dalla  LETTERATURA INTERNAZIONALE

 

Aggiornato  a domenica, 17. agosto 2008

 
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A rapid bail-out technique for reinsertion of a displaced tracheostomy tube in difficult situations.

Balacumaraswami L, Fernando S, Van Tornout FA.

John Radcliffe Hospital, Oxford, UK.

Safe and rapid repositioning of a displaced tracheostomy tube is vital to protect the airway and to avoid a potentially life threatening situation. This article describes a simple bail-out technique to avert prolonged airway compromise. This is particularly useful in patients with obesity, large goitre or maxillofacial injuries. Keywords: Tracheostomy; Maloney dilator.

PMID: 18682430 [PubMed - as supplied by publisher]
 
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Preparation, clinical support, and confidence of speech-language pathologists managing clients with a tracheostomy in australia.

Ward E, Agius E, Solley M, Cornwell P, Jones C.

Division of Speech Pathology, Therapies Building, The University of Queensland, St. Lucia, 4072 Australia. E-mail: liz.ward@uq.edu.au.

PURPOSE: To describe the preparation and training, clinical support, and confidence of speech-language pathologists (SLPs) in relation to tracheostomy client care in Australia. METHOD: A survey was sent to 90 SLPs involved in tracheostomy management across Australia. The survey contained questions relating to preparation and training, clinical support, and confidence. RESULTS: The response rate was high (76%). The majority of SLPs were pursuing a range of professional development activities, had clinical support available, and felt confident providing care of clients with tracheostomies. Despite these findings, 45% of SLPs were not up-to-date with evidence-based practice, less than 30% were knowledgeable of the advances in tracheostomy tube technology, and only 16% felt they worked as part of an optimal team. Only half were confident and had clinical support for managing clients who were ventilated. Most (88%) believed additional training opportunities would be beneficial. CONCLUSIONS: The current data highlight issues for health care facilities and education providers to address regarding the training and support needs of SLPs providing tracheostomy client care.
 
 
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Second redo percutaneous tracheostomy following complicated revision surgical tracheostomy.

Kinnear J, Lee M, Higgins D.

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PMID: 18699912 [PubMed - in process]

 
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Tracheostomy tube malposition in patients admitted to a respiratory acute care unit following prolonged ventilation.

Schmidt U, Hess D, Kwo J, Lagambina S, Gettings E, Khandwala F, Bigatello LM, Stelfox HT.

Department of Anesthesia & Critical Care, Massachusetts General Hospital, Gray 4, 55 Fruit St, Boston, MA 02114. uschmidt@partners.org.

BACKGROUND: Tracheostomy tube malposition is a barrier to weaning from mechanical ventilation. We determined the incidence of tracheostomy tube malposition, identified the associated risk factors, and examined the effect of malposition on clinical outcomes. METHODS: We performed a retrospective study on 403 consecutive patients with a tracheostomy who had been admitted to an acute care unit specializing in weaning from mechanical ventilation between July 1, 2002, and December 31, 2005. Bronchoscopy reports were reviewed for evidence of tracheostomy tube malposition (ie, > 50% occlusion of lumen by tissue). The main outcome parameters were the incidence of tracheostomy tube malposition; demographic, clinical, and tracheostomy-related factors associated with malposition; clinical response to correct the malposition; the duration of mechanical ventilation; the length of hospital stay; and mortality. RESULTS: Malpositioned tracheostomy tubes were identified in 40 of 403 patients (10%). The subspecialty of the surgical service physicians who performed the tracheostomy was most strongly associated with malposition. Thoracic and general surgeons were equally likely to have their patients associated with a malpositioned tracheostomy tube, while other subspecialty surgeons were more likely (odds ratio, 6.42; 95% confidence interval, 1.82 to 22.68; p = 0.004). Malpositioned tracheostomy tubes were changed in 80% of cases. Malposition was associated with prolonged mechanical ventilation posttracheostomy (median duration, 25 vs 15 d; p = 0.009), but not with increased hospital length of stay or mortality. CONCLUSION: Tracheostomy tube malposition appears to be a common and important complication in patients who are being weaned from mechanical ventilation. Surgical expertise may be an important factor that impacts this complication.

PMID: 18403659 [PubMed - in process]
 
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The effect of tracheostomy timing during critical illness on long-term survival.

Scales DC, Thiruchelvam D, Kiss A, Redelmeier DA.

From the Department of Critical Care (DCS), Sunnybrook Health Sciences Centre; Interdepartmental Division of Critical Care (DCS), University of Toronto; Institute for Clinical Evaluative Sciences (DCS, DT, AK, DAR); Department of Medicine (DAR), Sunnybrook Health Sciences Centre; and Clinical Epidemiology Program (DCS, AK, DAR), Department of Health Policy, Management and Evaluation, University of Toronto, ON, Canada.

BACKGROUND:: Tracheostomy is common in intensive care unit patients, but the appropriate timing is controversial. OBJECTIVE:: To determine whether earlier tracheostomy is associated with greater long-term survival. DESIGN:: Retrospective cohort analysis. SETTING:: Acute care hospitals in Ontario, Canada (n = 114). PATIENTS:: All mechanically-ventilated intensive care unit patients who received tracheostomy between April 1, 1992 and March 31, 2004, excluding extreme cases (<2 or >/=28 days) and children (<18 yrs). MEASUREMENTS:: For crude analyses, tracheostomy timing was classified as early (</=10 days) vs. late (>10 days) with mortality measured at multiple follow-up intervals. Proportional hazards analyses considered tracheostomy as a time-dependent variable to adjust for measurable confounders and possible survivor treatment bias. We used stratification, propensity-score, and instrumental variable analyses to adjust for patient differences. RESULTS:: A total of 10,927 patients received tracheostomy during the study, of which one-third (n = 3758) received early and two-thirds late (n = 7169). Patients receiving early tracheostomy had lower unadjusted 90-day (34.8% vs. 36.9%; p = 0.032), 1 yr (46.5% vs. 49.8%; p = 0.001), and study mortality (63.9% vs. 67.2%; p < 0.001) than patients receiving late tracheostomy. Multivariable analyses treating tracheostomy as a time-dependent variable showed that each additional delay of 1 day was associated with increased mortality (hazard ratio 1.008, 95% confidence interval 1.004-1.012), equivalent to an increase in 90-day mortality from 36.2% to 37.6% per week of delay (relative risk increase 3.9%; number needed to treat = 71 patients to save one life per week delay). LIMITATIONS:: This analysis provides guidance regarding timing but not patient selection for tracheostomy. CONCLUSIONS:: Physicians performing early tracheostomy should not anticipate a large potential survival benefit. Future research should concentrate on identifying which patients will receive the most benefit.
 
 
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Elective tracheostomy in mechanically ventilated children in Canada.

Principi T, Morrison GC, Matsui DM, Speechley KN, Seabrook JA, Singh RN, Kornecki A.

Critical Care Unit, Children's Hospital, London Health Sciences Centre, 800 Commissioners Road East, ON N6A5W9, London, ON, Canada.

OBJECTIVE: To determine the current practice and opinions of paediatric intensivists in Canada regarding tracheostomy in children with potentially reversible conditions which are anticipated to require prolonged mechanical ventilation. DESIGN AND SETTING: Self-administered survey among paediatric intensivists within paediatrics critical care units (PCCU) across Canada. MEASUREMENTS AND RESULTS: All 16 PCCUs participated in the survey with a response rate of 81% (63 physicians). In 14 of 16 centres one to five tracheostomies were performed during 2006. Two centres did not perform any tracheostomies. The overall rate of tracheostomy is less than 1.5%. Percutaneous technique is used in 3/16 (19%) of centres. Readiness to undertake tracheostomy during the first 21[Symbol: see text]days of illness is influenced by patient diagnosis; severe traumatic brain injury 66% vs. 42% in a 2-year-old with Guillain-Barré syndrome, 48% in a 9-year-old with Guillain-Barré syndrome, and 12% in a child with isolated ARDS. In a child with ARDS 25% of respondents would never consider tracheostomy. Age does not affect timing nor keenness for tracheostomy. The majority, 81%, believe that the risks associated with the procedure do not outweigh the potential benefits. Finally, 51% believe that tracheostomy is underutilized in children. CONCLUSIONS: Elective tracheostomy is rarely performed among ventilated children in Canada. However, 51% of physicians believe it is underutilized. The role of elective tracheostomy and the percutaneous technique in children requires further investigation.
 
 
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Graft repair of tracheo-innominate artery fistula following percutaneous tracheostomy.

Jamal-Eddine H, Ayed AK, Al-Moosa A, Al-Sarraf N.

Department of Thoracic Surgery, Chest Disease Hospital, Kuwait.

Tracheo-innominate fistula (TIF) is a rare complication following percutaneous dilatational tracheostomy (PDT), occurring in < or =1% of cases. It usually develops three days to six weeks after the procedure and is fatal in the majority of cases, even after successful initial repair. We present a successfully treated case of TIF using a Goretex graft to replace the severely destroyed segment of the innominate artery.
 
 
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Congenital alveolar fusion.

Gupta RK, Jadhav V, Gupta A, Sanghvi B, Shah H, Parelkar S.

Department of Pediatric Surgery, King Edward Memorial Hospital, Parel, Mumbai 400012, India. drrahulg78@yahoo.co.in

Congenital fusion of the jaws is rare. It may be unilateral or bilateral and may involve only the soft tissues or both the hard and soft tissues. This anomaly may be seen separately or in association with other syndromes. Congenital alveolar fusion restricts mouth opening, causing problems with feeding, swallowing, and respiration. Case 1 had membranous bands between the alveoli that required tracheostomy for stabilization, followed by osteotomy for release. Postoperatively, both patients had adequate mouth opening.
 
 
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Children with new tracheostomies: planning for family education and common impediments to discharge.

Graf JM, Montagnino BA, Hueckel R, McPherson ML.

Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA. jgraf@bcm.edu

OBJECTIVES: To describe an educational program and timeline for the discharge of children with a new tracheostomy and identify common impediments to the education and discharge process. METHODS: Retrospective pilot case series of 70 children and adolescents undergoing tracheostomy placement over a 24-month period in a large urban academic pediatric hospital. RESULTS: Eleven healthcare providers with expertise with technology dependent children identified the eight most common impediments to education and discharge for children with new tracheostomies. Length of stay, impediments to both education and discharge, and medical equipment needed at the time of discharge were extracted from hospital records. Caregivers of children with new tracheostomies needed a median of 14 days (range 5-110 days) to successfully complete a tracheostomy education program. Discharge occurred a median of 6.5 days (range 0-71 days) after education was completed. Common impediments to completing the education program included social issues (e.g., lack of sibling childcare), inter-current illness of the patient and/or language barriers. Impediments to discharge included patient's inter-current illnesses, social issues (e.g., lack of running water) and unavailability of home nursing. Our cohort of patients had a total median length of stay (LOS) of 46 days. At discharge, 55% of children required two or more medical devices (in addition to their tracheostomy) and 61% had some level of dependency on positive pressure ventilation. CONCLUSIONS: Pediatric patients with a new tracheostomy undergo lengthy initial hospitalizations and have complex educational and discharge needs. Multiple factors (both medical and social) can impede the child's transition to the outpatient setting. A structured education and discharge program may result in a shorter LOS for children with new tracheostomies. Impediments to family education and discharge should be anticipated. (c) 2008 Wiley-Liss, Inc.

PMID: 18613098 [PubMed - in process]
 
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Management of a temporary tracheostomy stoma.

Gudka R, Coyne S, Knepil GJ.

York Hospital, Wigginton Road, York, YO31 8HE, UK.

PMID: 18602200 [PubMed - as supplied by publisher]
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Percutaneous tracheostomy: a comparison of PercuTwist and multi-dilatators techniques.

Birbicer H, Doruk N, Yapici D, Atici S, Altunkan AA, Epozdemir S, Oral U.

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PMID: 18603757 [PubMed - in process]

 
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Positioning the tracheal tube during percutaneous tracheostomy: another use for videolaryngoscopy.

Gillies M, Smith J, Langrish C.

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PMID: 18556702 [PubMed - indexed for MEDLINE]

 
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The difficult airway in adult critical care.

Lavery GG, McCloskey BV.

School of Health & Life Sciences, University of Ulster, Belfast, UK. gavin.lavery@belfasttrust.hscni.net

INTRODUCTION: The difficult airway is a common problem in adult critical care patients. However, the challenge is not just the establishment of a safe airway, but also maintaining that safety over days, weeks, or longer. AIMS: This review considers the management of the difficult airway in the adult critical care environment. Central themes are the recognition of the potentially difficult airway and the necessary preparation for (and management of) difficult intubation and extubation. Problems associated with tracheostomy tubes and tube displacement are also discussed. RESULTS: All patients in critical care should initially be viewed as having a potentially difficult airway. They also have less physiological reserve than patients undergoing airway interventions in association with elective surgery. Making the critical care environment as conducive to difficult airway management as the operating room requires planning and teamwork. Extubation of the difficult airway should always be viewed as a potentially difficult reintubation. Tube displacement or obstruction should be strongly suspected in situations of new-onset difficult ventilation. CONCLUSIONS: Critical care physicians are presented with a significant number of difficult airway problems both during the insertion and removal of the airway. Critical care physicians need to be familiar with the difficult airway algorithms and have skill with relevant airway adjuncts.

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PMID: 18552680 [PubMed - indexed for MEDLINE]

 
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Amelioration of pathological yawning after tracheostomy in a patient with locked-in syndrome.

Chang CC, Chang ST, Chang HY, Tsai KC.

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PMID: 18452542 [PubMed - indexed for MEDLINE]

 
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Tracheostomy timing, enrollment and power in ICU clinical trials.

Scales DC, Kahn JM.

Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada.

PMID: 18592211 [PubMed - as supplied by publisher]
 
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Percutaneous tracheostomy in neurosurgical patients with intracranial pressure monitoring is safe.

Milanchi S, Magner D, Wilson MT, Mirocha J, Margulies DR.

Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA.

BACKGROUND: Percutaneous tracheostomy (PT) is performed routinely on neurosurgical patients in many critical care units. Some of these patients suffer from severe brain injury and require intracranial pressure (ICP) monitoring. It remains uncertain whether this procedure causes an increase in ICP or jeopardizes the cerebral perfusion pressure (CPP) in these patients. We studied the effects of PT on ICP and CPP in this group of patients. METHODS: Our study group consisted of 52 neurosurgical patients in the surgical intensive care unit of an urban, Level I Trauma Center who had ICP monitoring and underwent PT between 2001 and 2005. Data were collected from 24 hours before to 24 hours after PT. ICP, CPP, and Glasgow Coma Score (GCS) scale were measured hourly during the study period. RESULTS: There was no statistically significant change in the mean ICP over the 48-hour study period or after the procedure. There was a temporary increase in ICP during the procedure (1.60 mm Hg) which was statistically not significant. There was statistically significant increase in the mean CPP after the procedure, although this increase was clinically not significant. The risk of having a critically high ICP (>20 mm Hg) or low CPP (<60 mm Hg) values did not increase after the procedure. There was no significant change in GCS after the procedure. CONCLUSION: PT in neurosurgical patients with ICP monitor does not cause clinically significant or hazardous changes in ICP, CPP, and GCS. We therefore consider PT to be safe in neurosurgical patients.

PMID: 18580518 [PubMed - indexed for MEDLINE]
 
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[Tracheal aplasia - An Especially Rare and Dramatic Anomaly.]

[Article in German]

Erler T, Wetzel U, Biolik HB, Eichhorn T, Gurski A.

1Klinik für Kinder- und Jugendmedizin, Carl-Thiem-Klinikum Cottbus, Lehrkrankenhaus des Universitätsklinikums Charitè Berlin.

Tracheal agenesis (TA), aplasia or total atresia of the trachea are congenital anomalies which are still incompatible with life. Despite the many attempts of different interventions, there are yet no promising, long-term methods of treatment. Only with sufficient proportion of the proximal or distal trachea available, it is possible to place a tracheostomy, which also opens up new vistas of life for the affected child. In most cases the seldom deformation, trachealagenesis, does not get recognised before the child is born. It may there-fore be the immediate diagnosis postnatal that is decisive over the final prognosis of the child. The prepartal suspicion of a duodenal stenosis, an aphonic newborn as well as the frustrane attempts of intubation are possible guidelines of TA. In independence of peripartal and anamnestical factors, individual disciplinary decisions are necessary for further treatments. After the cancellation of intensiv care the premature infant of the case report died as consequence of postnatal diagnosed tracheal aplasia. Under circumstances, medical treatmets such as the ex utero intrapartum procedure (Exit), the temporary method of extracorporal membrane oxygenation (ECMO) or the use of cartilage tissue for the plastic trachea reconstruction can provide advanced medical opportunities.
 
 
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An unusual case of tracheal stenosis following percutaneous tracheostomy.

Rourke TJ, van Gijn D, Norris A, Odutoye B, Lee M.

Department of Otolaryngology, St Georges Hospital, London, UK. tomrourke@doctors.org.uk

PMID: 18585587 [PubMed - in process]
 
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New approach to anaesthetizing a patient at risk of pulmonary aspiration with a Montgomery T-tube in situ.

Wouters KM, Byreddy R, Gleeson M, Morley AP.

