A new surgical approach in the treatment of tracheostomy scars.

The tracheostomy procedure presents some long term complications such as the depressed scar. It can be responsible for a tracheal tug, invaginated scar, inaesthetic scar or all of them. No consensus has emerged in the treatment of this type of pathological scarring. We want to propose a new surgical approach to correct all these three pathological scarring mechanism by a subcutaneous flap in single operation.

Safe swallowing and communicating for ventilated intensive care patients with tracheostoma: implementation of the Passy Muir speaking valve / Sicheres Sprechen und Schlucken bei tracheotomierten, beatmeten Patientinnen und Patienten auf der Intensivstation: Implementierung des Passy Muir Sprechventils

Background: Between 4 to 45 % of intensive care patients suffer from prolonged ventilator dependence. Due to impeded weaning, verbal communication is impossible. The tracheal cannula affects breathing and swallowing. The Passy Muir speaking valve (PMV) allows patients on ventilators to speak. It counteracts pharyngeal as well as laryngeal desensitization and prevents an insufficient swallowing reflex. Aim and methods: To implement the PMV, we conducted a multiprofessional practice- and quality development project. The objective was to ensure safe swallowing and communicating for ventilated patients with tracheostoma. Results: Intensive care nurses, doctors and physiotherapists assessed patient safety as being high. In nine patients with 51 PMV applications, we observed three undesirable events in terms of dyspnea and oxygen desaturation. On one occasion, it was necessary to remove the PMV. Conclusion: A combination of mandatory training for the entire treatment team, presence of two professionals during PMV application, and a newly developed guiding document resulted in a high level of patient safety. By means of PMV, ventilated intensive care patients are able to communicate verbally and to swallow better. Complications can be identified early and solved effectively.

[Acute respiratory distress due to tracheostomy tube migration]. / Détresse respiratoire aiguë par migration d'une canule de trachéotomie.

Tracheostomy cannula care is of paramount importance in the daily management of tracheotomized patients. While some complications are commonplace, specific events can occur, often according to type of cannula. We herein report the case of a 71-year-old patient; following a lengthy stay in the intensive care unit, she had received a Safe T-Tube cannula designed to provide support in a stenotic trachea. At home, while suctioning her tracheal secretions, she suddenly experienced respiratory distress requiring a rapid intervention. On arrival, no seeable cannula was found, either in the tracheostomy or in the patient's immediate surroundings. Following her transfer to intensive care, a new cannula was inserted into the tracheostomy opening, enabling mechanical ventilation to begin and achieving rapid relief of dyspnea and improvement of the patient's overall condition. Bronchial fibroscopy was then performed, during which the Safe T-Tube cannula was found folded on itself in a supra-carinal intra-tracheal position. It was extracted and replaced by a cannula of the same model, which was sewn to the skin. Although rare and usually limited to flexible cannulas, this complication is potentially fatal. Generally speaking, when cannula obstruction is suspected, bronchial endoscopy in an intensive care setting is a vital necessity. It is not only the cornerstone of the diagnosis, but also of paramount importance in treatment taking into full account the mechanism of obstruction.

[Accidental silver nitrate inhalation]. / Inhalation accidentelle de nitrate d'argent.

INTRODUCTION: Silver nitrate pencil is often used to treat local granuloma caused by tracheotomy and tracheostomy cannula orifice. CASE REPORT: We report the case of a 69-year-old patient who accidentally inhaled silver nitrate lead from the tip of a pencil during treatment of local granuloma. Inhalation of this product, which is known to cause burns and a risk of perforation of the mucous membranes, could suggest locoregional complications. Clinical monitoring and radiological and endoscopic examinations were carried out. Antibiotics and corticosteroids were administered because of inflammatory lesions. After 6 months, the patient had recovered with restitutio ad integrum of anatomical structures. CONCLUSION: Silver nitrate pencil should be used with caution. Given the high risk of perforation, painstaking and repeated monitoring are necessary in case of accidental inhalation. Bronchial endoscopy is of central importance as a means of localizing the foreign substance, following which bronchial cleaning is performed, using physiological serum. Corticosteroid appears to be effective to limit the risk of inflammatory bronchial stenosis.

[How to reconcile therapeutic patient education and care pathology in oncology: Application in head and neck neoplams]. / Comment concilier éducation thérapeutique des patients et parcours de soin en cancérologie : application pour les voies aérodigestives supérieures.

