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PubMed1996

Laryngotracheal stenosis after intubation or tracheostomy in patients with neurological disease.

OBJECTIVE: This retrospective study evaluated the incidence of airway complications in neurological patients following translaryngeal intubation, tracheostomy, or both. DESIGN: The medical records of 315 consecutive patients (200 with traumatic brain injuries, 31 traumatic tetraplegics, and 84 with other neurological disorders) were reviewed. The type of artificial airway, duration of intubation, and use of nocturnal ventilation were recorded. Eighty-six percent of the patients underwent some combination of tracheal tomograms, flow-volume loop analysis, and fiberoptic tracheolaryngoscopy. Stenosis was classified as severe if it required surgery, if it required maintaining the tracheostomy, or was lethal. It was classified as benign if it was successfully treated by medical or local means. RESULTS: Fifty-five percent of the patients were intubated translaryngeally only (mean = 17 days). Three percent underwent tracheostomy only, and 42% underwent tracheostomy after intubation for a mean of 13 days. The overall incidence of airway stenosis was 20%, 1/4 of which was severe. Fifteen percent of these patients died as a result of tracheal complications. The incidence of stenosis was higher following tracheostomy than following intubation only (29% vs 13%, p < .01). The incidence of severe stenosis in intubated-only patients was low (1%) compared with that following tracheostomy (10%, p < .01). No significant relationship was found between the length of intubation or the timing of tracheostomy. CONCLUSION: Fewer complications are associated with transtracheal intubation than with tracheostomy. The data suggest that longer periods of intubation be used when attempting ventilator weaning before restoring to tracheostomy if weaning fails.

Adolescent↗

PubMed1999

Paediatric tracheostomy: an analysis of 40 cases.

Tracheostomy in the paediatric patient has been associated with significant morbidity and mortality compared to that in the adult. A retrospective analysis was made of 40 patients up to the age of 12 years having tracheostomies. Upper airway obstruction made up the commonest (32 patients, or 80 per cent) indication for paediatric tracheostomy in our series where males slightly outnumbered females. The majority (31 patients, or 77.5 per cent) underwent the operation under general anaesthesia with endotracheal intubation. Thirty-four (85 per cent) patients underwent 'planned' tracheostomies and six (15 per cent) underwent 'crash' procedures. Thirteen (32.5 per cent) patients were under the age of one year when tracheostomies were performed. The maximum duration of tracheostomies was between one week to within a month and after one month to within three months; each containing 11 (27.5 per cent) patients. Sixty-four different surgical procedures were performed on these patients in which laryngoscopy and bronchoscopy were the commonest procedures. Nine (22.5 per cent) had early post-operative and 14 (35 per cent) had late post-operative complications. Among these 40 children with tracheostomies, one (2.5 per cent) died due to a tracheostomy-related cause and 10 (25 per cent) due to the primary disease process itself. Tracheostomies performed to provide access for general anaesthesia for other surgical procedures were associated with a better prognosis.

Airway Obstruction↗

PubMed2003

An analysis of time and staff utilization for open versus percutaneous tracheostomies.

OBJECTIVE: We examined staff utilization and procedure length for percutaneous and open bedside tracheostomies in an intensive care setting. STUDY DESIGN: Prospective clinical outcomes study. METHODS: Intensive care unit (ICU) tracheostomy consults meeting criteria for bedside procedures were randomized to open or percutaneous procedures. The Cook percutaneous kit and a prepackaged tracheostomy tray were used. ICU nursing and respiratory therapy staff was present for all procedures. The total resident time, staff time, and procedure length were recorded. Twelve patients underwent percutaneous tracheostomy, and 12 received an open tracheostomy. RESULTS: An operating room nurse was present for 7 of the open procedures. Ancillary medical staff was present for 3 open tracheostomies: anesthesia for 2 and critical care for 1. Ancillary medical staff was present for 4 percutaneous tracheostomies: anesthesia staff for 1 and critical care for 3. The average resident presence, staff presence, and procedure length for open tracheostomies were 47, 30, and 12 minutes, respectively. For percutaneous tracheostomies, the times were 39, 29, and 12 minutes, respectively. One intraoperative complication occurred during a percutaneous procedure and 2 perioperative complications occurred: 1 in the open group and 1 in the percutaneous group. CONCLUSIONS: There was no significant difference in procedure length, resident time, or staff time between the 2 procedures. Ancillary staff was occasionally used but was not thought to be necessary for the majority of procedures. Both procedures can be safely and expediently performed in the ICU.

