La disfagia en cuidados intensivos, un problema real: análisis de factores de riesgo / Dysphagia in intensive care, a real problem: analysis of risk factors

Objetivos: Determinar los factores de riesgo presentes en los pacientes con disfagia en relación con una población de pacientes críticos. Método: Serie de casos de una cohorte de pacientes reclutados en la unidad de cuidados intensivos (UCI) hasta el alta hospitalaria. Se reclutaron a aquellos pacientes que dieron su consentimiento y cumplían los criterios de inclusión. El método de exploración clínica Volumen-Viscosidad fue utilizado para la detección de la disfagia. Se realizó un análisis estadístico uni- y bivariante, a través del odds ratio (OR) para detectar los factores de riesgo en la disfagia. Resultados: 103 pacientes fueron reclutados de 401 posibles. La media de edad fue de 59,33±13,23; los hombres representaban el 76,7%. La gravedad media fue: APACHE II (12,74±6,17) y Charlson (2,98±3,31). Un 45,6% de los pacientes desarrollaron disfagia, obteniendo valores significativos de OR (p<0,050) para el desarrollo de disfagia: la mayor edad, los antecedentes neurológicos, COVID19, la alta estancia en UCI y hospitalización y la presencia de traqueotomía. Los pacientes COVID19 representaban el 46,6%, por lo que se realizó un análisis de este subgrupo observando resultados similares, con un riesgo de Charlson (OR:4,65; IC95%: 1,31-16,47; p=0,014) y una estancia hospitalaria (OR: 8,50; IC95%: 2,20-32,83; p<0,001). Al alta de UCI, el 37,9% de la población presentaba todavía disfagia, y mantenía este problema al alta hospitalaria el 12,6%. Conclusiones: Casi la mitad de nuestros pacientes presentaron disfagia. Fueron factores de riesgo la gravedad clínica y la presencia de traqueotomía. Se observó en estos pacientes una mayor estancia tanto en UCI como en hospitalización.(AU)

Aims: To identify risk factors present in patients with dysphagia in a population of critically ill patients. Methods: Case series of a cohort of patients recruited in the intensive care unit (ICU) until hospital discharge. Patients who gave consent and met the inclusion criteria were recruited. The Volume-Viscosity clinical examination method was used for the screening of dysphagia. An uni- and bivariate statistical analysis was performed using odds ratio (OR) to detect risk factors for dysphagia. Outcomes: 103 patients were recruited from 401 possible. The mean age was 59,33±13,23, men represented 76,7%. The severity of the sample was: APACHE II (12,74±6,17) and Charlson (2,98±3,31). 45,6% of patients showed dysphagia, obtaining significant OR values (p<0,050) for the development of dysphagia: older age, neurological antecedents, COVID19, long stay in ICU and hospitalization, and the presence of tracheotomy. COVID19 patients represented 46,6% of the sample, so an analysis of this subgroup was performed, showing similar results, with a Charlson risk (OR:4,65; 95% CI:1,31-16,47; p=0,014) and a hospital stay (OR: 8,50; 95%CI: 2,20-32,83; p<0,001). On discharge from the ICU, 37,9% of the population still had dysphagia; 12,6% maintained this problem at hospital discharge. Conclusions: Almost half of our patients developed dysphagia. Clinical severity and the presence of tracheotomy were risk factors. We observed in patients with dysphagia a longer stay in both ICU and hospitalization.(AU)

Descripción y manejo del paciente traqueostomizado en Hospitalización Domiciliaria: experiencia en el Complejo Asistencial Doctor Sótero del Río / Description and management of the tracheostomy patient in Hospital at Home: experience in the Doctor Sótero del Río Care Complex