Department of Anaesthesia, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK.

We describe our airway management in a patient requiring emergency laparotomy with a Montgomery T-tube in situ. This uncuffed silicone T-tube acts as both stent and tracheostomy after laryngotracheal surgery, and entails various difficulties for the anaesthetist. Several anaesthetic techniques have been described for T-tube insertion. The management of patients with a T-tube in situ, at risk of pulmonary aspiration, has not been addressed. Below, we present some possible approaches to this problem and describe how we successfully carried out an awake fibreoptic intubation via the tracheal limb of the T-tube. This technique might be considered for patients in similar circumstances, but knowledge of relevant internal and external tube diameters, and appropriate tracheal tube size selection, is crucial.

PMID: 18552345 [PubMed - as supplied by publisher]
 
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Endotracheal tube or laryngeal mask for airway control during percutaneous dilatational tracheostomy.

Sabir N, Vaughan D.

Department of Anaesthetics, Northwick Park Hospital, Harrow, Middlesex HA1 3UJ.

PMID: 18646428 [PubMed - in process]
 
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Tracheostomy protocol: experience with development and potential utility.

Freeman BD, Kennedy C, Robertson TE, Coopersmith CM, Schallom M, Sona C, Cracchiolo L, Schuerer DJ, Boyle WA, Buchman TG.

Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA. freemanb@wustl.edu

OBJECTIVES: To examine the feasibility and potential utility of a tracheostomy protocol based on a standardized approach to ventilator weaning. DESIGN: Prospective, observational data collection. SETTING: Academic medical center. PATIENTS: Surgical intensive care unit patients requiring mechanical ventilatory support. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Tracheostomy practice in 200 patients was analyzed in relation to spontaneous breathing trial (SBT) weaning. Decision for, and performance of, tracheostomy occurred (median [interquartile range]) 5.0 (3.75-8.0) and 7.0 (5.0-10.0) days following initiation of mechanical ventilation, respectively. Duration of mechanical ventilation was greater in tracheostomy compared with nontracheostomy patients (15.0 [11.0-19.0] vs. 6.0 [4.0-8.0], p < .001). For patients requiring ventilatory support for > or = 20 days, 100% of patients were maintained via tracheostomy. A protocol based on weaning performance, which included technical considerations, was developed. Individuals who failed preliminary weaning assessment or SBT for 3 successive days following 5 days (nonreintubated patients) or 3 days (reintubated patients) of ventilatory support met tracheostomy criteria. The protocol was implemented on a pilot basis in 125 individuals. Of the 55 (44.0%) patients undergoing tracheostomy, 25 (45.5%) did so consistent with criteria. Eighteen patients (32.7%) underwent tracheostomy before the time interval of data collection targeting weaning protocol performance, and 12 patients (21.8%) passed SBT on one or more occasions, were not extubated, and proceeded to tracheostomy. CONCLUSIONS: A standardized approach in which the decision for tracheostomy is based on objective measures of weaning performance may be a means of using this procedure more consistently and effectively.

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PMID: 18496369 [PubMed - indexed for MEDLINE]

 
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Is post-sternotomy percutaneous dilatational tracheostomy a predictor for sternal wound infections?

Ngaage DL, Cale AR, Griffin S, Guvendik L, Cowen ME.

Castle Hill Hospital, Kingston-Upon-Hull, East Yorkshire HU16 5JQ, United Kingdom. dngaage@yahoo.com

OBJECTIVE: Early post-sternotomy tracheostomy is not infrequently considered in this era of percutaneous tracheostomy. There is, however, some controversy about its association with sternal wound infections. METHODS: Consecutive patients who had percutaneous tracheostomy following median sternotomy for cardiac operation at our institution from March 1998 through January 2007 were studied, and compared to contemporaneous patients. We identified risk factors for tracheostomy, and investigated the association between percutaneous tracheostomy and deep sternal wound infection (mediastinitis) by multivariate analysis. RESULTS: Of 7002 patients, 100 (1.4%) had percutaneous tracheostomy. The procedure-specific rates were: 8.6% for aortic surgery, 2.7% for mitral valve repair/replacement (MVR), 1.1% for aortic valve replacement (AVR), and 0.9% for coronary artery bypass grafting (CABG). Tracheostomy patients differed vastly from other patients on account of older age, severe symptoms, preoperative support, lower ejection fraction, more comorbidities, more non-elective and complex operations and higher EuroScore. Risk factors for tracheostomy were New York Heart Association class III/IV (OR 6.01, 95% CI 2.28-16.23, p<0.0001), chronic obstructive pulmonary disease (OR 1.84, 95% CI 1.01-3.37, p=0.05), preoperative renal failure (OR 3.57, 95% CI 1.41-9.01, p=0.007), prior stroke (OR 3.08, 95% CI 1.75-5.42, p<0.0001), ejection fraction<0.30% (OR 2.73, 95% CI 1.23-6.07, p=0.01), and bypass time (OR 1.008, 95% CI 1.004-1.012, p<0.0001). The incidences of deep (9% vs 0.7%, p<0.0001) and superficial sternal infections (31% vs 6.5%, p<0.0001) were significantly higher among tracheostomy patients. Multivariate analysis identified percutaneous tracheostomy as a predictor for deep sternal wound infection (OR 3.22, 95% CI 1.14-9.31, p<0.0001). CONCLUSIONS: Tracheostomy, often performed in high-risk patients, may further complicate recovery with sternal wound infections, including mediastinitis, therefore, patients and timing should be carefully selected for post-sternotomy tracheostomy.

 
 
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The role of airway stenting in pediatric tracheobronchial obstruction.

Antón-Pacheco JL, Cabezalí D, Tejedor R, López M, Luna C, Comas JV, de Miguel E.

Pediatric Airway Unit and Division of Pediatric Surgery, Pediatric Institute of the Heart, Doce de Octubre, University Hospital, Madrid, Spain. janton.hdoc@salud.madrid.org

OBJECTIVE: Tracheobronchial obstruction is infrequent in the pediatric age group but it is associated with significant morbidity and mortality. The purpose of this study is to review the results of a single institution experience with endoscopic stent placement in children with benign tracheobronchial obstruction, and with special concern on safety and clinical effectiveness. MATERIALS AND METHODS: Twenty-one patients with severe airway stenosing disease in which stent placement was performed between 1993 and 2006. Inclusion criteria according to the clinical status were: failure to wean from ventilation, episode of apnea, frequent respiratory infections (>3 pneumonia/year), and severe respiratory distress. Additional criteria for stent placement were: failure of surgical treatment, bronchomalacia, and tracheomalacia refractory to previous tracheostomy. Selection of the type of stent depended on the site of the lesion, the patient's age, and the stent availability when time of presentation. The following variables were retrospectively evaluated: age, type of obstruction, associated malformations, stent properties, technical and clinical success, complications and related reinterventions, outcome and follow-up period. RESULTS: Thirty-three stents were placed in the trachea (n=18) and/or bronchi (n=15) of 21 patients with a median age of 6 months (range, 9 days-19 years). Etiology of the airway obstruction included severe tracheomalacia and/or bronchomalacia in 19 cases (90%), and postoperative tracheal stenosis in two. Twelve children had a total of 20 balloon-expandable metallic stents placed, and 10 had 13 silicone-type stents (one patient had both). In nine patients (42%) more than one device was placed. Stent positioning was technically successful in all but one patient. Clinical improvement was observed in 18 patients (85%) but complications occurred in five of them (27%). Eight patients died during follow-up but only in one case it was related to airway stenting. Thirteen patients (62%) are alive and in good condition with a mean follow-up of 39 months (1-13.8 years). CONCLUSIONS: Although the results were based on a small series, placement of stents in the pediatric airway to treat tracheobronchial obstruction seems to be safe and effective. Stenting is a satisfactory therapeutic option when other procedures have failed or are not indicated.
 
 
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Cricothyrotomy in air medical transport.

McIntosh SE, Swanson ER, Barton ED.

University of Utah Health Sciences Center, Salt Lake City, Utah, USA. scott.mcintosh@hsc.utah.edu

BACKGROUND: Airway management is an essential skill for air medical transport (AMT) providers. The endpoint of airway maneuvers is a cricothyrotomy which may be live-saving if other measures fail. We reviewed cricothyrotomy cases in our AMT program to evaluate the success rate and the circumstances surrounding the procedure. METHODS: This was a retrospective review of cases in which a cricothyrotomy was performed at the University of Utah AirMed flight program during the years of 1995 to 2004. Data included incidence, indications, complications, neurologic outcome, and success rates of the procedure. RESULTS: Of the 14,994 transports during the study period, 17 cricothyrotomies were performed. Airway obstruction by blood and/or vomit was the most frequent indication (47%) followed by airway edema/distorted anatomy (24%). The total number of cricothyrotomies decreased during the study period. Seven (41%) patients survived with a reasonable neurologic outcome. The remaining 10 patients died during initial treatment or subsequent hospitalization. Success rate of the procedure in our series was 100%. These results were compared with those of other cricothyrotomy studies. CONCLUSION: Cricothyrotomy has become less common as an emergency rescue technique. However, AMT personnel have a high success rate when performing the cricothyrotomy procedure. This rate is as high as or higher than other emergency personnel.

PMID: 18545121 [PubMed - indexed for MEDLINE]
 
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Comparison of percutaneous dilatational tracheostomy with surgical tracheostomy.

Türkmen A, Altan A, Turgut N, Yildirim G, Ersoy A, Koksal C, Ayşe M, Kamali S.

SB Okmeydani Education and Research Hospital. aygenturkmen@tnn.net

RATIONALE: Tracheostomy is done mostly in critically ill patients, many of whom may not survive. We still do not know the long term complications oftracheostomy itself; tracheal and subglottic stenosis, and tracheomalacia. OBJECTIVES: To compare the complications of surgical tracheostomy (ST) versus percutaneous dilatational tracheostomy (PDT) by means of MRI control up to 1 month after closed tracheostomy. RESULTS: There was no death related to tracheostomy. In both groups there were two preoperative complications: one minor hemorrhage and one subcutaneous empysema in the ST group, and one minor bleeding and one puncture ofendotracheal tube cuff in the PDT group. When the early and the late postoperative complications of the two groups were compared, it was observed that in the ST group, five early (one minor bleeding, three stomal infections and one accidental decannulation), and two late (one peristomal granuloma and one persistent stoma) postoperative complications had occurred. In the PDT group, four early (minor bleeding) and two late postoperative complications (two minor bleeding) were observed. MRI of two patients in the PDT group demonstrated tracheal stenosis. CONCLUSIONS: PDT is as safe and as effective as ST. Although the early and late postoperative complication rates were not significant in the PDT group, we believe that further investigations with larger groups are necessary to find long-term outcome following PDT. MRI scanning provides an excellent non-invasive method of assessing the tracheal lumen.

PMID: 18637605 [PubMed - in process]
 
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Survival rate of patients with amyotrophic lateral sclerosis in Wakayama Prefecture, Japan, 1966 to 2005.

Kihira T, Yoshida S, Okamoto K, Kazimoto Y, Ookawa M, Hama K, Miwa H, Kondo T.

Department of Neurology, Wakayama Medical University, Wakayama City, Japan. tkihira@wakayama-med.ac.jp

To investigate longitudinal changes in the survival rate of patients with amyotrophic lateral sclerosis in Wakayama Prefecture, Japan, we made a retrospective hospital-based study of 454 patients diagnosed with motor neuron disease (MND) at Wakayama Medical University (WMU) Hospital between 1966 and 2005. Of the 454 patients, 240 who were born and who lived in Wakayama Prefecture were diagnosed with definite or probable ALS during this period, according to the El Escorial criteria. The clinical data of the 240 patients, including sex, birth date, birthplace, address, age at onset, initial symptoms, date when respiratory support was applied (tracheostomy, noninvasive positive pressure ventilation, or mandatory artificial ventilation), and date of death were reviewed retrospectively. The age at onset of patients who developed initial symptoms before 1990 was 53.4+/-10.6 (mean+/-S.D.) and that in 1990 or thereafter was 64.8+/-10.3, respectively, showing a significant difference (p<0.0001). Clinical duration was determined from onset to either date of death or initiation of respiratory support in this study. Survival rate was compared using the Kaplan-Meier method according to age at onset, sex, initial symptoms and year of onset. Mean age at onset shifted towards older age according to a later year of onset, due to the overwhelming senility rate in Wakayama Prefecture. Older onset patients had a significantly poorer survival rate than younger onset patients when it was compared based on 10-year age groups (log rank, p<0.0001). Male patients had a poorer survival rate than female patients (p<0.0001). ALS patients with bulbar palsy onset showed shorter clinical durations than those with lower leg onset (p<0.0071, Breslow-Gehan-Wilcoxon test). Patients over 70 years old more frequently showed bulbar palsy onset compared to those younger than 69 (p=0.003). In a comparison of year of onset before and after 1990, ALS patients after 1990 had characteristics of older age onset and shorter clinical duration, and more frequently showed bulbar palsy onset compared with those before 1990. These findings indicated that younger onset patients with ALS decreased after 1990 in Wakayama Prefecture and this might partly explain the recent decline of ALS incidence in Wakayama Prefecture. The shift of the mean age at onset to older age might be due to exogenous factors, including changes in lifestyle, food, and drinking water in this area. Bulbar palsy onset and age at onset were expected as predictors of the survival rate.

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PMID: 18164728 [PubMed - indexed for MEDLINE]

 
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[Submental tracheal intubation is an alternative to tracheostomy at oral surgery]

[Article in Russian]

[No authors listed]

A prospective study was performed in 17 patients who had undergone submental tracheal intubation in facial injury, tumors of the upper jaw, and congenital and acquired deformities of the facial skeleton. The time required for intubation, and the adequacy of gas exchange and ventilation during tracheal intubation and an operation was estimated. Submental intubation was successfully carried out in all the patients. The mean time spent on tracheal intubation was 5-6 min. At surgery, there was no chance extubation or endotracheal tube damage, the parameters of ventilation and gas exchange remained to be within the normal range. A submental scar was minimal. There was inflammation and formation of a bad scar or bleeding at the site of intubation in none case. Submental orotracheal intubation is a safe and simple procedure for airway patency and it may be used as an alternative to tracheostomy in maxillofacial injury, tumors of the upper jaw, and congenital and acquired deformities of the facial skeleton.

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PMID: 18655274 [PubMed - in process]

 
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Role of routine chest radiography after percutaneous dilatational tracheostomy.

Kumar VM, Grant CA, Hughes MW, Clarke E, Hill E, Jones TM, Dempsey GA.

Critical Care Unit, University Hospital Aintree, Liverpool, UK.

BACKGROUND: The role of routine chest radiography (CXR) after percutaneous dilatational tracheostomy (PDT) has been questioned. METHODS: We performed a prospective observational study, on a mixed medical/surgical critical care unit in a university teaching hospital. We studied all patients undergoing PDT as part of their critical care management from November 1, 2003 until July 31, 2007. All PDTs were performed under bronchoscopic guidance. After PDT, we reviewed the immediate post-procedural films to assess the utility of routine postoperative CXR. For the purposes of CXR review, we considered a procedure to be either uncomplicated or technically difficult. Clinically relevant CXR findings were new barotrauma (pneumothorax, pneumomediastinum) or a significant change in consolidation from the pre-procedure film. RESULTS: A total of 384 patients underwent PDT during the study period. Of these, 345 had immediate post-procedural CXRs available for review. There were 252 PDTs (73%) documented as uncomplicated. There were 93 (27%) technically difficult procedures, with 107 adverse events recorded. In 82 (24%) procedures, these difficulties were described as minor procedural complications [multiple attempts at needle insertion (> or = 3), minor bleeding or tracheal ring fracture]. Significant complications (mal-placement in the anterior mediastinum and major bleeding) were documented in 12 (3.5%) patients. New abnormalities were noted on 8 (2.3%) immediate post-procedural CXRs. In only one patient was there a new CXR change in an uncomplicated PDT. CONCLUSIONS: Immediate CXR after uncomplicated PDT performed under bronchoscopic guidance rarely reveals unexpected radiological abnormalities. The role of CXR after PDT appears to be restricted to those patients undergoing technically difficult and complicated procedures. A change in practice to this effect will lead to reductions in both medical costs and exposure of staff and patients to ionizing radiation.

PMID: 18369239 [PubMed - indexed for MEDLINE]
 
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How to do a safe tracheostomy.

Thiruchelvam JK, Cheng LH, Drewery H.

Chase Farm Hospital, UK. jkthir@yahoo.co.uk

A new technique of surgical tracheostomy is described. Prior to performing the tracheostomy, the endotracheal tube (ETT) is advanced further down the trachea so that the end of the tube is positioned just above the carina. Using the flexible endoscope within the ETT the positioning can be done with precision. This manoeuvre avoids the cuff of the ETT being perforated as it is well below the site of the tracheal window. Following the creation of an opening in the trachea, the patient continues to have a definitive airway. In this controlled environment, time is taken to obtain haemostasis at the tracheostomy site, place a rescue stitch and also suction above the cuff of the ETT. A study was carried out in a series of 15 patients by recording various measurements during the procedure to confirm the accuracy of this technique.

