on 10 human cadaver larynges (5 men, 5 women) with and without ET tubes. After supracricoid soft tissue resection, measurements were obtained, including the distance between the outer diameter of the ET tube and the medial aspect of the cricoarytenoid joint facet. Additionally, measurements of the circumferential arc of differently sized ET tubes were made alongside both cricoarytenoid joint capsules. This information was used to design a silastic stent that would function as a self-retaining interarytenoid spring to treat posterior glottic stenosis in 5 patients. Four of 5 patients included in the clinical study were tracheotomy dependent, primarily because of glottic stenosis. The human surgical technique is described in detail. RESULTS:: The shortest distance between the outer diameter of the ET tube to the medial cricoid facet averaged 5.02 mm in men and 3.62 mm in women. On the basis of the diameter of the intralaryngeal component of the initially round stent, and the position of the cricoarytenoid joint facets, the interarytenoid spring would have a subtended arc between 110° and 175°. These data helped fashion parameters for modifying a conventional T-tube to form a new self-retaining silastic interarytenoid spring. The first 5 human cases have been successful, allowing effective tracheotomy tube decannulation and excellent voice quality. CONCLUSIONS:: The anatomic investigation herein provided key insights into ET tube-induced glottic stenosis and facilitated a new straightforward procedure to surgically improve the airway yet preserve excellent vocal function in patients with acquired glottic stenosis. Level of Evidence: NA.

Retrospective comparison of Velcro® and twill tie outcomes following pediatric tracheotomy.

OBJECTIVES: To compare the rates of skin-related complications and accidental decannulation in pediatric patients who received Velcro® ties versus twill ties during the early postoperative period following tracheotomy. The rates of skin-related complications and accidental decannulation in patients with Velcro® ties was hypothesized to differ from those in patients with twill ties. METHODS: Medical records of 109 patients ≤18 years old who underwent elective tracheotomy were reviewed: 70 received twill ties and 39 received Velcro® ties. Patients were followed for the first seven postoperative days. The primary outcome was skin-related complications, which were further categorized into mild (irritation) and severe (breakdown). The secondary outcome was accidental decannulation. Rates of skin-related complication and accidental decannulation were compared across the two groups using chi-square analysis. RESULTS: Skin irritation occurred in 32 patients (45.7%) with twill ties and 10 patients (25.6%) with Velcro®. Skin breakdown occurred in 20 patients (28.6%) with twill ties and 6 patients (15.4%) with Velcro®. There were no accidental decannulation events. The use of Velcro® ties was associated with a decreased rate of skin irritation (OR: 0.41; 95% CI: 0.17-0.97; P = 0.039). CONCLUSIONS: The use of Velcro® ties was associated with a decrease in the rate of skin irritation. There were no accidental decannulation events. These findings support the use of Velcro® ties at the time of pediatric tracheotomy placement.

[Analysis of long-term effect of juvenile-onset recurrent respiratory papillomatosis].

Objective: To observe the clinical course of children with juvenile-onset recurrent respiratory papillomatosis (JORRP) until 14 years old. Methods: The clinical data of one hundred and twenty cases treated between Januray 1, 2002 and September 30, 2017 in Beijing Tongren Hospital were analyzed retrospectively. Excluding the deaths and the lost, patients who could be ≥ 5 years without recurrence, were defined as the cured group, and < 5 years with recurrence defined as the recurrent group. Furthermore, using statistical methods to analyze the differences of the age of initial operation, total number of operations, invasive lesion, HPV infection, tracheotomy, airway dissemination after tracheotomy and time of tube wear between the two groups. Results: One hundred and three cases were followed up, except for the six deaths.Numbers of operations in eight cases were ≤2, and ≥3 in eighty nine cases.Peak of the primary surgical age were about 4.5 years old, while the self-healing trend occurred at nine years old. In the cured group, forty three cases were cured, with a curative rate of 41.7% (43/103), and there were all fifty four survivors in the recurrent group.The total number of operations, invasive cases, HPV positive cases and the G score of hoarseness in the recurrent group were higher than those in the cured group (F=13.02, χ(2)=13.04, χ(2)=17.37, Z=-4.59, P<0.05). The number of tracheal dissemination caused by tracheotomy in the recurrent group (66.7%, 27.8%)was more than that in the cured group (χ(2)=16.01, P<0.05). Compared with the time of wearing a tracheostomy tube in cured group, the recurrent group was longer ((3.4±3.1) years vs (8.3±6.7) years, χ(2)=7.19, P<0.05). Conclusions: 41.7% of the patients had no relapse for at least five years.There exsisted differences between the cured and recurrent group in the following aspects: the total numbers of surgery, the agression of the lesions, tracheal intratracheal dissemination after tracheotomy, the time of tracheotomy, the HPV typing and the G grading of hoarseness.