Introducción: La traqueostomía (TQT) es uno de los procedimientos más antiguos y frecuentes realizados en los pacientes críticos. Se estima que 1 de cada 10 pacientes con apoyo de ventilación mecánica requerirán una TQT, siendo el manejo clínico en hospitalización domiciliaria (HD) muy similar de lo reportado en la literatura intrahospitalariaMétodo:Estudio descriptivo retrospectivo de los pacientes traqueostomizados ingresados a la Unidad de Hospitalización Domiciliaria del Complejo Asistencial Dr. Sótero del Río desde enero del año 2016 hasta abril del 2020. Para el análisis de datos se utilizó el programa estadístico IBM SPSS 24.Resultados:Un total de 96 pacientes traqueostomizados ingresaron al estudio, con una mediana de 64,5 (min. 16; máx. 88) años, el principal motivo de ingreso a HD fue por tratamiento de patologías respiratorias agudas (41,7%); los principales motivos por lo que estos pacientes poseían una TQT fue a causa de patologías neurológicas y debido a ventilación mecánica prolongada (40,6%). La mediana de uso de TQT previo al ingreso a HD fue de 90 (min. 2; máx. 3960) días y la mediana de estadía en HD fue de 22 (min. 2; máx. 150) días. En 87 (90.6%) usuarios se planteó el objetivo de manejo y educación en traqueotomía, y en 9 (9,3%) la rehabilitación para decanulación; teniendo éxito en 8 (88,8%) de ellos. Con relación a su manejo se basó en cuidados generales de TQT y estoma, educación, manejo de urgencias y decanulación.Conclusión:Resulta importante el abordaje multidisciplinario de los pacientes traqueostomizados en HD bajo el lineamiento de protocolos y estándares mínimos de atención, pudiéndose realizar procedimientos que antes se creían exclusivos de la atención intrahospitalaria (decanulación y cambios de cánula). Esto podría ser una alternativa viable en relación con el ahorro de la estancia hospitalaria y mejor gestión del recurso cama. (AU)

Introduction. Tracheostomy (TQT) is one of the oldest and most frequent procedures performed in critically ill patients. About 1 in 10 patients with mechanical ventilation support will require a TQT, with clinical management in hospital at home (HAH) being very similar to that reported in the in-hospital literature.Methods.Retrospective descriptive study of tracheostomized patients admitted to hospital at home Unit of Dr. Sótero del Río Care Complex from January 2016 to April 2020. The statistical program IBM SPSS 24 was used for data analysis.Results:A total of 96 tracheostomized patients entered the study, with a median of 64.5 (min. 16; max. 88) years of age, the main reason for admission to HAH was treatment of acute respiratory diseases (41.7%); the main reasons why these patients had TQT was due to neurological pathologies and due to prolonged mechanical ventilation (40.6%). The median used of TQT prior to admission to HD was 90 (min. 2; max. 3960) days and the median stay on HD was 22 (min. 2; max. 150) days. In 87 (90.6%) users the objective of tracheostomy management and education was set, and in 9 (9.3%) rehabilitation for decannulation; succeeding in 8 (88.8%) of them. In relation to its management, it was based on general TQT and stoma care, education, emergency management and decannulation.Conclusion:The multidisciplinary approach of tracheostomized patients on HAH is important under the guidelines of protocols and minimum standards of care, being able to perform procedures that were previously believed exclusive to in-hospital care (decannulation and cannula changes). This could be a viable alternative for decreasing hospital stay and optimize bed resource management. (AU)

Long-term Outcomes After Tracheostomy for COVID-19 / Resultados a largo plazo después de la traqueotomía en pacientes con COVID-19

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Medical complications in a telemedicine home care programme for paediatric ventilated patients.