PMID: 18342490 [PubMed - in process]
 
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An unusual bleeding-related complication following percutaneous dilatational tracheostomy.

Linstedt U, Langenheim KU, Braun JP.

Publication Types:


PMID: 18349219 [PubMed - indexed for MEDLINE]

 
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An evidence-based evaluation of tracheostomy care practices.

Dennis-Rouse MD, Davidson JE.

Emergency Department, Palomar Pomerado Health, Escondido, California 92025, USA. melissarousern@aol.com

Adverse outcomes related to tracheal occlusion and peritracheal skin breakdown stimulated a review of tracheostomy care. An evidence-based practice approach was taken to evaluate the problem. Organizational tracheostomy care policies were reviewed. Subcategories related to tracheostomy care were queried including securing devices, sutures and their removal, type and choice of dressings, prevention of skin breakdown, frequency of care and role delineation, and suctioning. A literature review was done. National experts were surveyed. A geographical survey was taken and vendors of tracheostomy products were interviewed. Collected evidence was scored along a continuum. Costs of supplies were evaluated. Physicians, staff, and patients were interviewed. Skin maceration on the neck was found on multiple audits. The type of tie was identified as a problem. Nurses and respiratory therapists reported difficulty providing tracheostomy care due to suturing technique and securing methods. The stocked dressing was too large to fit under sutures. Several conflicting policies existed regarding tracheostomy care, none of which identified responsibility for performing care: respiratory versus nursing or time standards for care. New supplies were trialed. A list of practice changes were agreed upon by respiratory, nursing, and medical staff. Primary responsibility for tracheostomy care was shifted to the registered nurse.

Publication Types:


PMID: 18360145 [PubMed - indexed for MEDLINE]

 
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[Massive subcutaneous emphysema following percutaneous tracheostomy]

[Article in Japanese]

Matsuura K, Nakanisi T, Nagakawa T, Katou S, Honda Y.

Department of Anesthesiology, Toyama City Hospital, Toyama 939-8511.

Although percutaneous dilatational tracheostomy (PDT) is fast becoming the method of choice for securing an airway in chronic ventilated patients in an intensive care unit (ICU). Subcutaneous emphysema is an unusual and sometimes lethal complication which may extend the length of stay in the ICU. We report a case of massive subcutaneous emphysema without tracheal wall laceration that occurred in the ICU after PDT. An 81-year-old woman was admitted to our ICU due to infective exacerbation of chronic obstructive airways disease. Her medical therapy included nebulized bronchodilators, steroids and empirical antibiotics. Within thirty-six hours of initial endotracheal intubation PDT was performed. Several hours following the procedure, the patient developed massive subcutaneous emphysema encompassing her entire body. No pneumothorax was identified on subsequent chest X-ray. Laryngoscopic and bronchoscopic examination showed no evidence of tracheal wall laceration. We discuss the etiology and management plan for this rare complication.

Publication Types:


PMID: 18416209 [PubMed - indexed for MEDLINE]

 
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Infant tracheotomy: results of a survey regarding technique.

Ruggiero FP, Carr MM.

Division of Otolaryngology, Department of Surgery, Penn State/Milton S. Hershey Medical Center, Hershey, Pennsylvania 17033, USA.

OBJECTIVE: To identify practice patterns regarding tracheotomy technique among pediatric otolaryngologists. DESIGN: Survey of physicians. SETTING: Academic medical center. PARTICIPANTS: Members of the American Society of Pediatric Otolaryngology (ASPO) residing in the United States. MAIN OUTCOME MEASURES: Physician responses to survey questions, including both multiple choice and free-text responses. We used chi(2) tests to determine if demographic factors (pediatric otolaryngology fellowship training, the number of tracheotomies performed yearly) correlated with differences in the technique used to perform infant tracheotomies. RESULTS: A total of 168 of 225 surveys mailed to ASPO members (75%) were completed and returned. Most respondents (87%) report that they make a simple vertical incision in the trachea. An even greater number (94%) use stay sutures routinely. On other technical points, such as management of the thyroid gland, the subcutaneous fat, and the method of securing the tracheostomy tube, there was much greater variability: 22% of respondents reported having had a serious tracheotomy-related complication in the immediate postoperative period, and 58% of these physicians changed their technique as a result. In several areas, chi(2) analysis revealed statistically significant differences in technique that were dependent on both fellowship training and the number of tracheotomies performed (P < or = .05). CONCLUSIONS: Among ASPO members practicing in the United States, there is near-unanimity on certain technical points, with considerable divergence on others. A substantial percentage of our colleagues have experienced a tracheotomy-related complication in the early postoperative period. In many cases, these incidents led to changes in surgical technique.

PMID: 18347250 [PubMed - indexed for MEDLINE]

 
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Pitfalls in percutaneous dilational tracheostomy using the Ciaglia one-step technique.

Sarani B, Kinkle W, Reilly P.

Division of Traumatology and Surgical Critical Care, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA. saranib@uphs.upenn.edu

Surgical tracheostomy was first described in 1909. Since then, it has become a standard procedure for patients requiring prolonged mechanical ventilation. More recently, bedside percutaneous tracheostomy has been shown to be as safe and effective as the surgical technique, but with the added advantage of also being technically straightforward and cost-efficient. Partly because of this, percutaneous tracheostomy is now being performed by nonsurgeon intensivists. However, the relative ease of the procedure may mask many potential pitfalls that can result in morbidity. As such, it is important for all intensivists to be familiar with the steps and potential pitfalls of this procedure. This is an evidence-based review of the common pitfalls associated with the Ciaglia one-step percutaneous tracheostomy technique, the method most commonly utilized for percutaneous tracheostomy insertion in the United States.

Publication Types:


PMID: 18364661 [PubMed - indexed for MEDLINE]

 

Crit Care. 2008 Feb 26;12(1):R26 .

Determinants of tracheostomy decannulation:

an international survey.

ABSTRACT: BACKGROUND: Although tracheostomy is probably the most common surgical procedure performed on critically ill patients, it is unknown when a tracheostomy tube can be safely removed. METHODS: We performed a cross-sectional survey of physicians and respiratory therapists with expertise in the management of tracheostomized patients at 118 medical centers to characterize contemporary opinions about tracheostomy decannulation practice and define factors that influence these practices. RESULTS: We surveyed 309 clinicians, of which 225 responded (73%). Clinicians rated patient level of consciousness, ability to tolerate tracheostomy tube capping, cough effectiveness and secretions as the most important factors in the decision to decannulate a patient. Decannulation failure was defined as the need to re-insert an artificial airway within 48 hours (45% of respondents) to 96 hours (20% of respondents) of tracheostomy removal with 2% to 5% the most frequent recommendation for an acceptable recannulation rate (44% of respondents). In clinical scenarios clinicians who worked in chronic care facilities (30%) were less likely to recommend decannulation than clinicians who worked in weaning (47%), rehabilitation (53%) or acute care facilities (55%) (p=0.015). Patients were most likely to be recommended for decannulation if they were alert and interactive (odds ratio, 4.76; 95% confidence interval (CI), 3.27 to 6.90; p<0.001), had a strong cough (odds ratio, 3.84; 95% CI, 2.66 to 5.54; p<0.001), scant thin secretions (odds ratio, 2.23; 95% CI, 1.56 to 3.19; p<0.001) and required minimal supplemental oxygen (odds ratio, 2.04; 95% CI, 1.45 to 2.86; p<0.001). CONCLUSIONS: Patient level of consciousness, cough effectiveness, secretions and oxygenation are important determinants of clinicians' tracheostomy decannulation opinions. Most surveyed clinicians defined decannulation failure as the need to re-insert an artificial airway within 48 to 96 hours of planned tracheostomy removal.

PMID: 18302759 [PubMed - as supplied by publisher]

 

 

Eur J Cardiothorac Surg. 2008 Feb 23 [Epub ahead of print] Links

The role of airway stenting in pediatric tracheobronchial obstruction.

Pediatric Airway Unit and Division of Pediatric Surgery, Pediatric Institute of the Heart, ‘Doce de Octubre’, University Hospital, Madrid, Spain.

Objective: Tracheobronchial obstruction is infrequent in the pediatric age group but it is associated with significant morbidity and mortality. The purpose of this study is to review the results of a single institution experience with endoscopic stent placement in children with benign tracheobronchial obstruction, and with special concern on safety and clinical effectiveness. Materials and methods: Twenty-one patients with severe airway stenosing disease in which stent placement was performed between 1993 and 2006. Inclusion criteria according to the clinical status were: failure to wean from ventilation, episode of apnea, frequent respiratory infections (>3 pneumonia/year), and severe respiratory distress. Additional criteria for stent placement were: failure of surgical treatment, bronchomalacia, and tracheomalacia refractory to previous tracheostomy. Selection of the type of stent depended on the site of the lesion, the patient's age, and the stent availability when time of presentation. The following variables were retrospectively evaluated: age, type of obstruction, associated malformations, stent properties, technical and clinical success, complications and related reinterventions, outcome and follow-up period. Results: Thirty-three stents were placed in the trachea (n=18) and/or bronchi (n=15) of 21 patients with a median age of 6 months (range, 9 days-19 years). Etiology of the airway obstruction included severe tracheomalacia and/or bronchomalacia in 19 cases (90%), and postoperative tracheal stenosis in two. Twelve children had a total of 20 balloon-expandable metallic stents placed, and 10 had 13 silicone-type stents (one patient had both). In nine patients (42%) more than one device was placed. Stent positioning was technically successful in all but one patient. Clinical improvement was observed in 18 patients (85%) but complications occurred in five of them (27%). Eight patients died during follow-up but only in one case it was related to airway stenting. Thirteen patients (62%) are alive and in good condition with a mean follow-up of 39 months (1-13.8 years). Conclusions: Although the results were based on a small series, placement of stents in the pediatric airway to treat tracheobronchial obstruction seems to be safe and effective. Stenting is a satisfactory therapeutic option when other procedures have failed or are not indicated.

 

 

Med Hypotheses. 2008 Feb 22 [Epub ahead of print] Links

On the development of idiopathic subglottic stenosis.

Division of Laryngology, Department of Otolaryngology/Head and Neck Surgery, Stanford University Medical Center, 801 Welch Road, Stanford, CA 94305, United States.

Idiopathic subglottic stenosis is a fibrotic narrowing of the airway at the level of the cricoid cartilage, which can result in severe dyspnea. There is an overwhelming female preponderance, and treatment usually involves dilation, tracheostomy or resection with reconstruction of the involved portion of the airway. The exact mechanism of action is unknown. Estrogen has been thought to play a role in the pathogenesis of this disease, but estrogen receptors have not been found in tissue specimens taken from afflicted individuals. A careful history taken from the patient often reveals a severe episode of coughing prior to the development of symptoms, and intraoperative examination can reveal impaction of the first tracheal ring within the lumen of the cricoid cartilage. Based on these observations, we surmise that an intermittent telescoping effect of the first tracheal ring within the lumen of the cricoid cartilage can lead to disruption of the local blood supply and trauma to the cricoid mucosa, with consequent mucosal edema, ischemia, and ultimately fibrosis. While estrogen has been shown to play a beneficial role in wound healing, abnormal wound healing may be potentiated by variations in estrogen receptor expression, and could also explain the female preponderance seen in this disease.

 

 
 
Anaesthesia. 2008 Mar;63(3):302-6. Links

An investigation into the length of standard tracheostomy tubes in critical care patients.

Leeds General Infirmary, Leeds, UK. Abhiram.Mallick@leedsth.nhs.uk

A number of problems have been reported with the use of standard length tracheostomy tubes in adult critical care patients. We measured the depth from the skin surface to the tracheal wall and the angle of the tracheal stoma during percutaneous tracheostomy. In vitro measurements were also performed on standard tracheostomy tubes. Comparison of in vivo and in vitro dimensions demonstrated that standard length tracheostomy tubes are too short for the average critical care patient. We recommend that both the stomal and intratracheal lengths should be made longer by approximately 1 cm and tubes should be redesigned to an angle of 110-120 degrees to allow optimal tracheal placement.

 

 
Masui. 2008 Feb;57(2):147-51. Links

[Percutaneous tracheostomy for the management of the patient with a difficult airway]

[Article in Japanese]

 

Anesthesia and Critical Care Service, Chiba Aoba Municipal Hospital, Chiba, Japan.

BACKGROUND: In recent years, percutaneous tracheostomy has been performed in patients with adverse conditions such as short neck, obesity, coagulopathy or in emergency. METHODS: We performed percutaneous tracheostomy with Griggs' or Ciaglia's technique in five patients with difficult airways due to laryngeal tumors, a laryngeal edema, a neck cancer or a cervical injury. RESULTS: Well-trained anesthesiologists performed all procedures. In four patients, percutaneous tracheostomy was completed rapidly without any complications. The rest of patients underwent orotracheal intubation successfully with a percutaneous tracheostomy set prepared for an emergency situation. We call this setting "Stand-by PCT". CONCLUSIONS: We believe that percutaneous tracheostomy in well-trained hands can be used safely for the management of the patient with a difficult airway.

 

 

 
J Laryngol Otol. 2008 Feb 20;:1-4 [Epub ahead of print] Links

Role of cricothyroid cannulation in head and neck surgery.

Departments of Otolaryngology, Head and Neck Surgery, Ninewells Hospital, Dundee, Scotland, UK.

Objectives:This paper outlines our use of cricothyroid cannulation in those patients undergoing head and neck surgery in whom a 'difficult airway' is anticipated. Audit results are presented.Materials and methods:Prospective data collection for all patients undergoing cricothyroid cannulation for management of head and neck neoplasms, over a two-year period.Results:Thirty-nine cricothyroid cannulae were sited in 32 patients. All patients with laryngeal tumours underwent the procedure while awake, prior to the anticipated difficult intubation, and the cannulae were removed within six hours. Most cannulations performed under general anaesthetic were for anticipated 'dangerous extubations' in patients with oral cavity tumours, and these cannulae remained in place for 24 hours. Tracheostomy was possibly avoided in six patients. No complications were identified.Conclusion:Cricothyroid cannulation can be a simple, safe, reliable technique which is a useful adjunct in the management of patients with a potentially difficult airway.

PMID: 18289395 [PubMed - as supplied by publisher]

 

 
Med Intensiva. 2008 Mar;32(2):91-93. Links

[Tracheostomy in ventilated patients. What do we do it for?]

Unidad de Cuidados Intensivos y Grandes Quemados. Hospital Universitario de Getafe. CIBER Enfermedades Respiratorias. Madrid. España. fjaladosarbol@supercable.es.

The tracheostomy has turned into one of the procedures most performed in the intensive care units. To this fact they have contributed the introduction of the percutaneous technique and the theoretical advantages that tracheostomy has: increase of the comfort of the patient, decrease of the dead space, improvement of the bronchial toilet and decrease in the requirement of sedation. But these advantages are not sufficient evidence for the indication of a tracheostomy. The comparative studies show that the performance of a tracheostomy, versus translaryngeal intubation, could relate to a lower mortality in the unit of intensive care, but tracheostomy does not improve other outcomes as length of stay in the unit of intensive care, length of stay in the hospital and the mortality in the hospital. More studies are needed to be able to estimate what patients would benefit from a tracheostomy and which is the optimal timing for its performance.

PMID: 18275757 [PubMed - as supplied by publisher]

 

Eur J Cardiothorac Surg. 2008 Feb 1 [Epub ahead of print] Links

Deep sternal wound infection requiring revision surgery: impact on mid-term survival following cardiac surgery.

Department of Cardiothoracic Surgery, University Hospital Birmingham NHS Foundation Trust, Birmingham B15 2TH, United Kingdom.

Objective: To assess the impact of deep sternal wound infection on in-hospital mortality and mid-term survival following adult cardiac surgery. Methods: Prospectively collected data on 4586 consecutive patients who underwent a cardiac surgical procedure via a median sternotomy from 1st January 2001 to 31st December 2005 were analysed. Patients with a deep sternal wound infection (DSWI) were identified in accordance with the Centres for Disease Control and Prevention guidelines. Nineteen variables (patient-related, operative and postoperative) were analysed. Logistic regression analysis was used to calculate a propensity score for each patient. Late survival data were obtained from the UK Central Cardiac Audit Database. Mean follow-up of DSWI patients was 2.28 years. Results: DSWI requiring revision surgery developed in 1.65% (76/4586) patients. Stepwise multivariable logistic regression analysis identified age, diabetes, a smoking history and ventilation time as independent predictors of a DSWI. DSWI patients were more likely to develop renal failure, require reventilation and a tracheostomy postoperatively. Treatment included vacuum assisted closure therapy in 81.5% (62/76) patients and sternectomy with musculocutaneous flap reconstruction in 35.5% (27/76) patients. In-hospital mortality was 9.2% (7/76) in DSWI patients and 3.7% (167/4510) in non-DSWI patients (OR 1.300 (0.434-3.894) p=0.639). Survival with Cox regression analysis with mean propensity score (co-variate) showed freedom from all-cause mortality in DSWI at 1, 2, 3 and 4 years was 91%, 89%, 84% and 79%, respectively compared with 95%, 93%, 90% and 86%, respectively for patients without DSWI ((p=0.082) HR 1.59 95% CI (0.94-2.68)). Conclusion: DSWI is not an independent predictor of a higher in-hospital mortality or reduced mid-term survival following cardiac surgery in this population.