Adult↗

PubMed1999

Percutaneous or surgical tracheostomy: a meta-analysis.

OBJECTIVE: To compare percutaneous with surgical tracheostomy using a meta-analysis of studies published from 1960 to 1996. DATA SOURCES: Publications obtained through a MEDLINE database search with a Boolean combination (tracheostomy or tracheotomy) and complications, with constraints for human studies and English language. STUDY SELECTION: Publications addressing all peri- and postoperative complications. Studies limited to specific tracheostomy complications or containing insufficient details were excluded. Two authors independently selected the publications. DATA EXTRACTION: A list of relevant surgical variables and complications was compiled. Complications were divided into peri- and postoperative groups and further subclassified into severe, intermediate, and minor groups. Because most studies of percutaneous tracheostomy were published after 1985, surgical tracheostomy studies were divided into two periods: 1960 to 1984 and 1985 to 1996. The articles were analyzed independently by three investigators, and rare discrepancies were resolved through discussion and data reexamination. DATA SYNTHESIS: Earlier surgical tracheostomy studies (n = 17; patients, 4185) have the highest rates of both peri- (8.5%) and postoperative (33%) complications. Comparison of recent surgical (n = 21; patients, 3512) and percutaneous (n = 27; patients, 1817) tracheostomy trials shows that perioperative complications are more frequent with the percutaneous technique (10% vs. 3%), whereas postoperative complications occur more often with surgical tracheotomy (10% vs. 7%). The bulk of the differences is in minor complications, except perioperative death (0.44% vs. 0.03%) and serious cardiorespiratory events (0.33% vs. 0.06%), which were higher with the percutaneous technique. Heterogeneity analysis of complication rates shows higher heterogeneity in older and surgical trials. CONCLUSIONS: Percutaneous tracheostomy is associated with a higher prevalence of perioperative complications and, especially, perioperative deaths and cardiorespiratory arrests. Postoperative complication rates are higher with surgical tracheostomy.

Adult↗

PubMed2000

Prediction and timing of tracheostomy in patients with infratentorial lesions requiring mechanical ventilatory support.

OBJECTIVES: To determine the frequency and predictors of successful extubations and tracheostomy in patients with infratentorial lesions requiring mechanical ventilation and to determine the optimal time for tracheostomy based on probability of successful extubation and in-hospital survival according to the duration of translaryngeal intubation. DESIGN: Retrospective chart review. SETTINGS: A neurocritical care unit at a university hospital. PATIENTS: A total of 69 patients with infratentorial lesions who were mechanically ventilated during their intensive care unit stay. MEASUREMENTS AND MAIN RESULTS: Of the 69 patients who were mechanically ventilated, 23 (33%) were successfully extubated. In logistic regression analysis, both the presence of a Glasgow Coma Scale score >7 at time of intubation (odds ratio, 4.8; 95% confidence interval, 1.2-21.7) and the absence of brainstem deficits (odds ratio, 4.3; 95% confidence interval, 1.3-16.7), were independently associated with successful extubation. After extubation, 11 patients were reintubated; seven were reintubated within the same day because of poor control over secretions, airway spasm, or hypoventilation. Tracheostomy was performed in 23 (33%) patients, of whom 19 were successfully weaned off mechanical ventilatory support over a mean period of 3.7+/-4.0 days after tracheostomy. Patients undergoing tracheostomy had a significantly longer intensive care unit stay (19.1+/-9.0 vs. 8.7+/-6.6 days, p < .01) and total hospital stay (34.8+/-18.7 vs. 20.1+/-9.9 days, p < .01) compared with patients who were successfully extubated. The probability of successful extubation or death before extubation or tracheostomy was 67% on the day of intubation, which decreased to 5.8% after translaryngeal intubation for >8 days. CONCLUSIONS: An aggressive policy toward tracheostomy is justified based on the low frequency of successful extubations and high frequency of extubation failures and tracheostomies in patients with infratentorial lesions. The decision regarding tracheostomy should be made on day 8 of mechanical ventilatory support because of the low probability of subsequent extubation or in-hospital death.