INTRODUCTION: Advances in paediatric medicine have increased survival rates for patients with severe chronic illnesses, of which the most complex are ventilator-dependent children (VDCs). Although home care improves their quality of life, morbidity and mortality rates are high. Our aim was to study the medical complications (events) that occur at home and assess the usefulness of telemedicine in their detection and treatment. METHODS: A prospective clinical study (2007-2017) was performed for tracheotomised VDCs. We used a high-density data telemedicine monitoring system from our Paediatric Intensive Care Unit and analysed events during the first two years of home care to study how different variables inter-correlated with the four most common ones: hospital admissions, admissions avoided, event durations and life-threatening events (LTEs); the significance level was set at an alpha of 0.05 in all cases. RESULTS: All our VDCs were included (n = 12); there were 141 events, and these were homogeneously distributed over the study period. The incidence was higher in children who were ventilator dependent for more than 12 h a day (70.9%, p < 0.001) and the main cause was respiratory (69.5%, p < 0.001). Telemedicine was the main initial care and monitoring approach (86.5% and 90.1%, respectively, p < 0.001); 13 events were LTEs, nine were resolved telemedically, four required medicalised transfer to hospital and three resulted in a hospital admission. DISCUSSION: Clinical complications are frequent in VDCs receiving home care, and respiratory decompensation is the most frequent cause. Telemedicine facilitated diagnosis and early treatment, and was useful in managing LTEs.

[Effect of enteral nutrition tolerance assessment standardized process management on ventilator associated pneumonia and prognosis in patients with tracheotomy and long-term mechanical ventilation in intensive care unit].

OBJECTIVE: To investigate the effect of enteral nutrition (EN) tolerance assessment standardized process management on nosocomial infection and prognosis in patients with tracheotomy and long-term mechanical ventilation (MV) in intensive care unit (ICU). METHODS: A prospective cohort study was conducted. Forty-six patients who required long-term MV due to tracheotomy admitted to ICU of Changzhou First People's Hospital from January 2015 to December 2017 were enrolled. Taking the standardized process management of EN tolerance assessment from June 30th, 2016 as the time spot, patients admitted from January 1st, 2015 to June 30th, 2016 were taken as the control group (25 cases) and patients admitted from July 1st, 2016 to December 31st, 2017 as the observation group (21 cases). The two groups were all given conventional EN treatment and conventional symptomatic supportive treatment. Patients in the observation group was given the EN tolerance standardized process management, and received the nutritional risk screening score. While the control group was given a conventional EN management protocol (nurses routinely reported to the doctor and then gave further action). The nutritional support related indicators within 30 days of treatment (including serum albumin, serum pre-albumin, serum cholinesterase), the EN feeding tolerance index (the average amount of gastrointestinal motility drugs used within 30 days, the average EN interruption time per patient, and the incidence of gastrointestinal bleeding) and the prognosis-related indicators [including the incidence of ventilator-associated pneumonia (VAP), the monthly average hospitalization cost, the proportion of drugs, and the ratio of antibiotics to drugs] were compared. RESULTS: Compared with the control group, serum albumin, pre-albumin and cholinesterase were significantly increased in the observation group [albumin (g/L): 32.86±4.83 vs. 28.16±3.62, pre-albumin (mg/L): 186.42±62.84 vs. 163.26±73.49, cholinesterase (U/L): 3 482.34±369.92 vs. 2 986.86±491.49, all P < 0.05], the average use of gastrointestinal motility drugs was significantly reduced (mg: 11.20±3.86 vs. 15.23±5.68, P < 0.05), the average EN interruption time was significantly longer in each patient (hours: 6.38±3.59 vs. 4.96±2.28, P < 0.05), and the incidence of gastrointestinal bleeding was significantly decreased (19.04% vs. 24.00%, P < 0.05), the incidence of VAP was significantly decreased (18.64% vs. 21.36%, P < 0.05), and the antibiotics accounted for a significant decrease (62.43% vs. 76.59%, P < 0.05), but there was no significant difference in the proportion of drugs and monthly average hospitalization expenses [drug ratio: 36.88% vs. 38.42%, monthly average hospitalization cost (ten thousand yuan): 4.36±0.57 vs. 4.39±0.49, both P > 0.05]. CONCLUSIONS: For the patients with tracheotomy and long-term MV of ICU, the enteral nutrition tolerance assessment standardized process management can improve the nutritional status, reduce the incidence of nosocomial infections, and improve the prognosis of the patients.