 

 
Injury. 2008 Mar;39(3):375-8. Links

Techniques for emergency tracheostomy.

Trauma Directorate, Department of Surgery, Chris Hani Baragwanath Hospital, Johannesburg, South Africa.

PMID: 18243196 [PubMed - in process]

 

 

Best Pract Res Clin Anaesthesiol. 2007 Dec;21(4):465-82. Links

Respiratory care.

Department of Anesthesiology, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356540, Seattle, WA 98195-6540, USA. irozet@u.washington.edu

PURPOSE OF THE REVIEW: Neurosurgical patients frequently develop respiratory complications, adversely affecting neurologic outcome and survival. The review summarizes current literature and management of respiratory complications associated with brain injury. MAJOR FINDINGS: Respiratory complications are commonly associated with traumatic brain injury and subarachnoid haemorrhage. Lung-protective ventilation with reduced tidal volumes improves outcome in acute lung injury, and should be applied to neurosurgical patients in the absence of increased intracranial pressure. Weaning from the mechanical ventilation should be initiated as soon as possible, although the role of neurological status in the weaning process is not clear. Prevention of pneumonia and aspiration improves survival. In patients with difficult weaning, early bedside percutaneous tracheostomy should be considered. FURTHER INVESTIGATIONS: Further studies are warranted to elucidate an optimal oxygenation and ventilation in brain-injured patients, weaning strategies, predictors of the failed weaning and extubation, respiratory support in patients with difficulties to wean, and early tracheostomy.

 

 
Br J Anaesth. 2007 Dec;99(6):912-5. Epub 2007 Oct 12. Links

Intubating laryngeal mask as a ventilatory device during percutaneous dilatational tracheostomy: a descriptive study.

Department of Anaesthesiology, Intensive Care Medicine, and Pain Therapy, Diako Hospital, Flensburg, Academic Teaching Hospital of the University of Kiel, Germany.

BACKGROUND: We use an intubating laryngeal mask (ILM) in preference to an endotracheal tube (ETT) as the ventilatory device during percutaneous dilatational tracheostomy (PDT) to overcome potential problems such as difficult ventilation, accidental extubation, damage of the ETT or of the bronchoscope, and need for additional assistant to secure the airway. We report our experience with this method. METHODS: In this prospective observational study, PDT was performed using the ILM in 86 patients. The insertion of the ILM, the quality of ventilation, and the view of the tracheal puncture site were rated as: 'very good', 'good', 'difficult', and 'not possible with ILM'. RESULTS: The bronchoscope was not damaged during any case, and all PDTs were performed by two physicians, without the need for an additional assistant. PDTs with ILM were successful in 95% of the patients (n=82). The ratings were 'very good' or 'good' in 80% of cases with regards to ventilation, in 90% for identification of relevant structures and tracheal puncture site, and in 85% for the view inside the trachea during PDT. Tracheal re-intubation was required for inadequate ventilation with ILM in four patients. CONCLUSIONS: The advantages of this procedure were lack of damage to the bronchoscope, the need for two instead of three persons to perform the PDT, and the excellent view inside the trachea. We recommend the ILM as a standard device for ventilation during bronchoscope-guided PDT.

PMID: 17933797 [PubMed - indexed for MEDLINE]

 

 
Ned Tijdschr Geneeskd. 2007 Oct 20;151(42):2308-12. Links

[The child with a tracheostomy, past and present: different indications, different children, different care]

Erasmus MC-Sophia Kinderziekenhuis, Dr. Molewaterplein 60, 3015 GJ Rotterdam. l.j.hoeve@erasmusmc.nl

--Until a few decades ago, acute infectious airway obstruction was the primary indication for tracheotomy in children. Its incidence has decreased considerably due to vaccination programmes and antibiotic treatment. --Today, the primary reasons for performing tracheotomy in a child are chronic airway obstruction (laryngeal injury after intubation, craniofacial malformation, lymphangioma) and prolonged artificial ventilation. --Consequently, the percentage of children who may be decannulated after a short period has decreased. --Tracheotomised children now require longer and more intensive care than before. --Hospital discharge is possible if parents and care providers are provided thorough training and counselling; this process requires specific medical, nursing and psychosocial support. --The increasing proportion of tracheotomised children cared for at home necessitates greater involvement from family practitioners.

PMID: 18064931 [PubMed - indexed for MEDLINE]

 

 

Neurol Neurochir Pol. 2007 November-December;41(6):504-509. Links

Percutaneous tracheostomy in patients with disorders of the central nervous system.

Zak³ad Neuroanestezjologii, Akademia Medyczna w Gdañsku, ul. Dêbinki 7, 81-212 Gdañsk, phone/fax +48 58 349 23 35, e-mail: malgosiawit@tlen.pl.

Background and purpose: Patients with disorders of the central nervous system frequently require maintenance of an artificial airway due to impairment of the cough reflex and swallowing, or due to the necessity to apply long-term mechanical ventilation. The technique of percutaneous tracheostomy, introduced in recent years to clinical practice globally, enables tracheostomy and establishment of an artificial airway in a bedside setting, in a quick, simple and minimally traumatic manner. It does not require the operating theatre environment and is associated with lower complication rates than the traditional surgical technique. Material and methods: In the period from March 2003 till February 2007, we performed 75 procedures of Griggs mode percutaneous tracheostomy in intravenous anaesthesia, with use of a disposable Percutaneous Tracheostomy Kit (SIMS Portex, UK). The group of patients comprised 36 women and 39 men. Mean patient age was 57.4+/-17.9 years. Results: On average, the procedure was performed on the 8th (7.8+/-2.6) day after intubation, and its average duration was 6.0+/-3.3 minutes. The most frequent complication was local bleeding from the site (13%), most of which, however, regressed spontaneously. Also observed were: puncture of the tracheal tube sealing cuff (7%), damage to the isthmus of the thyroid (3%), and extratracheal positioning of the tracheal tube (3%). In all the cases the procedure was concluded successfully. Conclusions: Griggs mode is a simple and safe technique enabling percutaneous tracheostomy in patients with pathology of the central nervous system. However, further research is needed to evaluate potential delayed complications of the procedure.

 

 

Saudi Med J. 2007 Dec;28(12):1926. Links

Standard surgical versus percutaneous dilatational tracheostomy in intensive care patients.

[No authors listed]

 

 

Isr Med Assoc J. 2007 Oct;9(10):717-9. Links

Can intensive care physicians safely perform percutaneous dilational tracheostomy? An analysis of 207 cases.

General Intensive Care Unit, Division of Anesthesiology and Critical Care, Soroka Medical Center, Beer Sheva, Israel. motiklein@yahoo.com

BACKGROUND: Percutaneous tracheostomy has largely replaced surgical tracheostomy in the intensive care unit setting. Although it seems logical that surgeons continue to do tracheostomies, anesthesiologists and intensive care specialists are familiar with airway control and guide wire techniques and could replace surgeons in the performance of PDT. OBJECTIVES: To assess the safety and effectiveness of bedside PDT in the ICU. METHODS: We conducted a retrospective chart review of 207 patients in the ICU who underwent PDT by an intensive care physician. RESULTS: Subcutaneous emphysema without pneumothorax occurred in one patient. Four patients underwent surgical revision following PDT. Early bleeding (during the first 48 hours following the procedure) was the indication in two patients and late bleeding, on the 10th post-PDT day, in one. In one case PDT was converted to surgical tracheostomy due to inadvertent early decannulation. There was one death directly related to the procedure, due to an unrecognized paratracheal insertion of the tracheostomy tube followed by mechanical ventilation, which led to bilateral pneumothorax, pneumomediastinum and cardio-circulatory collapse. No infectious complications were seen at the stoma site or surrounding tissues. CONCLUSIONS: PDT by intensive care physicians appears to be safe and should be included in the curriculum of intensive care residency.

 

 
J Med Assoc Thai. 2007 Aug;90(8):1512-7. Links

Percutaneous dilatational tracheostomy with bronchoscopic guidance: Ramathibodi experience.

Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand. bss-vb@hotmail.com

BACKGROUND: Tracheostomy is considered as the airway management of choice for patients in the ICU who require prolonged mechanical ventilation or airway protection. Percutaneous dilational tracheostomy (PDT) was first described in 1985 and now is a well-established procedure that can be performed at the bedside by a pulmonologist with less surgical equipment required. DESIGN: A retrospective analysis. MATERIAL AND METHOD: Twelve patients underwent PDT because of prolonged endotracheal intubation between March and December 2006. The procedures were done by using bedside percutaneous dilatation tracheostomy with guidewire dilator forceps (GWDF) technique with bronchoscopic guidance under general anesthesia in either the intensive care unit or the intermediate care unit of Department of Medicine, Ramathibodi Hospital. RESULTS: There were seven men and five women with a mean age of 55.0 +/- 11.8 years. Operative mortality was 0%. Procedure related complication was not found Operation time in each case was less than ten minutes. Bronchoscopic examination performed in one of the cases after one month of tracheostomy tube removed showed no scar at the tracheostomy site. CONCLUSION: PDT with bronchoscopic guidance is a safe and easy procedure that can be done by pulmonologist at the bedside setting.

PMID: 17926978 [PubMed - indexed for MEDLINE]

 

 
 
The use of tracheal stoma stents in high spinal cord injury: a patient-friendly alternative to long-term tracheostomy tubes.

Hall AM, Watt JW.

1North West Regional Spinal Injuries Centre, Southport and Formby District General Hospital, Southport, UK.

Study design:Case series.Setting:North West Regional Spinal Injuries Unit, Southport and Formby District General Hospital, UK.Objectives:To identify a novel type of tracheal stents for use in patients with high spinal cord injury. Patients with high spinal cord injury (above C4) frequently have significant respiratory impairment and may require long-term access to the trachea for respiratory support. For the most part, tracheostomy tubes are used for this purpose but a tracheal stoma stent can offer a suitable alternative in selected cases and deserves wider recognition.Methods:Following completion of a patient questionnaire survey, the authors describe the use of stoma stents in nine patients, five of whom had full-time diaphragm pacing. The stent in these cases is for retention of access for positive pressure ventilation, and for the prevention of obstructive sleep apnoea. This was also the indication in one self-ventilating patient with tetraplegia and sleep apnoea. Two patients with recurrent chest infections, in whom chest physiotherapy was difficult, benefited from the stoma stents. One patient, after ventilator weaning, required a further 4 months of tracheal access on account of episodic hypoventilation and temporarily had a tracheal stent as an inpatient.Conclusion:Patients who have had the benefit of tracheal stents report significant improvement in relation to local discomfort, tracheobronchial secretions and vocalization. With suitable training, the stents can be changed and cleaned easily in the home setting.Spinal Cord advance online publication, 18 March 2008; doi:10.1038/sc.2008.18.

PMID: 18347606 [PubMed - as supplied by publisher]

 

 
 
Tracheostomy can fatally exacerbate sleep-disordered breathing in multiple system atrophy.

Silber MH.

Publication Types:

Comment

Letter


PMID: 18347324 [PubMed - in process]

 

 
 
Infant tracheotomy: results of a survey regarding technique.

Ruggiero FP, Carr MM.

DDS, FRCSC, Division of Otolaryngology, Department of Surgery, Penn State/Milton S. Hershey Medical Center, PO Box 850. mcarr@psu.edu.

OBJECTIVE: To identify practice patterns regarding tracheotomy technique among pediatric otolaryngologists. DESIGN: Survey of physicians. SETTING: Academic medical center. PARTICIPANTS: Members of the American Society of Pediatric Otolaryngology (ASPO) residing in the United States. MAIN OUTCOME MEASURES: Physician responses to survey questions, including both multiple choice and free-text responses. We used chi(2) tests to determine if demographic factors (pediatric otolaryngology fellowship training, the number of tracheotomies performed yearly) correlated with differences in the technique used to perform infant tracheotomies. RESULTS: A total of 168 of 225 surveys mailed to ASPO members (75%) were completed and returned. Most respondents (87%) report that they make a simple vertical incision in the trachea. An even greater number (94%) use stay sutures routinely. On other technical points, such as management of the thyroid gland, the subcutaneous fat, and the method of securing the tracheostomy tube, there was much greater variability: 22% of respondents reported having had a serious tracheotomy-related complication in the immediate postoperative period, and 58% of these physicians changed their technique as a result. In several areas, chi(2) analysis revealed statistically significant differences in technique that were dependent on both fellowship training and the number of tracheotomies performed (P </= .05). CONCLUSIONS: Among ASPO members practicing in the United States, there is near-unanimity on certain technical points, with considerable divergence on others. A substantial percentage of our colleagues have experienced a tracheotomy-related complication in the early postoperative period. In many cases, these incidents led to changes in surgical technique.

PMID: 18347250 [PubMed - in process]

 

 
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Tracheostomy with thyroidectomy: Indications, management and outcome.

Elbashier EM, Hassan Widtalla AB, Elmakki Ahmed M.

Khartoum Teaching Hospital, Khartoum, Sudan.

OBJECTIVES: This study aims to determine the indications, course and outcome of pre-operative and post-thyroidectomy tracheostomy. SUBJECTS AND METHODS: This is a prospective descriptive study conducted in Khartoum Teaching Hospital in the period between March 2000 and March 2005. Fifty-nine patients had tracheostomy out of 964 thyroidectomy patients, giving an incidence of 6%. RESULTS: The decision of doing tracheostomy was taken intra-operatively in 41 patients (69%), all presenting with strider. In 25 of those 41 patients there was intra-operative tracheal deformity with narrowing (>50% of tracheal circumference on radiology) and gland adherence to the tracheal wall; the remaining 16 patients had tracheomalacia. Of those 41 patients, 25 presented with severe strider and needed urgent surgery (5 with recurrent anaplastic carcinoma, 5 with intrathoracic goitres that necessitated median sternotomy and 15 with huge goitres (of whom 7 were recurrent goitres). In the remaining 18 patients (31%) emergency post-operative tracheostomy was done following endotracheal extubation up to 48h post-operatively. There were 2 deaths (3.4%); one patient died due to tracheostomy care and the other from myocardial infarction. CONCLUSION: Tracheostomy is a safe procedure and gives a good alternative to delayed endotracheal extubation in post-thyroidectomy patients expected to have respiratory failure in places where post-operative anaesthetic care is lacking.

PMID: 18343210 [PubMed - as supplied by publisher]

 

 
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How to do a safe tracheostomy Technical note.

Thiruchelvam JK, Cheng LH, Drewery H.

Chase Farm Hospital, UK.

A new technique of surgical tracheostomy is described. Prior to performing the tracheostomy, the endotracheal tube (ETT) is advanced further down the trachea so that the end of the tube is positioned just above the carina. Using the flexible endoscope within the ETT the positioning can be done with precision. This manoeuvre avoids the cuff of the ETT being perforated as it is well below the site of the tracheal window. Following the creation of an opening in the trachea, the patient continues to have a definitive airway. In this controlled environment, time is taken to obtain haemostasis at the tracheostomy site, place a rescue stitch and also suction above the cuff of the ETT. A study was carried out in a series of 15 patients by recording various measurements during the procedure to confirm the accuracy of this technique.

PMID: 18342490 [PubMed - as supplied by publisher]

 

 
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[Airway obstruction after tracheostomy in a neurologically impaired child]

[Article in Japanese]

Kawase M, Arakura K, Kawase S, Shiozawa R, Inoue Y.

Matsumoto Dental University, Nagano 399-0781.

A 14-year-old boy neurologically impaired was scheduled for tracheostomy under general anesthesia because of the prolonged tracheal intubation. He had twice received artificial respiration under tracheal intubation for aspiration pneumonia. During emergence from anesthesia, bucking occurred and suddenly the patient's lungs could not be ventilated. Neither anesthetic circuit nor tracheostomy tube were not functioning well, and airway obstruction was not relieved by manual and positive pressure ventilation within 40 mmHg. SpO2 gradually decreased to 48%, resulting in bradicardia. However, it became possible to inflate the lungs immediately because of the respiratory effort decreased. SpO2 rapidly increased to normal range and heart rate recovered. The patient was suspected of having tracheomalacia as a result of flexible bronchoscopy performed through tracheostomy tube, revealing slight collapse of the trachea. Tracheomalacia can be a cause of sudden difficult ventilation in neurologically impaired children.

Publication Types:

English Abstract


PMID: 18341003 [PubMed - in process]

 

 
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Axillary catheter for hemodialysis, an alternative vascular access.

[Article in Spanish, English]

Restrepo Valencia CA.