Therapeutic education is an educational approach that allows the patient and his entourage to acquire or maintain the skills necessary to manage their daily lives. It requires a global care of patients and caregivers and is much broader than a learning of technical gesture. While their development is encouraged in the plan cancer 2014-2018, few programs exist in cancer surgery because the process is very cumbersome to implement due to a very strict administrative framework. In the absence of permission from the Regional health agency, "therapeutic education" term should not be used under penalty of a fine. The aim of this article is to present the principles and rules of therapeutic education defined by the french « Haute Autorité de Santé ¼ and to illustrate them through the example of our therapeutic education program for patients with tracheostomy and/or gastrostomy. The patient pathway with the chronology, the speakers, the competency references, the possible interactions with the announcement scheme as desired by the French National Cancer Institute are specified. This information will facilitate the filling of the program authorization in order to participate in the development of therapeutic education in our specialty.

[Tracheostomy performed in ICU: Professional practice assessment and patient outcome]. / Trachéotomie en réanimation : évaluation des pratiques professionnelles et devenir des patients.

INTRODUCTION: Tracheostomy is a commonly performed procedure. The aim of this study was to assess professional practice, describe patient characteristics and examine short and long-term outcomes. METHODS: All patients with CCAM GEPA004 code were retrospectively included. RESULTS: Two hundred and fourteen (7%) patients who were mecanically ventilated had a tracheostomy performed in intensive care unit (ICU). Median time to tracheostomy was 22 (14-28) days. In total, 95.3% of tracheostomy procedures were surgical. Median age was 58 (48-67) years. Eighty-three (38.8%) tracheostomies were performed for respiratory reasons. Twenty-eight-day and 90-day mortality were 4.2% and 35.5%. One-year mortality was 52.4%. Patients with tracheostomies performed for weaning from mechanical ventilation had a higher mortality rate. After ICU discharge, mortality rate was 29.8% and was higher in non-decannulated patients. Patient characteristics, timing, technique, indication and outcomes were stable over the years. CONCLUSION: Young patients weaning from mechanical ventilation were more likely to receive a tracheostomy. More than half died during the first year. Patients discharged from ICU with a tracheostomy tube in place had higher mortality rate.

[Nursing care in reconstructive surgery in cases of head and neck cancer]. / Les soins infirmiers dans la chirurgie de reconstruction lors d'un cancer ORL.

The treatment of cancers of the upper aerodigestive tract favours an organ- and function- preserving surgical approach. The nursing care draws on multiple skills, on both a technical and educational level, in order to assure global patient management.

[Nursing care for tracheotomy and tracheostomy patients]. / Les soins infirmiers aux patients trachéotomisés et trachéostomisés.

Nursing care is specific in otorhinolaryngology, particularly in oncology. The three dimensions of the care, technical, relational and educational, are essential and reflect the quality of the patient management which must be multi-disciplinary.

[Patient treated with sub-mental intubation for maxillofacial trauma]. / Intubation sub-mentale chez un patient victime d'un traumatisme maxillo-facial.

Maxillo-facial traumas are frequent and most often occur in young patients. Naso-tracheal or orotracheal intubation may be contraindicated in case of combined occlusal fracture and nasal or ethmoido-nasal fracture. This study was carried out a clinical case of a patient treated at the Lille University Hospital for a maxillofacial trauma associating fracture of nose and maxilla. The purpose was to assess the reliability of submental intubation as an alternative to tracheotomy. Submental intubation is a reliable single and safe technique allowing an one-stage surgical treatment in case of complex association of fractures without using tracheotomy. Its use should be implemented on a larger scale.

[Difficult intubation: should follow the recommendations]. / Intubation difficile: il faut suivre les recommandations.

Intubation and ventilation impossible mask is a dramatic situation with potentially serious consequences. We report the case of a patient of 43 years, followed for a goiter, which was scheduled for a total thyroidectomy under general anesthesia. Preoperative evaluation is not noted signs of compression or tracheal deviation, and there were no criteria predictive of intubation or difficult mask ventilation. The induction of anesthesia was standard. Mask ventilation was effective allowing paralysis. The standard laryngoscopy showed a score of Cormack and Lehane grade IV. Several attempts at intubation were made leading to a situation of intubation and ventilation impossible mask with deep desaturation. A tracheostomy was done urgently. The patient was operated on, six months later, with a fiber optic intubation. Through this case, the authors draw attention to the difficulty of achieving an emergency tracheotomy in the presence of goiter and emphasize the need for integration of different modes of learning and retention of management skills of the upper airway.

[Life-saving cricothyrotomy before surgical tracheotomy: two cases]. / Cricothyroïdotomie de sauvetage avant trachéotomie chirurgicale: à propos de deux cas.

The two current cases reported present the situation of "can't intubate can't ventilate" patients with life-saving cricothyrotomy before surgical tracheotomy. These situations emphasize the necessity for clinicians to master difficult intubation and oxygenation algorithms and all available alternative techniques.