How family carers engage with technical health procedures in the home: a grounded theory study.

OBJECTIVES: To explore the experiences of family carers who manage technical health procedures at home and describe their learning process. DESIGN: A qualitative study using grounded theory. PARTICIPANTS: New Zealand family carers (21 women, 5 men) who managed technical health procedures such as enteral feeding, peritoneal dialysis, tracheostomy care, a central venous line or urinary catheter. In addition, 15 health professionals involved in teaching carers were interviewed. METHODS: Semistructured interviews were coded soon after completion and preliminary analysis influenced subsequent interviews. Additional data were compared with existing material and as analysis proceeded, initial codes were grouped into higher order concepts until a core concept was described. Interviewing continued until no new ideas emerged and concepts were well defined. RESULTS: The response of carers to the role of managing technical health procedures in the home is presented in terms of five dispositions: (1) Embracing care, (2) Resisting, (3) Reluctant acceptance, (4) Relinquishing and (5) Being overwhelmed. These dispositions were not static and carers commonly changed between them. Embracing care included cognitive understanding of the purpose and benefits of a procedure; accepting a 'technical' solution; practical management; and an emotional response. Accepting embrace is primarily motivated by perceived benefits for the recipient. It may also be driven by a lack of alternatives. Resisting or reluctant acceptance results from a lack of understanding about the procedure or willingness to manage it. Carers need adequate support to avoid becoming overwhelmed, and there are times when it is appropriate to encourage them to relinquish care for the sake of their own needs. CONCLUSIONS: The concept of embracing care encourages health professionals to extend their attention beyond simply the practical aspects of technical procedures to assessing and addressing carers' emotional and behavioural responses to health technology during the training process.

Selective rehabilitative approach to neurological dysfunctions of the oro-pharyngo-laryngeal trivium.

CONCLUSION: A dedicated team proved to provide the optimal approach for the rehabilitation of patients with neurological oro-pharyngo-laryngeal dysfunctions. OBJECTIVES: To assess the effectiveness of a dedicated and specialist team (otolaryngologist, phoniatrician, speech therapist) in the management of patients with severe neurological impairments of the upper airways and digestive routes. METHODS: Fifty-one subjects with neurological impairment of the upper airways and digestive tract due to either central or peripheral causes, who underwent tracheotomy if needed, were recruited at a tertiary university hospital. Two different rehabilitative approaches were used: the classic approach (CA), where a specialist ENT consultation was requested by the professionals if needed; and a selective approach (SA) where a specialist team directly followed and monitored the different phases of management and rehabilitation. Different temporal parameters, in relation to tracheotomy, fenestration of the tracheal tube, and decannulation time, were taken into account and compared between these two approaches. RESULTS: The decannulation time, management of the tracheal tube, and recovery of swallowing function were significantly shorter in patients who were treated according to the SA (p < 0.05). The presence of the tracheal tube and the site of the damage did not affect the outcome in the different study groups (p > 0.05).

Aproximación cualitativa de la experiencia vivida por la mujer de un enfermo con laringectomía / Qualitative approach of the experience lived by the woman of a patient with laringectomy

España presenta la tasa más alta de Europa de cáncer de laringe en varones, con una tasa de supervivencia a los 5 años post cirugía de un 66,7%. El objetivo de este estudio fue conocer la vivencia de una mujer convertida bruscamente en cuidadora de un enfermo, sometido a cirugía laríngea radical y el cambio en su forma de vida. Utilizamos la metodología de Investigación Cualitativa de trayectoria fenomenológica. El análisis se realizó con la propuesta práctica de Taylor-Bogdan. De las categorías seleccionadas se interpreta que la mujer vive la experiencia con estrés elevado, el temor a la muerte de su marido es permanente, le resulta complejo realizar los cuidados del traqueostoma. Su vida, la relación y comunicación con su marido han cambiado radicalmente (AU)