Objective: To establish if the implantation of catheters for hemodialysis in axillary veins is an acceptable alternative in patients with Acute or Chronic Renal Failure (ARF o CRF) with limitations for other type of central catheter. Place: Manizales City Hospital's Intensive Care Units and ambulatory procedure rooms of the Renal Unity RTS Ltda Caldas Subsidiary, Santa Sofia Hospital and Infantile Hospital. Patients: All the patients with ARF or CRF, who required hemodialysis therapy, but that their pathology of base or the depletion of their classical access routes, required the implantation of catheters bilumenes by non conventional routes, during a period of 10 years that was extended from may 1997 to may 2007. Methods: Those patients with ARF or CRF that required tracheostomy as support for ventilation due to their base illness; and those with ARF or CRF in whom the ambulatory or intra-hospital implantation of a central catheter for hemodialysis was not possible were carefully identified. The implantation of a double lumen central catheter for hemodialysis in axillary vein by palpation or anatomical guide was offered as an alternative to both the patients and their families. The procedure was practiced to those that accepted and gave their written consent; radiologically confirming its location; establishing their functionability at the time, as well as the complications associated to the procedure and it permanency. Results: 27 procedures were practiced in 26 patients. Average age: 54.6 years; 9 women and 17 men. 7 of them had ARF and 19 CRF. In two patients the axillary vein puncture was not possible. Of the 25 axillary catheters that were implanted, 1 was permanent and 24 transitory. The technique was used by anatomical references in 16 patients and by palpation in 8. In the patients 15 left axillary veins were canalized unlike the remaining 10 that were right axillary veins. 18 patients presented impossibility of obtaining an alternative central venous access (different to femoral) and 7 patients required tracheostomy. The radiological location was satisfactorily confirmed in 24 procedures (96%). The amount of time the catheters were used was an average of 68.6 days; 6 patients died with the catheter in use. The main cause for the catheter's removal was the transference to peritoneal dialysis. The axillary artery was accidentally punctured in 3 patients, one of whom presented a soft tissue hematoma without a major hemodynamics repercussion; this had a spontaneous resolution in a few weeks. The venous canalization was not possible in 3 patients. Conclusions: The implantation of bilumenes catheters for hemodialysis in patients with ARF or CRF is a relatively safe alternative to consider when other classical routes have totally spent or the patients present tracheostomy.

PMID: 18336136 [PubMed - as supplied by publisher]

 

 
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Treatment options for duchenne muscular dystrophy.

Ciafaloni E, Moxley RT.

Emma Ciafaloni, MD Department of Neurology, University of Rochester, 601 Elmwood Avenue, Box 673, Rochester, NY 14642, USA. emma_ciafaloni@urmc.rochester.edu.

The main goal in the treatment of Duchenne muscular dystrophy (DMD) is to maintain ambulation for as long as possible and to anticipate and manage the associated complications, such as joint contractures, scoliosis, cardiomyopathy, respiratory insufficiency, and weight gain. Cognitive and behavioral symptoms occur in about one third of patients, and it is important to recognize and manage them promptly, developing an individualized plan at school and at home to maximize the patient's cognitive abilities. In the late phase of the disease, palliative care is of paramount importance. Corticosteroid therapy (prednisone and deflazacort) is the only effective pharmacologic treatment for DMD. Daily prednisone treatment increases muscle strength and function, improves pulmonary function, and significantly slows the progression of weakness. Deflazacort has a similar effect on muscle strength, but it is not available in the United States. Treatment with corticosteroid should be offered to all patients with DMD, but the beneficial effects and potential adverse effects should be fully discussed before treatment begins. The optimal dose of prednisone is 0.75 mg/kg per day, up to a maximum of 40 mg/d. If adverse effects occur, a decrease in dosage is appropriate. Monitoring of muscle function and adverse effects by a neurologist or neuromuscular specialist is strongly recommended. Physical and occupational therapists should be involved early in the treatment of patients with DMD to develop a program that includes heel cord stretching and exercise. In the later phases, these therapists can recommend adaptive equipment and maximize independence. Orthopedic consultation is important in monitoring and managing scoliosis and joint contractures in the nonambulatory phase of the disease. Pulmonary evaluation for ventilatory care is important; pulmonary consultation is essential when vital capacity declines. The use of assistive cough devices, nasal bilevel positive airway pressure, and tracheostomy must be discussed with patients and their families. For all patients with DMD, particularly those receiving prednisone, consultation with a dietitian is very helpful to control weight and maintain a healthy diet.

PMID: 18334131 [PubMed - in process]

 

 
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An assessment of early tracheostomy after anterior cervical stabilization in patients with acute cervical spine trauma.

Berney S, Opdam H, Bellomo R, Liew S, Skinner E, Egi M, Denehy L.

Departments of Physiotherapy, Austin Hospital, Melbourne, Australia. sue.berney@austin.org.au

BACKGROUND: The optimal timing of tracheostomy after anterior cervical spine surgery remains controversial because of the potential for deep infection. The aims of this study were to compare the infection rates in patients requiring tracheostomy who underwent anterior versus posterior cervical spine surgery, and to report the timing of tracheostomy tube placement in such patients. METHOD: All patients admitted to a referral Intensive Care Unit for spinal trauma from January 1998 until May 2005, who underwent surgical stabilization with instrumentation and also received a tracheostomy, were retrospectively evaluated for demographic data, severity of neurologic injury, and complications including infection to a surgical site and timing and type of tracheostomy procedure. RESULTS: We identified 71 patients, all who had a diagnosis of acute cervical spine injury. Thirty-two (45%) underwent anterior stabilization, 15 (21%) had posterior stabilizations, and 24 (34%) required both anterior and posterior approaches. The mean time from stabilization to tracheostomy for an anterior approach was 3.8 +/- 2.6 days. There was no significant difference in the timing of tracheostomy for different surgical approaches. Seventeen patients (25%) had a positive culture of their cervical and or tracheostomy incision site. Only one patient, however, had infection with the same organism at both the tracheostomy site and the anterior stabilization site. Suspected infection was managed with antibiotics and no further surgical intervention was required. CONCLUSIONS: Early tracheostomy after spinal stabilization is associated with a low risk of infection even after the anterior approach.

PMID: 18332819 [PubMed - in process]

 

 
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Is post-sternotomy percutaneous dilatational tracheostomy a predictor for sternal wound infections?

Ngaage DL, Cale AR, Griffin S, Guvendik L, Cowen ME.

Castle Hill Hospital, Kingston-Upon-Hull, East Yorkshire HU16 5JQ, United Kingdom.

Objective: Early post-sternotomy tracheostomy is not infrequently considered in this era of percutaneous tracheostomy. There is, however, some controversy about its association with sternal wound infections. Methods: Consecutive patients who had percutaneous tracheostomy following median sternotomy for cardiac operation at our institution from March 1998 through January 2007 were studied, and compared to contemporaneous patients. We identified risk factors for tracheostomy, and investigated the association between percutaneous tracheostomy and deep sternal wound infection (mediastinitis) by multivariate analysis. Results: Of 7002 patients, 100 (1.4%) had percutaneous tracheostomy. The procedure-specific rates were: 8.6% for aortic surgery, 2.7% for mitral valve repair/replacement (MVR), 1.1% for aortic valve replacement (AVR), and 0.9% for coronary artery bypass grafting (CABG). Tracheostomy patients differed vastly from other patients on account of older age, severe symptoms, preoperative support, lower ejection fraction, more comorbidities, more non-elective and complex operations and higher EuroScore. Risk factors for tracheostomy were New York Heart Association class III/IV (OR 6.01, 95% CI 2.28-16.23, p<0.0001), chronic obstructive pulmonary disease (OR 1.84, 95% CI 1.01-3.37, p=0.05), preoperative renal failure (OR 3.57, 95% CI 1.41-9.01, p=0.007), prior stroke (OR 3.08, 95% CI 1.75-5.42, p<0.0001), ejection fraction<0.30% (OR 2.73, 95% CI 1.23-6.07, p=0.01), and bypass time (OR 1.008, 95% CI 1.004-1.012, p<0.0001). The incidences of deep (9% vs 0.7%, p<0.0001) and superficial sternal infections (31% vs 6.5%, p<0.0001) were significantly higher among tracheostomy patients. Multivariate analysis identified percutaneous tracheostomy as a predictor for deep sternal wound infection (OR 3.22, 95% CI 1.14-9.31, p<0.0001). Conclusions: Tracheostomy, often performed in high-risk patients, may further complicate recovery with sternal wound infections, including mediastinitis, therefore, patients and timing should be carefully selected for post-sternotomy tracheostomy.

PMID: 18328721 [PubMed - as supplied by publisher]

 

 
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Prevalence and Risk Factors for Nosocomial Infections in Hospitals of the Veneto Region, North-Eastern Italy.

Pellizzer G, Mantoan P, Timillero L, Allegranzi B, Fedeli U, Schievano E, Benedetti P, Saia M, Sax H, Spolaore P.

Infectious Diseases Unit, San Bortolo Hospital, Vicenza, Italy.

OBJECTIVE: The study aimed to assess prevalence and risk factors for nosocomial infection (NI) in 21 hospitals of the Veneto Region (Italy). METHODS: In May 2003, a one-week-period prevalence study of NI was carried out in 21 hospitals, representing 63% of all hospital beds for acute patients of the Veneto Region. Intensive care units represented 84% of all intensive care beds of the Region. Long term care, neonatal intensive care, burn, psychiatric and dermatology units were excluded. RESULTS: Overall, 6,352 patients were surveyed. The prevalence of NI was 7.6% (range 2.6%-17.7%), while 6.9% of patients (range 2.6%-15.5%) were affected by at least one NI. The prevalence of patients with NI in medical, surgical and intensive care areas was 6.6%, 5.0% and 25.8%, respectively. The sites most frequently affected were the following: urinary tract (28.4%), surgical site (20.3%), blood stream (19.3%), pulmonary and lower respiratory tract (17.6%). At multivariate analysis risk factors independently associated to NI were: Charlson index score >1, severity of underlying disease, exposure to antibiotics, surgical intervention, trauma at admission, presence of central venous catheter >24 h, urinary catheter, intubation, tracheostomy, and duration since admission >15 days. CONCLUSION: The study provided baseline data of NI in the Veneto Region hospitals. It showed that NI are frequent, and display a wide inter-hospital variability of rates. The highest prevalence has been reported in intensive care units. The unusual high frequency of blood stream infections and the relatively lower prevalence rate of surgical site infections highlighted the limits of prevalence studies.

PMID: 18327681 [PubMed - as supplied by publisher]

 

 
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Organ-preservation surgery following failed radiotherapy for laryngeal cancer. Evaluation, patient selection, functional outcome and survival.

Marioni G, Marchese-Ragona R, Lucioni M, Staffieri A.

Department of Medical and Surgical Specialties, Section of Otolaryngology, University of Padova, Padova, Italy. gino.marioni@unipd.it

PURPOSE OF THE REVIEW: Although radiotherapy is a well codified treatment for laryngeal carcinomas, the management of local recurrence after failed radiotherapy remains controversial. Total laryngectomy is the classical salvage surgical approach. Recent evidence showed that selected laryngeal recurrences may be successfully treated with partial laryngectomies with comparable survival rates, acceptable morbidity, tracheostomy closure, effective swallowing, and satisfactory voice intelligibility. RECENT FINDINGS: Recurrent laryngeal carcinoma after radiotherapy failure requires a comprehensive clinical, radiological and pathological restaging. Strict selection criteria are mandatory for the identification of radiotherapy failure cases amenable to conservative laryngeal surgery. Although larger series confirmation is necessary, conservative salvage surgery seems definitely promising. Salvage endolaryngeal laser surgery after irradiation failure allows in selected cases a mean local control rate of 65%. Selectively, supracricoid laryngectomy can be a flexible alternative to salvage total laryngectomy being conservative of laryngeal functions (mean local control rate of 85%). Selected laryngeal recurrences can be correctly treated also with vertical or horizontal supraglottic laryngectomies. In partial laryngectomies, intraoperative frozen sections are mandatory: postoperatively permanent sections have to confirm all margins. SUMMARY: When proper selection criteria for conservative salvage laryngeal surgery are used, laryngeal function can be preserved with oncological efficacy also after radiotherapy failure.

PMID: 18327033 [PubMed - in process]

 

 
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Safety of percutaneous tracheostomy in obese critically ill patients: a prospective cohort study.

Aldawood AS, Arabi YM, Haddad S.

Intensive Care Unit, King Fahad Hospital, King Abdulaziz Medical City, Riyadh, Saudi Arabia.

Obesity has been described as a relative contraindication for percutaneous tracheostomy. The objective of our study was to examine the safety and complications of percutaneous tracheostomy in obese patients. We conducted a prospective cohort study of all consecutive patients who underwent percutaneous tracheostomy at a tertiary medical-surgical intensive care unit between May 2004 and October 2005. We compared percutaneous tracheostomy in obese patients (body mass index > or = 30 kg/m2) to non-obese patients. We documented the occurrence of the following complications: aborting the procedure, accidental extubation, conversion to surgical tracheostomy, paratracheal placement, the development of pneumothorax, major bleeding (requiring blood product transfusion or surgical intervention) or death. We also documented hypoxia, minor bleeding (requiring pressure dressing or suturing), subcutaneous emphysema and transient hypotension. During the study period, 227 percutaneous tracheostomies were performed. There were 50 percutaneous tracheostomies in the obese group and 177 in the non-obese group. In 45 obese patients, percutaneous tracheostomy was performed without bronchoscopic guidance. Major complications were significantly higher in obese patients (12% vs. 2%, P = 0.04), while the rate of minor complications was not significantly different between the two groups. There were no instances of death or pneumothorax, subcutaneous emphysema or need for surgical intervention during or in the postoperative period in either group. Our study suggests that percutaneous tracheostomy can be performed safely in the majority of obese patients.

PMID: 18326135 [PubMed - in process]

 

 
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Editorial comment Danger of early percutaneous tracheostomy in cardiac surgical patients.

Ricci M, Panos AL, Salerno TA.

University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL 33136, USA.

PMID: 18325777 [PubMed - as supplied by publisher]

 

 
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Trans-tracheostomic endoscopy of the larynx in the evaluation of dysphagia.

Ricci Maccarini A, Stacchini M, Salsi D, Pieri F, Magnani M, Casolino D.

Department of Surgical Specialities, Otorhinolaryngology Unit, Bufalini Hospital, Cesena, Italy.

Laryngeal endoscopy plays a determinant role in clinical evaluation of dysphagia. The examination is performed by means of a trans-nasal approach with a flexible fiberoptic endoscope, able to visualize the pre- and post-deglutitory steps of the pharyngeal phase of swallowing. In patients with tracheostomy, it is possible to visualize the glottic or neoglottic function during the intra-deglutitory phase, performing the examination through a trans-tracheostomic route. The procedure and indications of this endoscopic technique are described.

PMID: 18320834 [PubMed - in process]

 

 
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Cytokine levels in sputum of patients with tracheostomy and profound multiple disabilities.

Asada K, Ichiyama T, Okuda Y, Okino F, Hashimoto K, Nishikawa M, Sugio Y, Furukawa S.

Department of Pediatrics, National Hospital Organization Sanyo Hospital, Yamaguchi, Japan.

Background. Airway immunopathogenesis is unclear in patients with profound multiple disabilities (PMD) who undergo tracheostomy. Methods. The levels of tumor necrosis factor-alpha (TNF-alpha), interleukin-1beta (IL-1beta), IL-6, IL-8, IL-10, and IL-12p70 cytokines were determined in sputum of 28 patients with PMD who underwent tracheostomy and in 14 healthy subjects, using a cytometric bead array. Results. The concentrations of IL-1beta, IL-6 and IL-8 in the patients were significantly higher than those in controls (p < 0.001). IL-6, and IL-8 levels in eight PMD patients in the febrile period were significantly higher than those in the afebrile period (p < 0.01 and p < 0.05, respectively). Serum CRP levels were slightly elevated in 12 of the 28 patients (43%) in the afebrile period, but there were no significant differences in the level of any cytokine between patients with normal and elevated serum CRP. Conclusion. PMD patients with tracheostomy have chronic airway inflammation.

PMID: 18316201 [PubMed - as supplied by publisher]

 

 
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Care of a parturient with preeclampsia, morbid obesity, and Crouzon's syndrome.

Martin TJ, Hartnett JM, Jacobson DJ, Gross JB.

Department of Anesthesiology, University of Connecticut School of Medicine, Farmington, CT 06030-2015, USA. t-mart@comcast.net

We present the case of a 31-year-old woman with severe preeclampsia, morbid obesity, and a craniofacial syndrome who developed respiratory failure necessitating intubation and delivery by cesarean section. Her airway management was complicated by supraglottic edema and macroglossia. Fiberoptic intubation was difficult but successful. After delivery of the infant, tracheostomy was performed to provide a secure airway until the supraglottic edema resolved over the subsequent two weeks. The airway implications of preeclampsia and Crouzon's syndrome are reviewed.

PMID: 18308555 [PubMed - in process]

 

 
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Determinants of tracheostomy decannulation: an international survey.

Stelfox HT, Crimi C, Berra L, Noto A, Schmidt U, Bigatello LM, Hess D.

Department of Critical Care Medicine, University of Calgary, Foothills Medical Centre, EG23A, 1403-29 Street NW, Calgary, AB, Canada, T2N 2T9. tom.stelfox@calgaryhealthregion.ca.