Peak inspiratory flow as predictor for tracheotomy.

OBJECTIVES: Quantitative evaluation of upper airway obstruction cannot be commonly performed under acute dyspnea, especially in head and neck cancer (HNC); the decision whether or not to perform airway control surgery may be difficult to reach. Peak inspiratory flow (PIF) has been previously demonstrated to be a useful tool to decide on decannulation after HNC surgery. The aim of the present study was to assess the role of PIF as a standardized non-invasive tool in quantifying severe inspiratory dyspnea requiring emergency tracheostomy. MATERIALS AND METHODS: A single-center prospective observational pilot study analyzed PIF measurements in 22 patients exhibiting acute dyspnea due to upper airway obstruction. MAIN OUTCOME MEASURES: The decision whether or not to perform tracheotomy was taken prior to PIF measurement. PIF was measured with a hand-held PIF meter (In-Check method), and laryngeal fiberoscopy was then performed. Obstruction severity was defined by PIF values. RESULTS: PIF could be measured prior to tracheotomy (imminent in 21 cases, postponed in 1) in all cases. PIF values below 53.1 L/min (i.e., 18.3% of theoretic value) correlated with necessity for emergency tracheotomy. This threshold is concordant with that previously found for the feasibility of decannulation (60L/min). CONCLUSIONS: PIF is a non-invasive quantitative parameter assessing severity of upper airway obstruction, that may be helpful in decision-making for tracheostomy. Testing is simple, quick and reproducible.

Application of a flexible lightwand in percutaneous dilatational tracheotomy.

PURPOSE: By comparing flexible lightwand-assisted and conventional endotracheal tube (ETT) withdrawal in percutaneous dilatational tracheotomy (PDT), this paper aims to provide guidance for precise ETT withdrawal by anesthesiologists and accurate determination of the incision site by surgeons. METHODS: Sixty patients who underwent PDT in our hospital were randomly divided into the lightwand group (Group L, n=30) and the withdrawal group (Group W, n=30) using the envelope method. For Group L patients, a flexible lightwand was inserted into an ETT (based on the patient's size), the light source was positioned at the root of the cuff, and the depth from the root of the cuff to the end of the ETT was marked. The flexible lightwand was inserted into the patient's ETT to the marked depth. The ETT along with the flexible lightwand was withdrawn until the highlighted spot was located at the level of the thyroid cartilage. The incision site was approximately 3 finger widths (approximately 4.8cm) below the highlighted spot. For Group W patients, the ETT was withdrawn to a tube depth of 17cm at the upper incisors in males and 15cm in females, and surgeons determined incision sites without assistance. The following metrics were recorded for the two groups: occurrences of inadvertent extubation, ETT puncture and cuff rupture; success rate of first puncture; hypoxia rate; SpO2 at the time of tracheostomy cannula intubation (T1); and postoperative hemorrhage rate. RESULTS: Inadvertent extubation, ETT puncture and cuff rupture occurred significantly less frequently in Group L than in Group W, and the success rate of first puncture and SpO2 at T1 were markedly higher in Group L than in Group W. Moreover, significant between-group differences in hypoxia rate and postoperative hemorrhage rate were observed. CONCLUSIONS: The use of a flexible lightwand in PDT is a safe and effective approach. This approach can effectively and directly guide precise ETT repositioning and provide incision site confirmation with few intra- and postoperative anesthesia-related or operative complications compared with the traditional technique of ETT withdrawal to a pre-determined depth.