Spain displays the high rate but of Europe of of men with a larynx cancer and a rate of survival after five years post surgery of about 66.7%. The objective of this study was to know the experience a woman turned abruptly into nursemaid of a patient submissive radical laryngeal surgery and the change into its form of life. We used the Qualitative Research Methodology of Phenomenological Trajectory. The analysis is realised with the practical proposal of Taylor-Bogdan. Of the selected categories it is interpreted that the woman lives the experience with elevated stress, the fear to the death is permanent, it turns out to him complex to realise the cares of tracheotomy. Its life and the relation and communication with its husband has changed radically (AU)

Functional recovery following physical training in tracheotomized and chronically ventilated patients.

BACKGROUND: Rehabilitation is a non-pharmacologic therapy that can restore health and reverse the patient's disability, but the efficacy of rehabilitation in critically ill patients is not well documented. METHODS: In a prospective cohort study, we assessed whether the degree of change in functional status after comprehensive rehabilitation influenced clinical outcomes in 77 tracheotomized patients (mean ± SD age 75 ± 7 y) admitted for difficult weaning to our regional weaning center. The care plan, including peripheral muscle training, was delivered daily. We recorded admission demographic, anthropometric, and functional characteristics. We measured the change in basic activities of daily living score (ΔBADL), survival, and weaning success rate as clinical outcomes. We performed the Pearson correlation analysis and linear regression, with ΔBADL as the dependent variable, to test the predictive power of the baseline measurements. RESULTS: Sixty-seven patients (87%) survived, and 55 of them (74%) succeeded in weaning during their stay in the weaning center. The mean ± SD ΔBADL improvement was 2.5 ± 2.0 points (median 2 points). Baseline performance of the latissimus dorsi predicted ΔBADL (ß = 0.388, 95% CI 0.111-1,664, P = .03). The probability of remaining ventilator-free (P = .043) and survival (P = .001) differed across the 4 ΔBADL categories (0 = no change, 1-2 = least improvement, and > 2 = improvement above median change). CONCLUSIONS: Mortality rate and weaning success differ according to ΔBADL following active rehabilitation/training in tracheotomized, ventilated, difficult-to-wean patients. The performance of the latissimus dorsi was the only significant predictor of change.

Distribución de los pacientes con lesiones medulares agudas por grupos relacionados diagnósticos / Distribution of acute spinal cord injuries by diagnoses related groups

Introducción. La atención de la lesión medular (LM) se ha visto modificada desde la introducción de los grupos relacionados diagnósticos (GRD). Material y métodos. Estudio retrospectivo de los pacientes con LM aguda dados de alta por la Unidad de Lesionados Medulares del Hospital Vall d’Hebron en el período comprendido entre el 1 de enero de 1997 y el 31 de diciembre de 2006. Material y métodos. El objetivo es conocer con qué GRD se clasifican los pacientes con LM aguda, el peso relativo de los GRD y obtener unos indicadores que nos informen sobre el tipo de pacientes con LM aguda en nuestro medio a través de los GRD. Resultados. El número de pacientes con LM aguda dados de alta por la Unidad de Lesionados Medulares del Hospital Vall d’Hebron en los últimos 10 años ha sido de 698. La edad media de la muestra fue de 40,27 (DE: 18,85); la mediana fue de 36, con un rango de 73 años. La estancia media fue de 70,34 días (DE: 43,49); la mediana fue de 65 con un rango de 182 días. El peso medio del GRD fue de 4,658 (DE: 4,99) con un rango que variaba entre 0,51–20,04. El número de pacientes considerados outliers, según grupo GRD específico, fue de 302, con una media de 30,3 pacientes outliers anualmente. Resultados. Los pacientes con LM aguda se clasifican mayoritariamente con un GRD quirúrgico, siendo el más frecuente el de las intervenciones espinales. Pero el que mayor coste genera es el GRD de traqueotomía (GRD 483-541-542) con un peso 3,7 veces superior al peso medio de nuestra muestra. Conclusiones. Se suelen clasificar con GRD quirúrgicos, pero consideramos que esta clasificación no tiene en cuenta la funcionalidad que obtienen (AU)