ABSTRACT: BACKGROUND: Although tracheostomy is probably the most common surgical procedure performed on critically ill patients, it is unknown when a tracheostomy tube can be safely removed. METHODS: We performed a cross-sectional survey of physicians and respiratory therapists with expertise in the management of tracheostomized patients at 118 medical centers to characterize contemporary opinions about tracheostomy decannulation practice and to define factors that influence these practices. RESULTS: We surveyed 309 clinicians, of whom 225 responded (73%). Clinicians rated patient level of consciousness, ability to tolerate tracheostomy tube capping, cough effectiveness, and secretions as the most important factors in the decision to decannulate a patient. Decannulation failure was defined as the need to reinsert an artificial airway within 48 hours (45% of respondents) to 96 hours (20% of respondents) of tracheostomy removal, and 2% to 5% was the most frequent recommendation for an acceptable recannulation rate (44% of respondents). In clinical scenarios, clinicians who worked in chronic care facilities (30%) were less likely to recommend decannulation than clinicians who worked in weaning (47%), rehabilitation (53%), or acute care (55%) facilities (p = 0.015). Patients were most likely to be recommended for decannulation if they were alert and interactive (odds ratio [OR] 4.76, 95% confidence interval [CI] 3.27 to 6.90; p < 0.001), had a strong cough (OR 3.84, 95% CI 2.66 to 5.54; p < 0.001), had scant thin secretions (OR 2.23, 95% CI 1.56 to 3.19; p < 0.001), and required minimal supplemental oxygen (OR 2.04, 95% CI 1.45 to 2.86; p < 0.001). CONCLUSION: Patient level of consciousness, cough effectiveness, secretions, and oxygenation are important determinants of clinicians' tracheostomy decannulation opinions. Most surveyed clinicians defined decannulation failure as the need to reinsert an artificial airway within 48 to 96 hours of planned tracheostomy removal.

PMID: 18302759 [PubMed - as supplied by publisher]

 

 
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The role of airway stenting in pediatric tracheobronchial obstruction.

Antón-Pacheco JL, Cabezalí D, Tejedor R, López M, Luna C, Comas JV, de Miguel E.

Pediatric Airway Unit and Division of Pediatric Surgery, Pediatric Institute of the Heart, ‘Doce de Octubre’, University Hospital, Madrid, Spain.

Objective: Tracheobronchial obstruction is infrequent in the pediatric age group but it is associated with significant morbidity and mortality. The purpose of this study is to review the results of a single institution experience with endoscopic stent placement in children with benign tracheobronchial obstruction, and with special concern on safety and clinical effectiveness. Materials and methods: Twenty-one patients with severe airway stenosing disease in which stent placement was performed between 1993 and 2006. Inclusion criteria according to the clinical status were: failure to wean from ventilation, episode of apnea, frequent respiratory infections (>3 pneumonia/year), and severe respiratory distress. Additional criteria for stent placement were: failure of surgical treatment, bronchomalacia, and tracheomalacia refractory to previous tracheostomy. Selection of the type of stent depended on the site of the lesion, the patient's age, and the stent availability when time of presentation. The following variables were retrospectively evaluated: age, type of obstruction, associated malformations, stent properties, technical and clinical success, complications and related reinterventions, outcome and follow-up period. Results: Thirty-three stents were placed in the trachea (n=18) and/or bronchi (n=15) of 21 patients with a median age of 6 months (range, 9 days-19 years). Etiology of the airway obstruction included severe tracheomalacia and/or bronchomalacia in 19 cases (90%), and postoperative tracheal stenosis in two. Twelve children had a total of 20 balloon-expandable metallic stents placed, and 10 had 13 silicone-type stents (one patient had both). In nine patients (42%) more than one device was placed. Stent positioning was technically successful in all but one patient. Clinical improvement was observed in 18 patients (85%) but complications occurred in five of them (27%). Eight patients died during follow-up but only in one case it was related to airway stenting. Thirteen patients (62%) are alive and in good condition with a mean follow-up of 39 months (1-13.8 years). Conclusions: Although the results were based on a small series, placement of stents in the pediatric airway to treat tracheobronchial obstruction seems to be safe and effective. Stenting is a satisfactory therapeutic option when other procedures have failed or are not indicated.

PMID: 18299200 [PubMed - as supplied by publisher]

 

 
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On the development of idiopathic subglottic stenosis.

Damrose EJ.

Division of Laryngology, Department of Otolaryngology/Head and Neck Surgery, Stanford University Medical Center, 801 Welch Road, Stanford, CA 94305, United States.

Idiopathic subglottic stenosis is a fibrotic narrowing of the airway at the level of the cricoid cartilage, which can result in severe dyspnea. There is an overwhelming female preponderance, and treatment usually involves dilation, tracheostomy or resection with reconstruction of the involved portion of the airway. The exact mechanism of action is unknown. Estrogen has been thought to play a role in the pathogenesis of this disease, but estrogen receptors have not been found in tissue specimens taken from afflicted individuals. A careful history taken from the patient often reveals a severe episode of coughing prior to the development of symptoms, and intraoperative examination can reveal impaction of the first tracheal ring within the lumen of the cricoid cartilage. Based on these observations, we surmise that an intermittent telescoping effect of the first tracheal ring within the lumen of the cricoid cartilage can lead to disruption of the local blood supply and trauma to the cricoid mucosa, with consequent mucosal edema, ischemia, and ultimately fibrosis. While estrogen has been shown to play a beneficial role in wound healing, abnormal wound healing may be potentiated by variations in estrogen receptor expression, and could also explain the female preponderance seen in this disease.

PMID: 18295979 [PubMed - as supplied by publisher]

 

 
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Outcomes and survival in surgical treatment of descending thoracic aorta with acute dissection.

Bozinovski J, Coselli JS.

Cardiovascular Surgery Service, The Texas Heart Institute at St. Luke's Episcopal Hospital, Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas 77030, USA.

BACKGROUND: Thoracic aortic replacement for acute DeBakey type III aortic dissection is associated with significant morbidity and mortality. We report the outcomes of 76 consecutive patients who underwent surgical repair of the descending thoracic aorta or the thoracoabdominal aorta for acute dissection. METHODS: During a 16-year period (1989 to 2004), we identified 76 patients who underwent surgery for acute type III aortic dissection. The average patient age was 64.1 +/- 12.3 years (range, 36 to 84), and 55 patients (72.4%) were male. Surgical adjuncts included hypothermic circulatory arrest (8 patients), left heart bypass (15 patients), and cerebrospinal fluid drainage (5 patients). The mean aortic clamp time was 38.4 +/- 17.3 minutes. Rupture was present in 17 patients (22.4%). RESULTS: There was 1 intraoperative death. Operative mortality was 22.4% (17 patients), including 11 patients (14.5%) who died within 30 days of operation. Five patients (6.6%) had paraplegia, and 15 patients (19.7%) required hemodialysis, 7 temporarily. Cardiac complications occurred in 33 patients (43.4%), 2 patients (2.6%) were returned to the operating room for bleeding, and 10 patients (13.6%) required tracheostomy. The mean hospital stay was 26.0 +/- 29.7 days. Rupture was not associated with increased risk of postoperative complications or operative mortality. CONCLUSIONS: In selected patients with emergent indications, operative intervention with open replacement of the descending thoracic aorta or thoracoabdominal aorta for acute dissection repair can be carried out with respectable mortality, morbidity, and survival rates.
 

 

 
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Hypothermic circulatory arrest: safety and efficacy in the operative treatment of descending and thoracoabdominal aortic aneurysms.

Coselli JS, Bozinovski J, Cheung C.

The Texas Heart Institute, St. Luke's Episcopal Hospital, and Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas 77030, USA. jcoselli@bcm.edu

BACKGROUND: The safety and efficacy of hypothermic circulatory arrest in the operative treatment of descending thoracic aortic aneurysms and thoracoabdominal aortic aneurysms are not clearly established. We evaluated our experience with repair of descending thoracic and thoracoabdominal aortic aneurysms using hypothermic circulatory arrest. METHODS: In all, 111 patients with descending thoracic aortic aneurysms (83) or thoracoabdominal aortic aneurysms (28) underwent graft replacement of the involved aortic segments using hypothermic circulatory arrest. The technique was used when the location, extent, and severity of disease precluded placement of a proximal aortic clamp. Mean patient age was 61.4 +/- 13.1 years and 81 (73%) were male. Nine patients (8%) presented with acute dissection; 74 (67%) had chronic dissection; 56 patients (51%) required emergency operations, including 16 (14%) with ruptured aneurysms. Mean circulatory arrest time was 39.7 +/- 16.2 minutes. RESULTS: There were no intraoperative deaths. There were 31 operative deaths (28%), including 23 patients (21%) who died within 30 days. Operative mortality was 29% (30 of 102) for patients undergoing emergent or urgent operations and 1% (1 of 9) for all elective cases (p = 0.4). Postoperative paraplegia developed in 1 patient (1%) and 17 patients (15%) had postoperative renal failure. Cardiac complications occurred in 26 patients (23%), reoperation for bleeding in 6 (5%), tracheostomy was required in 24 (22%), and 10 (9%) sustained postoperative stroke. CONCLUSIONS: When cross clamping the aorta is not feasible, hypothermic circulatory arrest can be performed but with an increased morbidity and mortality rate.


PMID: 18291178 [PubMed - indexed for MEDLINE]

 

 
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Role of cricothyroid cannulation in head and neck surgery.

Ryan JC, McGuire B.

Departments of Otolaryngology, Head and Neck Surgery, Ninewells Hospital, Dundee, Scotland, UK.

Objectives:This paper outlines our use of cricothyroid cannulation in those patients undergoing head and neck surgery in whom a 'difficult airway' is anticipated. Audit results are presented.Materials and methods:Prospective data collection for all patients undergoing cricothyroid cannulation for management of head and neck neoplasms, over a two-year period.Results:Thirty-nine cricothyroid cannulae were sited in 32 patients. All patients with laryngeal tumours underwent the procedure while awake, prior to the anticipated difficult intubation, and the cannulae were removed within six hours. Most cannulations performed under general anaesthetic were for anticipated 'dangerous extubations' in patients with oral cavity tumours, and these cannulae remained in place for 24 hours. Tracheostomy was possibly avoided in six patients. No complications were identified.Conclusion:Cricothyroid cannulation can be a simple, safe, reliable technique which is a useful adjunct in the management of patients with a potentially difficult airway.

PMID: 18289395 [PubMed - as supplied by publisher]

 

 
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An investigation into the length of standard tracheostomy tubes in critical care patients.

Mallick A, Bodenham A, Elliot S, Oram J.

Leeds General Infirmary, Leeds, UK. Abhiram.Mallick@leedsth.nhs.uk

A number of problems have been reported with the use of standard length tracheostomy tubes in adult critical care patients. We measured the depth from the skin surface to the tracheal wall and the angle of the tracheal stoma during percutaneous tracheostomy. In vitro measurements were also performed on standard tracheostomy tubes. Comparison of in vivo and in vitro dimensions demonstrated that standard length tracheostomy tubes are too short for the average critical care patient. We recommend that both the stomal and intratracheal lengths should be made longer by approximately 1 cm and tubes should be redesigned to an angle of 110-120 degrees to allow optimal tracheal placement.


PMID: 18289238 [PubMed - indexed for MEDLINE]

 

 
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Respiratory care.

Rozet I, Domino KB.

Department of Anesthesiology, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356540, Seattle, WA 98195-6540, USA. irozet@u.washington.edu

PURPOSE OF THE REVIEW: Neurosurgical patients frequently develop respiratory complications, adversely affecting neurologic outcome and survival. The review summarizes current literature and management of respiratory complications associated with brain injury. MAJOR FINDINGS: Respiratory complications are commonly associated with traumatic brain injury and subarachnoid haemorrhage. Lung-protective ventilation with reduced tidal volumes improves outcome in acute lung injury, and should be applied to neurosurgical patients in the absence of increased intracranial pressure. Weaning from the mechanical ventilation should be initiated as soon as possible, although the role of neurological status in the weaning process is not clear. Prevention of pneumonia and aspiration improves survival. In patients with difficult weaning, early bedside percutaneous tracheostomy should be considered. FURTHER INVESTIGATIONS: Further studies are warranted to elucidate an optimal oxygenation and ventilation in brain-injured patients, weaning strategies, predictors of the failed weaning and extubation, respiratory support in patients with difficulties to wean, and early tracheostomy.

PMID: 18286832 [PubMed - in process]

 

 
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Rhinosporidiosis of trachea: a clinical cause for concern.

Arora R, Gupta R, Dinda AK.

Department of Pathology, All India Institute of Medical Sciences, New Delhi, India.

Background:Rhinosporidiosis is a granulomatous infection usually affecting the nasal mucosa and conjunctiva. The disease is widely prevalent in India and Sri Lanka. Tracheo-bronchial involvement is extremely rare and is potentially life threatening. Diagnosis of tracheal involvement is a challenge due to the risk of bleeding during attempted bronchoscopic biopsy.Case:A 73-year-old man was admitted with severe respiratory distress, for which emergency tracheostomy was performed. At tracheostomy, a fleshy mass was seen emerging from the wound. Pathological examination of the mass confirmed rhinosporidiosis involving the trachea. Complete excision of the mass was performed after initial stabilisation of the patient.Conclusion:Tracheo-bronchial rhinosporidiosis, a rare complication of nasopharyngeal infection, should be considered in a known case presenting with severe respiratory distress.

PMID: 18282336 [PubMed - as supplied by publisher]

 

 
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Transoral laser surgery for laryngeal cancer: Outcome, complications and prognostic factors in 275 patients.

Preuss SF, Cramer K, Klussmann JP, Eckel HE, Guntinas-Lichius O.

Department of Otorhinolaryngology, Head and Neck Surgery, Cologne, School of Medicine, University of Cologne, Joseph Stelzmann Str. 9, 50924 Cologne, Germany.

AIM: Curative treatment options for laryngeal carcinoma include primary radiation therapy, open surgical techniques and transoral laser surgery (TLS). In the last decade, TLS has become an important tool in the treatment of laryngeal cancer and has become the standard approach in many institutions. The aim of this study was to review the experience of a single center institution with TLS for early and advanced laryngeal cancer. METHODS: We retrospectively analyzed 275 patients who underwent TLS in regard to the survival outcome and surgical complications. RESULTS: The 5-year disease-free survival estimate was 90.3% and the 10-year disease-free survival estimate was 88.2%. The 5-year larynx preservation rate estimate was 88.2% and the 10-year larynx preservation rate estimate was 87.3%. The disease-free survival was significantly worsened by the variables T and N (p=0.0003; p<0.001, respectively). Two percent of all patients required intraoperative tracheostomy and the rate of minor postoperative complications was 17%. There were no fatal complications. CONCLUSIONS: We conclude that TLS is a valid treatment method for early laryngeal carcinoma. Selected cases of advanced carcinomas may also benefit from TLS.

PMID: 18281184 [PubMed - as supplied by publisher]

 

 
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The use of mechanical ventilation is appropriate in children with genetically proven spinal muscular atrophy type 1: the motion for.

Bach JR.

Department of Physical Medicine and Rehabilitation, UMDNJ-New Jersey Medical School, Newark, NJ, USA.

The purpose of this paper is to report prolongation of survival for Werdnig-Hoffman's disease (spinal muscular atrophy type 1, SMA 1) by use of non-invasive respiratory muscle aids compared with tracheostomy, and to present reasons for offering this as an option to the parents of these children. Ninety per cent of typical untreated SMA 1 patients die before 12 months of age and 100% by 24 months of age. Tracheostomy can prolong survival to over 20 years of age in some cases, but patients with tubes do not develop the ability to speak and lose all ability to breathe from the point of the tracheotomy. In contrast, the majority of non-invasively managed SMA 1 patients develop the ability to communicate verbally and maintain some autonomous breathing ability. Clinicians' treatment paradigms associate ventilatory support with invasive tubes and do not recognise aiding respiratory muscles. Clinicians also significantly underestimate the care providers' view of the patient's quality of life. As a result, they rarely offer non-invasive means to prolong life. In conclusion, both non-invasive aids and tracheostomy can prolong survival for SMA 1 patients, and it should be left up to the family to decide which, if either, they would like to use.

PMID: 18280979 [PubMed - in process]

 

 
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[Percutaneous tracheostomy for the management of the patient with a difficult airway]

[Article in Japanese]

Suzuki H, Aoyagi M.

Anesthesia and Critical Care Service, Chiba Aoba Municipal Hospital, Chiba, Japan.

BACKGROUND: In recent years, percutaneous tracheostomy has been performed in patients with adverse conditions such as short neck, obesity, coagulopathy or in emergency. METHODS: We performed percutaneous tracheostomy with Griggs' or Ciaglia's technique in five patients with difficult airways due to laryngeal tumors, a laryngeal edema, a neck cancer or a cervical injury. RESULTS: Well-trained anesthesiologists performed all procedures. In four patients, percutaneous tracheostomy was completed rapidly without any complications. The rest of patients underwent orotracheal intubation successfully with a percutaneous tracheostomy set prepared for an emergency situation. We call this setting "Stand-by PCT". CONCLUSIONS: We believe that percutaneous tracheostomy in well-trained hands can be used safely for the management of the patient with a difficult airway.

Publication Types:

English Abstract


PMID: 18277559 [PubMed - in process]

 

 
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[Tracheostomy in ventilated patients. What do we do it for?]

[Article in Spanish]

Salcedo O, Frutos-Vivar F.

Unidad de Cuidados Intensivos y Grandes Quemados. Hospital Universitario de Getafe. CIBER Enfermedades Respiratorias. Madrid. España. fjaladosarbol@supercable.es.

