Airway Management Strategy Using Seldinger Minitracheostomy Kit to Prevent Airway Obstruction after Oral Cancer Surgery: A Retrospective Study.

A minitracheostomy (MTS) is performed after surgery for oral cancer at our institution in patients who are at risk of postoperative airway obstruction. The aim of this study was to evaluate outcomes of preventive airway management with this procedure. A total of 105 patients undergoing preventive airway management with a Seldinger MTS kit after oral cancer surgery between October 2014 and March 2020 were enrolled. Information on patient characteristics, time required for the MTS, duration of tracheal cannula placement, and MTS-related complications was obtained from both the medical and anesthesia records. In addition, the numbers of postoperative instances of tracheotomy between April 2009 and September 2014 and extubation between October 2014 and March 2020 were also counted for a comparison. The time required for an MTS was 3.2±2.6 min. Minor complications, including mild subcutaneous or mediastinal emphysema and bleeding, were found in 5 patients, but all recovered in a short time. The median duration of tracheal cannula placement was 2 days, with a range of from 0 to 8 days. A total of 348 oral cancer surgeries were performed between April 2009 and September 2014. Among patients undergoing these procedures, 111 underwent a tracheostomy (32%), 235 extubation (68%), and 2 sustained intubation. A total of 580 oral cancer surgeries were performed between October 2014 and March 2020. Here, 121 patients underwent a tracheostomy (21%), 105 an MTS (18%), and 354 extubation (61%). The results suggest that an MTS can be performed safely and smoothly with no significant complications. They also suggest that an MTS reduces the need for a full tracheostomy and the risk of airway obstruction after extubation. We conclude that airway management strategy with an MTS is a useful option in preventing airway obstruction following oral cancer surgery.

Clinical value of a prophylactic minitracheostomy after esophagectomy: analysis in patients at high risk for postoperative pulmonary complications.

BACKGROUND: The aim of this study is to evaluate the clinical value of a prophylactic minitracheostomy (PMT) in patients undergoing an esophagectomy for esophageal cancer and to clarify the indications for a PMT. METHODS: Ninety-four patients who underwent right transthoracic esophagectomy for esophageal cancer between January 2009 and December 2013 were studied. Short surgical outcomes were retrospectively compared between 30 patients at high risk for postoperative pulmonary complications who underwent a PMT (PMT group) and 64 patients at standard risk without a PMT (non-PMT group). Furthermore, 12 patients who required a delayed minitracheostomy (DMT) due to postoperative sputum retention were reviewed in detail, and risk factors related to a DMT were also analyzed to assess the indications for a PMT. RESULTS: Preoperative pulmonary function was lower in the PMT group than in the non-PMT group: FEV1.0 (2.41 vs. 2.68 L, p = 0.035), and the proportion of patients with FEV1.0% <60 (13.3% vs. 0%, p = 0.009). No between-group differences were observed in the proportion of patients who suffered from postoperative pneumonia, atelectasis, or re-intubation due to respiratory failure. Of the 12 patients with a DMT, 11 developed postoperative pneumonia, and three required re-intubation due to severe pneumonia. Multivariate analysis revealed FEV1.0% <70% and vocal cord palsy were independent risk factors related to a DMT. CONCLUSION: A PMT for high-risk patients may prevent an increase in the incidence of postoperative pneumonia and re-intubation. The PMT indications should be expanded for patients with vocal cord palsy or mild obstructive respiratory disturbances.

Fatal airway obstruction due to a ball-valve clot with identical signs of tension pneumothorax.

Endo-tracheal tube obstruction due to an extensive blood clot is a recognized but very rare complication. A ball-valve obstruction in the airway could function as a check valve for the lung and thorax, resulting in tension pneumothorax-like abnormalities. A 47-year-old female patient had undergone implantation of a left ventricular assist device 3 weeks prior. On post-operative day 17, planned thoracentesis was performed for drainage of a pleural effusion. Despite the drainage, the patient's oxygenation did not improve, and emergency tracheal intubation was conducted. Subsequent computed tomography revealed bilateral pneumothorax. Two days later, the patient's trachea was extubated without complication, and a mini-tracheostomy tube was placed. Three hours later, reintubation was conducted due to progressive tachypnea. Although successful intubation was confirmed, ventilation became increasingly difficult and finally impossible. Marked increase in pulmonary artery and central venous pressures suggested progression of the previous tension pneumothorax. After emergency extracorporeal membrane oxygenation was initiated, fiberoptic bronchoscopy revealed the presence of a massive clot and ball-valve obstruction of the endotracheal tube. Two weeks later, the patient died due to severe hypoxic brain damage. Diagnosis of ball valve clot is not simple, but intensivists should consider this rare complication.