Introduction. The care of spinal cord injury (LM) has been changed since the introduction of GRDs. Material and methods. Retrospective study of acute spinal cord injured patients discharged by the spinal injury unit at the Hospital Vall d’Hebron (ULM_HVH) in the period from January 1 1997 and December 31, 2006. Material and methods. The aim of this study was to know that GRD classify patients with acute LM, as well as the relative weight of GRDs and get some indicators that inform us about the type of patients with acute LM in our environment through the GRDS. Results. The number of patients with acute LM discharged by the ULM-HVH in the last 10 years was 698. The average age of the sample was 40.27 (of 18.85), median 36, with a range of 73 years. The mean (EM) was 70.34 days (43.49), 65 with a median rank of 182 days. The average weight of the DRG was 4.658 (4.99) with a range that varied between 0,51–20,04. The number of patients considered outliers, as specific DRG group was 302, with an average of 30.3 patients annually outliers. Results. Acute spinal cord injured patients are classified mostly with a surgical DRG, the most frequent spinal interventions. But the greatest cost is generated by tracheotomy GRD (GRD 483-541-542) with a mass 3.7 times the average weight of our sample. Conclusions. These are usually classified GRDs surgical. But we believe that this classification does not account for the functionality that these patients have (AU)

Lower respiratory events in seated tracheotomized tetraplegic patients.

AIM: Retrospective study on the changing position impact on respiratory events in 14 rehabilitation tracheotomized tetraplegic patients, during 25 months. METHODS: Three positions were compared: permanently supine (16 periods), seated on or=6 days/week (10 periods). The end-point was the incidence of the following respiratory events: pneumonia, atelectasis and plugging of tracheal/bronchial secretions. Patients were considered as their own control but data were pooled for analysis. RESULTS: Pneumonia and plugging incidences were significantly higher in the permanently supine position than in the seated or=6 days position. Atelectasis occurred only in the supine position. CONCLUSION: Plugging prevalence was significantly higher in the permanently supine position (53.3%) than in the seated or=6 days position (14.6%, P=0.001).

Entrenamiento muscular en paciente traqueostomizado: a propósito de un caso / Respiratory muscle training in tracheostomized patient: a case report

Se presenta el caso de una niña de 14 años portadora de Síndrome de Escobar, trastorno congénito caracterizado por alteraciones musculoesqueléticas, entre ellas escoliosis, que determinan una alteración ventilatoria restrictiva, similar a la presentada por pacientes neuromusculares. La Paciente está traqueostomizada con soporte ventilatorio en su domicilio. Se plantea un programa de Rehabilitación Respiratoria con Entrenamiento Físico general y de la musculatura específica inspiratoria. Este entrenamiento específico es realizado con una válvula Threshold IMT® con una carga de un 30 por ciento de la fuerza generada, medida a través de la Presión Inspiratoria Máxima. En un corto período presentó una mejoría significativa de su valor basal en un 42 por ciento. Es interesante destacar la factibilidad de entrenar pacientes con traqueostomía.

Passy-Muir valve in children with tracheotomy.

INTRODUCTION: Early vocalization and speech production remains a goal in children who require tracheotomy for airway obstruction or chronic ventilation. Although studies document the efficacy of the Passy-Muir valve (PMV) in adults, none have reviewed its efficacy in children. We performed this study to better understand the clinical complexity of its use in children. MATERIALS AND METHODS: Retrospective evaluation of 55 consecutive cases of children with tracheotomy using the PMV. RESULTS: The children ranged in age from 3 days to 18 years at the time of their tracheotomies, and nearly half were 12 months old or younger. Successful use often requires patient and family conditioning. Overall, 52 children out of the 55 who were evaluated as candidates for the PMV tolerated its use. Many required two or more trials prior to the patient and family being comfortable with its use. CONCLUSIONS: The PMV may be used successfully in children with a variety of airway pathologies as well as diverse medical problems. Discussed is the current protocol for the evaluation of the patient and the introduction of the valve.