The tracheostomy has turned into one of the procedures most performed in the intensive care units. To this fact they have contributed the introduction of the percutaneous technique and the theoretical advantages that tracheostomy has: increase of the comfort of the patient, decrease of the dead space, improvement of the bronchial toilet and decrease in the requirement of sedation. But these advantages are not sufficient evidence for the indication of a tracheostomy. The comparative studies show that the performance of a tracheostomy, versus translaryngeal intubation, could relate to a lower mortality in the unit of intensive care, but tracheostomy does not improve other outcomes as length of stay in the unit of intensive care, length of stay in the hospital and the mortality in the hospital. More studies are needed to be able to estimate what patients would benefit from a tracheostomy and which is the optimal timing for its performance.

PMID: 18275757 [PubMed - as supplied by publisher]

 

 
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Thoracic aortic aneurysm repair. Direct hospital cost and Diagnosis Related Group reimbursement.

Mishra V, Geiran O, Krohg-Sørensen K, Andresen S.

Health Professional Support Department, Rikshospitalet Radiumhospitalet Medical Center, Oslo, Norway.

Objective. The main objective of this study was to analyze direct hospital cost and to compare cost with existing DRG reimbursement for open repair of thoracic and thoraco-abdominal aortic disease. Study sample and methodology. Between January 2003 and September 2003, the cost of treatment for 24 surgical procedures on ascending aorta and arch, descending or thoraco-abdominal aortic disease were examined prospectively. Seven patients had urgent or emergency surgeries. Ten had sternotomies for disease of the ascending aorta and aortic arch; two had left thoracotomies and three thoraco-laparotomy incisions with procedures performed on x-corporeal circulation. Nine other patients had more distal thoraco-abdominal aortic operations with a clamp-and-sew technique. Micro-cost analysis was performed on each hospital stay, in addition overhead hospital costs were allocated to each procedure. Results. The patients were grouped by discharge diagnosis (ICD-10) and surgical procedure performed (NCSP) into Norwegian DRG code. Patient with surgery on ascending aorta & aortic arch were allocated to DRG 108 (n =9) or 483 (tracheostomy, n =1) while patient with surgery on descending or thoraco-abdominal aorta were allocated to DRG 108 (n =3), 110 (n =4), 111 (n =4) or 483 (tracheostomy, n =3). The mean EuroSCORE for patients with proximal aortic disease was 11 5-18 5 6 7 8 9 10 11 12 13 14 15 16 17 18 , and the length of stay was 5 days (range 3-8 days), spending 2 days (range 1-7 days) in thoracic intensive care unit. For patients with distal aortic disease the mean Euroscore was 7 2-14 2 3 4 5 6 7 8 9 10 11 12 13 14 , and the mean length of stay 10 days (range 4-23 days) with a mean 4 days (range 1-13 days) in intensive care unit. Eight patients developed medical problems requiring new surgical procedures or prolonged ICU stay. The average direct hospital cost for proximal aortic surgery was USD 15 877 (USD 1 =NOK 7.5) while the respective 100% DRG reimbursement including one patient needing a tracheostomy, was 19 803 USD. For patients with distal aortic disease, average direct hospital cost was 23 005 USD and DRG reimbursement including patients needing a tracheostomy was 31543 USD. Conclusion. Our results underscore previous findings that these patients are resource intensive. This study shows that Norwegian 100% DRG reimbursement did over-compensate observed total hospital costs in this cohort. Detailed analysis showed that this was due to the higher DRG reimbursement for patients needing prolonged ventilatory support. Thus the actual DRG reimbursement seems to be relevant to the tertiary hospital actual costs when these complicated patients are considered as a group. It remains however unclear whether this reimbursement is sufficient to support the scientific infrastructure for new knowledge and skills needed for the further refinement of treatment.

PMID: 18273734 [PubMed - in process]

 

 
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Evidence-Based Surgical Management of Substernal Goiter.

White ML, Doherty GM, Gauger PG.

Division of Endocrine Surgery, Department of Surgery, University of Michigan, 2920 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, Michigan, 48109-0331, USA.

BACKGROUND: A number of reports have been published concerning the surgical treatment of substernal goiters; however, there is yet to be a comprehensive review of this body of literature using evidence-based methodology. METHODS: This article is a systematic review of the literature using evidence-based criteria and a review of unpublished data from our institution. RESULTS: Issue 1. Limited level III/IV data suggest that the incidence of cancer in substernal goiters is not higher than the incidence of cancer in cervical goiters. Risk factors for malignancy in substernal goiters may include a family history of thyroid pathology, a history of cervical radiation therapy, recurrent goiter, and the presence of cervical adenopathy (grade C recommendation). Issue 2. Prospective level V data suggest that, for most patients, expert endocrine surgeons utilize an extracervical approach approximately 2% of the time to remove a substernal goiter safely; a sternotomy or thoracotomy appears more likely in cases of a primary substernal goiter or a mass larger than the thoracic inlet (no recommendation). Issue 3. There may be a higher rate of permanent hypoparathyroidism and unintentional permanent recurrent laryngeal nerve injury when total thyroidectomy is performed for removal of a substernal goiter than for removal of a cervical goiter alone (grade C recommendation). Injury of the external branch of the superior laryngeal nerve was not specifically addressed and is almost certainly underreported. Issue 4. The presence of a substernal goiter, especially being present more than 5 years and causing significant tracheal compression, is likely a risk factor for tracheomalacia and tracheostomy (grade C recommendation). Tracheomalacia with substernal goiter is an infrequent occurrence, and many cases of tracheomalacia can be managed without tracheostomy (no recommendation). Issue 5. Prospective level V data suggest that about 5% to 10% of operations for substernal goiters are performed because of recurrent or persistent disease, although retrospective level V data report an even higher rate, up to 37%. The most common initial operations with recurrence or persistence appear to be subtotal or hemithyroidectomy (no recommendation). CONCLUSION: Evidence-based recommendations provide reliable information regarding the pathologic findings and operative management of substernal goiters in expert hands.

PMID: 18266028 [PubMed - as supplied by publisher]

 

 
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Neonatal upper airway obstruction in osteogenesis imperfecta: series of three cases and review of the literature.

Johnson K, Pineda M, Darrow D, Proud V, Derkay C.

Department of Otolaryngology-Head and Neck Surgery, Eastern Virginia Medical School, Norfolk, Virginia, USA.

OBJECTIVES: Osteogenesis imperfecta (OI) is a genetic disorder characterized by variable degrees of dysfunction in type I collagen formation. We sought to explore an association between OI and upper airway obstruction (UAO) in light of our recent experience. METHODS: We performed a retrospective chart audit and a review of the literature. RESULTS: Three consecutive cases of OI at our institution required otolaryngological evaluation for UAO. The first patient had the mildest mutation type and did well until he developed severe reflux-triggered laryngospasm that improved with Nissen fundoplication and gastrostomy tube placement. He had mild hypotonia on endoscopy. The second patient had severe OI and the greatest acute fracture burden at birth. He required tracheotomy after early respiratory failure, and some mild bronchomalacia was noted. The third patient had severe OI and underwent cesarean section delivery. She developed respiratory failure after 1 month, requiring tracheotomy; mild tracheomalacia and glottic narrowing were noted on endoscopy. CONCLUSIONS: The UAO consisted of mild hypotonia or malacia in 3 consecutive cases of OI, and may have contributed to pulmonary and mechanical causes of tracheotomy requirement. The greatest predictors of tracheotomy requirement appear to be the severity of the OI mutation and the fracture burden. Elective cesarean section should be considered in severe cases of OI.

Publication Types:

Case Reports


PMID: 18254368 [PubMed - indexed for MEDLINE]

 

 
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Utilization of the LifeStat emergency airway device.

Mouadeb DA, Rees CJ, Belafsky PC.

Department of Otolaryngology-Head and Neck Surgery, University of California-Davis Medical Center, 2521 Stockton Blvd, Suite 7200, Sacramento, CA 95817, USA.

OBJECTIVES: Management of the airway in an emergency may be a harrowing experience. The equipment necessary to perform this procedure is often inaccessible. The LifeStat emergency airway is a portable device approved by the US Food and Drug Administration in 1997 for emergency cricothyrotomy. It is small enough to secure to a keychain, thus allowing instantaneous access at all times. We present a retrospective case series to report the experience of clinicians who have used the LifeStat device. METHODS: A survey instrument was sent to a convenience sample of health-care professionals who purchased the LifeStat emergency airway. The survey queried device use, user demographics, and the success, ease, complications, and location of use. RESULTS: One thousand surveys were distributed, and 100 individuals responded. Fifteen percent (15 of 100) reported use of the device on 17 occasions. The LifeStat was used successfully in all 17 cases. Eighty-two percent (14 of 17) of emergency use was in hospitals. In all cases the device was positioned successfully on the first attempt. No complications were reported. CONCLUSIONS: The LifeStat device provides a relatively safe and effective means of performing emergency cricothyrotomy. The majority of emergency situations in which the device was deployed occurred in hospital settings.
 


PMID: 18254362 [PubMed - indexed for MEDLINE]

 

 
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The Prediction of Extubation Success of Postoperative Neurosurgical Patients Using Frequency-Tidal Volume Ratios.

Vidotto MC, Sogame LC, Calciolari CC, Nascimento OA, Jardim JR.

Respiratory Physiotherapy Especialization Course, Federal University of São Paulo (Unifesp), Sao Paulo, Brazil, milenavidotto@hotmail.com.

BACKGROUND: The process of discontinuing neurological patients from mechanical ventilation is still controversial. The aim of this study was to report the outcome from extubating patients undergoing elective craniotomy and correlate the result with the measured f/V (t) ratio. MATERIALS AND METHODS: In a cohort prospective study, all consecutive patients who required mechanical ventilation for up to 6 h after elective craniotomy were eligible for inclusion in this study. Patients passing daily screening criteria automatically received a spontaneous breathing trial (SBT). Immediately previous to the extubation, the expired minute volume (VE), breathing frequency (f), and tidal volume (V (t)) were measured and the breathing frequency-to-tidal volume ratio (f/V (t)) was calculated; consciousness level based on Glasgow Coma Scale (GCS) was evaluated at the same time. The extubation was considered a failure when patients needed reintubation within 48 h. RESULTS: Ninety-two patients were extubated and failure occurred in 16%. Despite 15 patients failed extubation just one of them presented the f/V (t) score over 105. The best cutoff value for f/V (t) observed was 62, but with low specificity (0.53) and negative predictive values (0.29). Area under the ROC curve for the f/V (t) was 0.69 +/- 0.07 (P = 0.02). Patients who failed the extubation process presented higher incidence of pneumonia (80%), higher need for tracheostomy (33%) and mortality rate of 40%. CONCLUSION: The f/V (t) ratio does not predict extubation failure in patients who have undergone elective craniotomy. Patients who fail extubation present higher incidence of pneumonia, tracheostomy and higher mortality rate.

PMID: 18250977 [PubMed - as supplied by publisher]

 

 
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Endoscopic-assisted craniofacial resection: a case series and post-operative outcome.

Gendeh BS, Salina H, Selladurai B, Jegan T.

Department of Otorhinolaryngology, Hospital Universiti, Kebangsaan Malaysia, Jalan Tenteram, Cheras, Kuala Lumpur.

Craniofacial resection is commonly performed in the surgical resection of sinonasal tumours involving anterior skull base. It entails a bicoronal scalp flap with lateral rhinotomy or an extended lateral rhinotomy to expose the anterior skull base. Transfacial approach is necessary in the resection of the nasal part of the tumour. The choice of surgical approach is based heavily on the surgeon's experience and training. The results of endoscopic-assisted craniofacial resection for sinonasal tumours performed in our center in eight patients from 1998 to 2005 were reviewed. There were seven males and one female with age ranging from 18 to 62 years (mean 42.4 years). There was each a case of mature teratoma, poorly differentiated squamous cell carcinoma, undifferentiated squamous cell carcinoma, olfactory neuroblastoma, fibrous dysplasia, inverted papilloma and two cases of sinonasal neuroendocrine carcinoma. The mean follow up duration for these eight patients post surgery was 21.4 months. Out of eight patients, five underwent surgery with no adverse complications. The complications encountered were a cerebrospinal leak and a postoperative transient V and VI cranial nerve palsy. One patient with sinonasal undifferentiated carcinoma died of lung metastasis at 11 months post-surgery. The endoscopic-assisted craniofacial resection is a highly useful surgical technique to avoid the unsightly facial scar of the lateral rhinotomy or the Weber-Ferguson incision, postoperative paranasal sinuses infection and avoidance of tracheostomy in selected cases. We found that this approach has lower morbidity rate in selected cases.
 


PMID: 18246914 [PubMed - indexed for MEDLINE]

 

 
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[Modified frontolateral partial larnygectomy without tracheostomy for early laryngeal cancer of the true vocal cord]

[Article in Chinese]

Dong P, Wang Q, Li XY, Li L, Chen L, Wang GL, Chen XW.

Department of Otolaryngology and Head & Neck Surgery, First Shanghai People's Hospital, Shanghai Jiao Tong University, Shanghai 200080, China.

OBJECTIVE: To investigate the feasibility of modified frontolateral partial laryngectomy without tracheostomy in the treatment for early laryngeal cancer or severe atypical hyperplasia of the true vocal cord. METHODS: A retrospective analysis of 41 patients treated in the past 6 years with modified frontolateral partial laryngectomy without tracheostomy was carried out. There were 39 early laryngeal cancers of the lateral vocal cord with 34 in T1a stage and 5 in T2, and the remain 2 patients had severe atypical hyperplasia of the lateral vocal cord. An ipsilateral false vocal cord flap was used in 39 patients and cervical skin flap in 2 to reconstruct the defect after resection of the true vocal cord. In order to get a large laryngeal cavity, a reverted sternohyoid fascia was used to cover the front area, which made the new laryngeal lumen become ladder-shaped. RESULTS: The incisions of all 41 patients healed up by first intention. The only postoperative complication was subcutaneous emphysema, which developed postoperatively in 9 patients, but subsided prior to discharge. The estimated 1-, 3- and 5-year survival rates were all 100%. No patients died during the postoperative period. CONCLUSION: Modified frontolateral partial laryngectomy without tracheostomy is effective with a high rate of success in eradicating early or selected invasive glottic squamous cell carcinoma or severe atypical hyperplasia of the true vocal cord.

Publication Types:

English Abstract


PMID: 18246805 [PubMed - in process]

 

 
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Deep sternal wound infection requiring revision surgery: impact on mid-term survival following cardiac surgery.

Sachithanandan A, Nanjaiah P, Nightingale P, Wilson IC, Graham TR, Rooney SJ, Keogh BE, Pagano D.

Department of Cardiothoracic Surgery, University Hospital Birmingham NHS Foundation Trust, Birmingham B15 2TH, United Kingdom.

Objective: To assess the impact of deep sternal wound infection on in-hospital mortality and mid-term survival following adult cardiac surgery. Methods: Prospectively collected data on 4586 consecutive patients who underwent a cardiac surgical procedure via a median sternotomy from 1st January 2001 to 31st December 2005 were analysed. Patients with a deep sternal wound infection (DSWI) were identified in accordance with the Centres for Disease Control and Prevention guidelines. Nineteen variables (patient-related, operative and postoperative) were analysed. Logistic regression analysis was used to calculate a propensity score for each patient. Late survival data were obtained from the UK Central Cardiac Audit Database. Mean follow-up of DSWI patients was 2.28 years. Results: DSWI requiring revision surgery developed in 1.65% (76/4586) patients. Stepwise multivariable logistic regression analysis identified age, diabetes, a smoking history and ventilation time as independent predictors of a DSWI. DSWI patients were more likely to develop renal failure, require reventilation and a tracheostomy postoperatively. Treatment included vacuum assisted closure therapy in 81.5% (62/76) patients and sternectomy with musculocutaneous flap reconstruction in 35.5% (27/76) patients. In-hospital mortality was 9.2% (7/76) in DSWI patients and 3.7% (167/4510) in non-DSWI patients (OR 1.300 (0.434-3.894) p=0.639). Survival with Cox regression analysis with mean propensity score (co-variate) showed freedom from all-cause mortality in DSWI at 1, 2, 3 and 4 years was 91%, 89%, 84% and 79%, respectively compared with 95%, 93%, 90% and 86%, respectively for patients without DSWI ((p=0.082) HR 1.59 95% CI (0.94-2.68)). Conclusion: DSWI is not an independent predictor of a higher in-hospital mortality or reduced mid-term survival following cardiac surgery in this population.

PMID: 18243720 [PubMed - in process]

 

 
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Techniques for emergency tracheostomy.

Bonanno FG.

Trauma Directorate, Department of Surgery, Chris Hani Baragwanath Hospital, Johannesburg, South Africa.

PMID: 18243196 [PubMed - in process]

 

 
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Thoracoscopic-assisted esophagectomy and laparoscopic gastric pull-up for lye injury.

Kane TD, Nwomeh BC, Nadler EP.