[Tracheostomy in French ICUs and patient outcome: national opinion survey]. / Trachéotomies en réanimation et devenir des patients: enquête déclarative nationale.

OBJECTIVES: Tracheostomy is a frequent procedure in ICU but patient follow-up and management after ICU has been poorly documented. We conducted a practice survey in French general ICUs and in neurointensive care units concerning tracheostomized ICU patients and their management after ICU. STUDY DESIGN: National observational descriptive transversal study as survey of opinion and practices. MATERIALS AND METHODS: An email, with a link to an automated online questionnaire, was sent to two medical doctors of each French ICU. Demographic data and reported practices concerning indications, technique and post-ICU management were collected. RESULTS: We received 148 intensivists responses from different ICUs, of which 15% from neurointensivists. There was no difference between general intensivists and neurointensivists concerning the reported use of tracheostomy (10±13% vs 20±22%, P=0.05) and concerning the usual timing of the procedure (predominantly between the 10th and the 21th day) (P=0.62). Indications were weaning failure from the ventilator and neurological ventilatory dysfunction. Percutaneous tracheostomy was mainly performed irrespective of the type of unit. Only 48% of doctors declared usually be able to wean patient from the cannula before ICU discharge. Usual difficulties for post-ICU transfer due only to the presence of the cannula were found by 80% of respondants. Eighty-nine per cent of respondents felt that management of tracheostomized patients after the ICU could be improved. CONCLUSION: Tracheostomy is a frequent procedure, mostly percutaneous. Indications and timing for tracheostomy correspond to the recommendations. Reported difficulties in post-ICU management are important and present nationwide.

[Bilateral pneumothorax, cervicofacial and mediastinal emphysema after surgical tracheostomy]. / Pneumothorax bilatéral, pneumomédiastin et emphysème sous-cutané cervico-facial après une trachéotomie chirurgicale.

Tracheotomy is a surgical procedure for various indications, such as ventilator dependence and airway obstruction. Reported rates in the literature of complications of tracheostomy vary widely. We report an unusual presentation of serious complication after surgical tracheostomy. The correct timing of tracheostomy is still controversial in the literature. A 74-year-old male had emergency surgical tracheostomy under general anesthesia. At the end of the procedure, in recovery room, he developed subcutaneous emphysema of the eyes. There was no pneumothorax seen on chest X-ray. Bronchoscopic examination through the tracheostomy tube showed no evidence of damage to the posterior tracheal wall. Three hours later patient had difficulty breathing requiring sedation with respiratory assistance. X-ray of the chest at this stage showed a right pneumothorax and extensive subcutaneous emphysema of the chest wall. Pneumothorax was managed using a chest tube. Two days after, a control CT scan of the chest showed a left pneumothorax and pneumomediastinum. The pneumothorax was managed using a chest tube. Bronchoscopic examination showed no obvious lesion in the tracheobronchial tree. The patient was treated successfully with supportive care and large doses of antibiotic to prevent mediastinitis. Seven days later, recovery was rapid and complete and CT scan of the chest was completely normal. The patient was discharged from the hospital on the 13th postoperative day. This case illustrates that complications occurring after surgical tracheostomy could be dramatic. Management of tracheotomy is important to prevent complications. There is still debate on optimal timing of tracheotomy. The last three trials have shown no interest to perform an early tracheotomy, neither in terms of vital prognosis nor in terms of the duration of mechanical ventilation.

Evolution of life expectancy of patients with Duchenne muscular dystrophy at AFM Yolaine de Kepper centre between 1981 and 2011.

OBJECTIVES: Retrospective study over the last 30 years of life expectancy in patients suffering from Duchenne muscular dystrophy (DMD). Analysis of the role of ventilatory assistance and causes of death. PATIENTS AND METHODS: One hundred and nineteen adult DMD patients were hosted during 1981 to 2011 at AFM Yolaine de Kepper centre, Saint-Georges-sur-Loire, France. Patients' life expectancy was calculated using Kaplan-Meier model. RESULTS: Life expectancy without or with ventilatory assistance was 22.16 and 36.23 years, respectively. Similarly, life expectancy of patients born from 1970 (mostly with ventilatory assistance) was 40.95 years old from 1970 and 25.77 years old before 1970. Causes of death changed. Cardiac origins of death have increased from 8% to 44%. CONCLUSION: Ventilator assistance, in this study mostly through tracheotomy prolongs by more than 15 years life expectancy of DMD patients. It allows conservation of a satisfactory quality of life, and should be systematically proposed to patients.