Laryngeal reconstruction in children. Assessment of vocal quality.

During the past decade, the outcome of laryngotracheal reconstruction in children has improved substantially regarding airway patency. Now that we feel comfortable with airway results, attention should be directed toward vocal quality. The aims of this article are to present our evaluation process, which has been developed during the past 3 years, and our assessment of results. Six patients who underwent successful laryngotracheal reconstruction and could be examined preoperatively and postoperatively were studied. Information about disease and reconstruction techniques was recorded. Vocal quality assessment was done using psychoacoustic evaluation and objective techniques, including acoustic analysis. Children offer a specific challenge, especially when their chronological or developmental age is younger than 3 years. Objective assessment still lacks the ability of using cooperative patients, and adequate samples for acoustic analysis are difficult to obtain and standardize. Preoperative abnormalities continued to persist postoperatively. Laryngotracheal reconstruction is instrumental in making oral communication possible, but the vocal quality is disturbed in most patients.

Revision of a vertical tracheotomy scar using the W-plasty technique.

Repair of a vertical tracheotomy scar using a W-plasty technique is discussed, and an illustrative case is presented. The indications and technique of the W-plasty repair are reviewed. The advantages over the classical running Z-plasty in this type of scar repair are outlined.

Aspiration in rehabilitation patients: videofluoroscopy vs bedside clinical assessment.

This paper reports the results of a blinded study comparing videofluoroscopy with bedside clinical evaluations by speech/language pathologists in the diagnosis of aspiration. One hundred and seven inpatients from a general rehabilitation hospital were evaluated over a four-month period. Of the total patient population, 43 (40%) aspirated at least one consistency of food during videofluoroscopy. Bedside evaluation identified only 18 (42%) of these patients. The positive predictive value of bedside assessment was 0.75; negative predictive value was 0.70. Aspirators on videofluoroscopy were more likely to have brainstem or multilobe central nervous system involvement than nonaspirators. However, there was no statistically significant difference in lesion sites between clinically detected and "silent" aspirators. While the significance of aspiration noted on videofluoroscopy is debatable, it is clear that bedside evaluation alone underestimates the frequency of aspiration in patients with neurologic dysfunction.

[Results of an educational program on the autonomy of patients tracheotomized for chronic respiratory insufficiency]. / Résultats d'un programme d'éducation à l'autonomie des insuffisants respiratoires chroniques trachéotomisés.

In 1984 an educational programme was drawn up for patients with chronic respiratory failure and tracheotomies (IRCT) aimed at their obtaining independence and self-sufficiency. A prospective evaluation was made in parallel with the diary cards of the nurses (SI) measuring the level of dependence of care, defined by 15 characteristics and based on objective and analysable data. After excluding those patients who are already independent (22), decreased or transferred on account of decompensation (23) or removal of the tracheostomy tube (27), 92 patients (46 obstructive and 46 restrictive) coming from 31 centres of respiratory care or intensive care were studied between January 1985 and December 1986: 17 patients were bed-ridden and non-educable and were used as control subjects (T), and 75 patients entered the educational programme. For the results 3 different categories were defined: 1. Success (S): complete self-sufficiency for all care and the maintenance of the equipment, 2. A partial result (RP) with complete independence of the patient but only with stimulation where the patients aspirate by themselves but do not change the tubing and/or do not maintain the equipment, 3. Failure (E): no autonomy. Success was obtained in 43 cases (57%), a partial success in 20 cases (27%) and failure in 12 cases (16%). At entry as well as at the end the T group had significantly lower SI scores than the S, RP and E groups (P less than 0.001 to less than 0.01). The S, RP and E did not differ between each other nor by duration of stay, nor by the PaO2, nor PaCO2.(ABSTRACT TRUNCATED AT 250 WORDS)