Lower airway obstruction due to a massive clot resulting from late bleeding following mini-tracheostomy tube insertion and subsequent clot removal and re-intubation.

BACKGROUND: Easier to perform than the conventional procedure, mini-tracheostomy (MT) is widely used in the operating room or intensive care unit to remove sputum or other obstructions of the upper airway. This option, however, does carry the risk of various complications, including malposition, disposition, bleeding, and subcutaneous emphysema. Here, we report a case of endotracheal tube obstruction due to a massive clot resulting from late bleeding around the insertion site of an MT tube. This necessitated removal of the endotracheal tube together with the clot followed tube re-introduction. CASE PRESENTATION: The patient was an 85-year-old man in whom an MT tube had been inserted 6 days earlier following aortic replacement surgery. On re-admittance to our intensive care unit, large amounts of hemosputum and clotting were observed around the insertion site of the tube. The MT tube was subsequently removed and tracheal intubation performed. Ventilation via the endotracheal tube proved impossible, however, and cardiac arrest ensued. Fiberoptic bronchoscopy revealed that the endotracheal tube was completely obstructed by a massive clot. Therefore, we immediately pushed the clot toward the right main bronchus to secure ventilation via the left lung. After many attempts to remove the massive clot, including suction and grasping with basket forceps, it was successfully dislodged by replacing the endotracheal tube with a new one while maintaining oxygenation by one-lung ventilation. Any small fragments of the clot that still remained were then removed by suction under fiberoptic bronchoscopy. CONCLUSIONS: Here, we report a case of endotracheal tube obstruction due to a clot derived from very late (6 days) bleeding after insertion of an MT tube. The patient was successfully rescued by replacing the clot-bearing endotracheal tube with a new one. This experience suggests that the intensive care physician should be aware of the potential risk of clot retention in endotracheal tubes after the elapse of several days.

IS TRACHEOSTOMY OBSOLETE?

Standard Tracheostomy is the method routinely used to relieve upper airway obstruction. This method though effective has its attendant complications. Minitracheostomy, which is a small cannula of 4 mm diameter introduced through the cricothyroid membrane has been tried in our series to relieve inspiratory stridor and also to deliver anaesthesia. The arterial oxygen saturation increased very significantly from 81.66% to 97.67%. The cannula was well accepted by the patients and there were very few complications.

MINITRACHEOSTOMY IN VENTILATORY INSUFFICIENCY.

Sputum retention is a very common problem in comatose and postoperative patients. The biochemical changes of hypoxia and hypercarbia associated with it ultimately lead to respiratory failure. Tracheobronchial toilet can be achieved by various methods all of which have their disadvantages. Minitracheostomy has been suggested as the best available method for tracheobronchial toilet Nineteen patients in our series underwent minitracheostomy for tracheobronchial toilet Fifteen patients showed full recovery. The oxygen saturation improved from 85.47% to 98.53%. There were very few complications and the procedure was comfortable and acceptable to patients.

The efficacy of minitracheostomy for the management of sputum retention: a systematic review.

BACKGROUND: Suction via a minitracheostomy is a safe procedure, but its efficacy in facilitating sputum clearance in individuals with an acute condition has not been systematically reviewed. OBJECTIVES: The aim of this study was to identify and synthesise the efficacy of the insertion of a minitracheostomy and tracheal suction via minitracheostomy for sputum clearance in adults who have undergone surgery or have an acute condition characterised by sputum retention. DATA SOURCES: A systematic literature search using the electronic databases MEDLINE, CINAHL, EMBASE, Cochrane Library and PEDro, with searches limited to English language journal articles published between 1984 and September 2011. DATA EXTRACTION AND DATA SYNTHESIS: All study designs were included. Two independent reviewers used pre-defined inclusion and exclusion criteria to identify all eligible articles. RESULTS: Six studies in six patient groups met the inclusion criteria, with two randomised controlled trials and four case series included. These studies presented the results of 278 patients following surgery and 13 with acute medical conditions. There were a range of criteria that defined the efficacy of minitracheostomy for sputum retention. Studies reporting the adjunctive role found a reduced incidence of complications associated with sputum retention following thoracic surgery. Other studies reported limited benefit in overall respiratory status with minitracheostomy. Heterogeneity among the studies was evident, with major limitations identified. CONCLUSIONS: Limited evidence suggests that minitracheostomy may be a useful adjunct in optimising sputum clearance in adults following thoracic surgery, but the effects in adults with an acute condition and other types of surgery are inconclusive.