University of Pittsburgh School of Medicine, Department of Surgery, Division Pediatric Surgery, Children's Hospital of Pittsburgh, Pittsburgh, PA 15213-2583, USA. timothy.kane@chp.edu

BACKGROUND: Acquired esophageal strictures in children are often the result of ingestion of caustic agents. We describe 2 children with severe esophageal strictures following lye ingestion, who successfully underwent esophagectomy and gastric pull-up utilizing combined thoracoscopic and laparoscopic techniques. METHODS: This was a retrospective chart analysis of both patients. CASE 1: A 17-year-old female, who ingested a lye-containing substance, which lead to the need for gastrostomy and esophageal dilatations, developed an esophageal stricture. Thoracoscopic esophagectomy, laparoscopic gastric conduit creation, pyloroplasty, gastric pull-up, and esophagogastric anastomosis was performed one year later. She was tolerating a regular diet for almost 4 years following esophageal replacement when she developed a gastric ulcer with gastrobronchial fistula that required open repair via a right thoracotomy. She has since recovered and resumed her regular diet. CASE 2: A 13-month-old female who ingested a lye-based cleaner underwent tracheostomy and gastrostomy on the day of injury, and esophageal dilatations beginning 1 month later. Despite dilatations, she developed severe strictures for which at age 21 months she underwent thoracoscopic esophageal mobilization, laparoscopic creation of gastric conduit, pyloroplasty, and esophagogastric anastomosis. A right thoracotomy was necessary to negotiate the conduit safely up to the neck. She is tolerating feeds and has not developed any complications for nearly 3 years following esophageal replacement. CONCLUSIONS: Esophagectomy and gastric pull-up for esophageal lye injuries can be accomplished utilizing a combination of thoracoscopy and laparoscopy with excellent results. Long-term follow-up is necessary to manage potential complications in these patients.

Publication Types:

Case Reports


 


 


PMID: 18237514 [PubMed - indexed for MEDLINE]

 

 
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Myiasis of the tracheostomy wound: case report.

Franza R, Leo L, Minerva T, Sanapo F.

Otorhinolaryngology Unit, Card. G. Panico Hospital, Tricase (LE), Italy. franzren@libero.it

"Myiasis" is a parasitic infestation of live human or vertebrate animal tissues or cavities caused by dipterous larvae (maggots) which feed on the host's dead or living tissue, liquid body substances or ingested food. They are extremely rare in Western countries, especially in E.N.T. practice, and to the best of our knowledge, only two cases of myiasis in a tracheostomy wound have been reported in the English literature. The case is reported, probably the first, of percutaneous tracheotomy myiasis. It was caused by infestation with larvae of Lucilia Caesar. The patient had undergone Griggs percutaneous tracheostomy 3 years earlier and was in a persistent vegetative state on account of a pontomesencephalic haemorrhage but maintained spontaneous breathing. The condition was treated by applying ether to the tracheotomy wound, which caused spontaneous exit of approximately 30 larvae, easily removed with forceps. The laboratory microbiologist observed and photographed macroscopic and microscopic characters of the larvae, of primary importance for species diagnosis. Predisposing factors could be: 1. smaller dimension of percutaneous tracheostomy in comparison to surgical tracheostomy; 2. vegetative state of patient; 3. poor hygiene of outer and inner tube; 4. bad smell of wound, which attracts flies; 5. living in a rural area. Although this is not a lethal disorder, knowledge of the disease is necessary from the preventive, diagnostic and curative standpoint. It is important to proceed with identification of the larvae, distinguishing them from other types of myiasis involving different therapeutic implications. Ecology, classification, and treatment of myiasis are reviewed.

Publication Types:


MeSH Terms:


PMID: 18236640 [PubMed - indexed for MEDLINE]

 

 
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A potentially fatal complication of postoperative vomiting: Boerhaave's syndrome.

Reddy S, Butt MW, Samra GS.

Publication Types:

Case Reports  Letter
PMID: 18226284 [PubMed - indexed for MEDLINE]

 

 
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Percutaneous tracheostomy in patients with disorders of the central nervous system.

Witkowska M, Kaczmarek E, Graff M, Karwacki Z, Słoniewski P, Nyka W.

Zak³ad Neuroanestezjologii, Akademia Medyczna w Gdañsku, ul. Dêbinki 7, 81-212 Gdañsk, phone/fax +48 58 349 23 35, e-mail: malgosiawit@tlen.pl.

Background and purpose: Patients with disorders of the central nervous system frequently require maintenance of an artificial airway due to impairment of the cough reflex and swallowing, or due to the necessity to apply long-term mechanical ventilation. The technique of percutaneous tracheostomy, introduced in recent years to clinical practice globally, enables tracheostomy and establishment of an artificial airway in a bedside setting, in a quick, simple and minimally traumatic manner. It does not require the operating theatre environment and is associated with lower complication rates than the traditional surgical technique. Material and methods: In the period from March 2003 till February 2007, we performed 75 procedures of Griggs mode percutaneous tracheostomy in intravenous anaesthesia, with use of a disposable Percutaneous Tracheostomy Kit (SIMS Portex, UK). The group of patients comprised 36 women and 39 men. Mean patient age was 57.4+/-17.9 years. Results: On average, the procedure was performed on the 8th (7.8+/-2.6) day after intubation, and its average duration was 6.0+/-3.3 minutes. The most frequent complication was local bleeding from the site (13%), most of which, however, regressed spontaneously. Also observed were: puncture of the tracheal tube sealing cuff (7%), damage to the isthmus of the thyroid (3%), and extratracheal positioning of the tracheal tube (3%). In all the cases the procedure was concluded successfully. Conclusions: Griggs mode is a simple and safe technique enabling percutaneous tracheostomy in patients with pathology of the central nervous system. However, further research is needed to evaluate potential delayed complications of the procedure.

PMID: 18224572 [PubMed - as supplied by publisher]
 
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Beware of the aberrant innominate artery.

Upadhyaya PK, Bertellotti R, Laeeq A, Sugimoto J.

Department of Surgery and Cardiothoracic Surgery, Creighton University, Omaha, Nebraska 68131, USA. kpupadhyaya@gmail.com

The anatomy of aortic great vessels is relevant in surgeries of the anterior neck, especially with a tracheostomy, thyroidectomy, or mediastinoscopy. Variations in their anatomy could lead to severe complications if not recognized. An aberrant high-riding innominate artery incidentally encountered during mediastinoscopy is presented.

Publication Types:

Case Reports



PMID: 18222291 [PubMed - indexed for MEDLINE]

 

 
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Mandibular distraction osteogenesis in a patient with Melnick-Needles syndrome.

Molina FM, Morales C, Taylor JA.

Department of Plastic and Reconstructive Surgery, Post-graduate Division of the Medical School, Universidad Nacional Autónoma de México, Hospital General Dr. Manuel Gea González, México City, Mexico. Fermomo57@hotmail.com

Melnick-Needles syndrome is an X-inked-dominant skeletal dysplasia in which there is deficient osteoblastic activity. Patients present with craniofacial anomalies consisting of a prominent forehead, exorbitism, mandibular hypoplasia, cheek fullness, and class II malocclusion. Severe mandibular hypoplasia leads to upper airway restriction, an increased incidence of sleep apnea and pneumonias, and occasionally respiratory failure. This is a report of a patient with Melnick-Needles syndrome who presented to our unit after multiple bouts of respiratory failure and with a tracheostomy in whom mandibular distraction osteogenesis was used to retire her tracheostomy and to cure her sleep apnea. The patient underwent bilateral, external, unidirectional mandibular distraction with a vector parallel to the occlusal plane. After a latency period of 5 days, distraction was initiated at a rate of 1 mm/day for 34 days. At this point, the patient was able to breathe with the tracheostomy plugged, and her occlusion had changed from a class II to a class III relationship. She no longer snored, and pulse oximetry on room air was normal while standing or supine. Interestingly, the patient's consolidation phase was prolonged--255 days--possibly attributable to altered bony metabolism. To our knowledge, this is the first reported case of mandibular distraction osteogenesis used to cure obstructive sleep apnea and eliminate the need for tracheostomy in a patient with Melnick-Needles syndrome. In the future, prophylactic mandibular distraction may prevent the need for tracheostomy in this group of patients.

PMID: 18216701 [PubMed - in process]

 

 
Related Articles, Links
 
Single-staged laryngotracheal resection and reconstruction for benign strictures in adults.

Marulli G, Rizzardi G, Bortolotti L, Loy M, Breda C, Hamad AM, Sartori F, Rea F.

University of Padua, Italy.

Laryngotracheal stenosis (LTS) is a challenging problem, and its management is complex. This study evaluated both short- and long-term outcomes following laryngotracheal resection and anastomosis. Between 1994 and 2006, 37 patients underwent surgery for LTS. The cause of stenosis was post-intubation or post-tracheostomy injury in 28 cases and idiopathic in nine. Pearson's technique was used for anterolateral cricotracheal resection (n=23), and Grillo's technique of providing a posterior membranous tracheal flap was used in cases of circumferential stenosis (n=14). Since 1998, we have modified the techniques in 21 cases, using a continuous 4/0 polydioxanone suture for the posterior part of the anastomosis. No peri-operative mortality was recorded. Three (8.1%) patients developed major complications (2 fistulae and 1 early stenosis) that required a second surgical look. We had 16 minor complications in 14 (37.8%) patients. The long-term results were excellent to satisfactory in 36 patients (97.3%) and unsatisfactory in one (2.7%). Single-staged laryngotracheal resection is a demanding operation, but can be performed successfully with acceptable morbidity in specialized centers. The continuous suture in the posterior part of the anastomosis simplifies the procedure without causing technique-related complications. In our experience, this procedure guaranteed excellent to satisfactory results in more than 90% of patients. Keywords: Laryngotracheal stenosis; Tracheal surgery; Airway resection.

PMID: 18216046 [PubMed - as supplied by publisher]
 

 
  • Endoscopic management of recurrent tracheoesophageal fistula.

    Richter GT, Ryckman F, Brown RL, Rutter MJ.

    Department of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45208, USA.

    RATIONAL: Recurrent tracheoesophageal fistulas (RTEFs) remain a therapeutic challenge because open surgical approaches have been associated with substantial rates of morbidity, mortality, and repeat recurrences. Recently, endoscopic techniques for the repair of RTEF have provided an alternative approach with the potential for improved surgical outcomes. However, previous reports have been limited by small patient numbers and variations in technique. By examining a single institution's experience and performing a systematic review of previously published results, we aimed to identify an optimal approach to managing RTEF endoscopically. METHODS: Retrospective chart review of patients undergoing endoscopic management of RTEF at a single tertiary care institution was performed. Medline search and summated analysis of previously published cases of endoscopically treated RTEF from 1975 to 2007 was conducted. RESULTS: Four patients with RTEF were identified and selected for endoscopic repair at our institution from 2003 to 2007 (mean age, 11.5 months). Under endoscopic guidance, fistula tracts were de-epithelialized with a Bugbee fulgurating diathermy electrode (5-15 W) and then sealed with fibrin glue (Tisseel with added aprotinin). Closure of RTEF was successful in 3 patients after a single attempt. One revision was required after inadvertent recannulation of the tract with an emergent tracheostomy tube change. No patient has evidence of recurrence (mean follow-up, 16 months). In 15 articles of endoscopically repaired RTEF, 37 cases have been reported from 1975 until present. In general, 3 approaches to endoscopic repair have been explored. Analysis of all reported cases in the literature and results from our patient series suggests that endoscopic techniques designed to both de-epithelialize the fistula tract and seal with fibrin glue have the best chance for cure after a single attempt. Patients with long, thin, and small diameter fistula who have enough distal trachea to accommodate a postoperative cuffed ventilating tube beyond the fistula are ideal candidates for endoscopic repair. CONCLUSION: In select patients, endoscopic management of RTEF using Bugbee cautery and tissue adhesives can reduce morbidity and recurrence associated with open approaches and alternative endoscopic techniques.

    MeSH Terms:

    Combined Modality Therapy

    Endoscopy/methods*

    Esophagoscopy/methods

    Female

    Fibrin Tissue Adhesive/therapeutic use*

    Follow-Up Studies

    Humans

    Infant

    Infant, Newborn

    Laryngoscopy/methods

    Male

    Postoperative Care/methods

    Recurrence

    Retrospective Studies

    Risk Assessment

    Tracheoesophageal Fistula/congenital*

    Tracheoesophageal Fistula/diagnosis

    Tracheoesophageal Fistula/surgery*

    Treatment Outcome


    Substances:

    Fibrin Tissue Adhesive


    PMID: 18206490 [PubMed - indexed for MEDLINE]

 

 
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Long-term results of laryngotracheal resection for benign stenosis.

D'Andrilli A, Ciccone AM, Venuta F, Ibrahim M, Andreetti C, Massullo D, Formisano R, Rendina EA.

Department of Thoracic Surgery, University of Rome ‘La Sapienza’, Sant’Andrea Hospital, Rome, Italy.

Objective: We report the long-term results of our 16-year experience with laryngotracheal resection for benign stenosis. Methods: Between 1991 and 2006, 35 consecutive patients (19 males, 16 females) underwent laryngotracheal resection for subglottic postintubation (32) or idiopathic (3) stenosis. Mean age was 43 years (range 14-71). At the time of surgery 13 patients presented with tracheostomy and 7 with a Dumon stent. The upper limit of the stenosis was from 0.6 to 1.5cm below the vocal cords. The length of airway resection ranged between 1.5 and 6cm. Suprahyoid release was performed in two patients and pericardial release in one. Nine patients had psychiatric and/or neurological post-coma disorders. Mean follow-up is over 5 years (61 months; range 3-194). Results: There was no perioperative mortality. Thirty patients (85.7%) had excellent or good anatomic and functional results. Four patients (11.4%) presented restenosis at a distance of 25-110 days from the operation. Restenosis was successfully treated by endoscopic procedures in all four patients. One patient (2.9%) presented anastomotic dehiscence that required temporary tracheostomy closed after 1 year with no sequelae. Three patients (8.4%) had wound infection. Long-term follow-up was uneventful also in patients who had early complications. Conclusions: Long-term follow-up confirms that laryngotracheal resection is the definitive curative treatment for benign subglottic stenosis. Surgical complications can be successfully managed by non-operative procedures. Despite the occurrence of early complications, excellent and stable results can still be obtained at long term.

PMID: 18201890 [PubMed - as supplied by publisher]

 

 
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[Tracheostomy in the ICU: is it worthwhile?]

[Article in Portuguese]

Perfeito JA, Mata CA, Forte V, Carnaghi M, Tamura N, Leão LE.

Universidade Federal de São Paulo/Escola Paulista de Medicina, São Paulo, SP, Brasil. japerfeito.dcir@epm.br

OBJECTIVE: To determine the feasibility of performing tracheostomy in the intensive care unit (ICU) environment and to assess procedure-related complications and mortality. METHODS: The medical records of the 73 patients submitted to tracheostomy in the ICU of the Federal University of São Paulo Hospital São Paulo between January and November of 2003 were evaluated retrospectively. All operations were performed by surgical residents, under the supervision of a thoracic surgeon, using the open technique standardized at the facility. RESULTS: The mean age of the patients was 55.2 years. Of the 73 patients evaluated, 47 (64.4%) were male and 26 (35.6%) were female. The most common indication was prolonged orotracheal intubation (76.7%). There was no procedure-related mortality, and, in all patients, the procedure was successfully performed in the ICU. Early complications occurred in 2 patients (2.7%), who presented increased local bleeding, which was controlled using compression. The late complication was infection at the incision site, which occurred in 2 patients (2.7%) and was treated by applying local dressings, without further clinical repercussions. CONCLUSIONS: Based on the results of our analysis, which are comparable to those found in the literature regarding tracheostomy performed in the operating room, we concluded that tracheostomy in the ICU is feasible and presents a low rate of complications, even when performed in critically ill patients and by surgeons in training. Therefore, in our view, it is possible to state that performing tracheostomy in the ICU is worthwhile.

Publication Types:


PMID: 18200369 [PubMed - in process]

 

 

Ann Otol Rhinol Laryngol. 2008 Jan;117(1):1-4. Links

Utilization of the LifeStat emergency airway device.

Department of Otolaryngology-Head and Neck Surgery, University of California-Davis Medical Center, 2521 Stockton Blvd, Suite 7200, Sacramento, CA 95817, USA.

OBJECTIVES: Management of the airway in an emergency may be a harrowing experience. The equipment necessary to perform this procedure is often inaccessible. The LifeStat emergency airway is a portable device approved by the US Food and Drug Administration in 1997 for emergency cricothyrotomy. It is small enough to secure to a keychain, thus allowing instantaneous access at all times. We present a retrospective case series to report the experience of clinicians who have used the LifeStat device. METHODS: A survey instrument was sent to a convenience sample of health-care professionals who purchased the LifeStat emergency airway. The survey queried device use, user demographics, and the success, ease, complications, and location of use. RESULTS: One thousand surveys were distributed, and 100 individuals responded. Fifteen percent (15 of 100) reported use of the device on 17 occasions. The LifeStat was used successfully in all 17 cases. Eighty-two percent (14 of 17) of emergency use was in hospitals. In all cases the device was positioned successfully on the first attempt. No complications were reported. CONCLUSIONS: The LifeStat device provides a relatively safe and effective means of performing emergency cricothyrotomy. The majority of emergency situations in which the device was deployed occurred in hospital settings.