Adult↗

PubMed2002

Percutaneous tracheostomy: prospective comparison of the translaryngeal technique versus the forceps-dilational technique in 100 critically ill adults.

OBJECTIVE: To compare two different techniques of percutaneous tracheostomy: Griggs' forceps-dilational technique and Fantoni's translaryngeal technique, both performed with the manufacturer's basic kit and with bronchoscopic guidance. DESIGN: A prospective, randomized trial was designed to compare the two tracheostomy techniques. Critically ill patients requiring elective tracheostomy for long-term ventilation were randomized for translaryngeal tracheostomy or forceps-dilational tracheostomy. SETTING: Intensive care unit of a military teaching hospital. PATIENTS: A total of 100 adult patients in the intensive care unit who were mechanically ventilated. PROCEDURES: All tracheostomy procedures were performed at the bedside by using a commercially available set. The procedures were performed by two surgeons, one for bronchoscopic guidance and management of the airway and one for the tracheostomy. MEASUREMENTS AND MAIN RESULTS: The measurements were divided into procedure-related variables (duration, technical difficulties, oxygenation): major and minor complications. The procedure was longer in the translaryngeal technique group (12.9 vs. 6.9 mins, p =.0018). Technical difficulties occurred in 11 patients in the translaryngeal technique group. Uneventful forceps dilational tracheostomy was performed instead. There has been no mortality associated with either technique. Serious complications occurred in one patient in the forceps-dilational technique group (one posterior tracheal wall injury) and in four patients in the translaryngeal technique group (one with a posterior tracheal wall injury and three with severe hypoxia). Significant hypercarbia and acidosis occurred in both the translaryngeal technique group and the forceps-dilational technique group. A significant decrease in Pao2 was observed in the translaryngeal technique group (311 to 261, p =.0069). No bleeding requiring intervention occurred. CONCLUSIONS: Serious complications related to percutaneous tracheostomy occurred in 8.5% and 1.8% of the cases in the translaryngeal technique and the forceps-dilational technique group, respectively (p <.001). Technical difficulties were not rare when using the translaryngeal technique (23%). On the basis of our results, we concluded that the forceps-dilation technique is superior to the translaryngeal technique, with fewer technical difficulties and fewer complications for critically ill patients.

Bronchoscopy↗

PubMed2000

Tracheostomy in children: there is a place for acceptable risk.

BACKGROUND: Tracheostomy in children remains controversial regarding the risk of complications. METHODS: Forty-six trauma patients (35 male and 11 female, mean age = 6.8 years) were admitted to the intensive care unit between 1987 and 1991 with severe head injury plus coma. Tracheostomy was performed with standard technique after 5.9 days (range, 2-12 days) of intubation. RESULTS: There were no deaths from tracheostomy, but six deaths resulted from severe head injury. One child was discharged with tracheostomy. The 39 survivors remained with tracheostomy 16.14 days (range, 4-71 days) in the intensive care unit. After cannula removal, 31 remained asymptomatic; 8 had respiratory distress: 2 were normal, 5 had endoscopic treatment for subglottic granulomas/stenosis from intubation, and 1 had tracheomalacia from tracheostomy. In 1997, the 18 patients located for follow-up were asymptomatic. At endoscopy, 8 were normal, 9 had subglottal granulomas from intubation, and 1 had 20% tracheal stenosis from tracheostomy. CONCLUSION: Most complications after tracheostomy result from intubation. Tracheostomy has an acceptable risk in children with severe head injury who need prolonged ventilatory support.

Adolescent↗

PubMed2003

Regular tracheostomy tube changes to prevent formation of granulation tissue.

OBJECTIVES/HYPOTHESIS: Tracheostomy is a commonly performed operative procedure that has been described since 2000 B.C. The early indications for tracheostomy were for upper airway obstruction, usually occurring in young people as a result of an infectious process. Recently, tracheostomies are more commonly performed in the critically ill patient to assist in long-term ventilatory support. Granulation tissue at the stoma and the trachea has been described as a late complication resulting in bleeding, drainage, and difficulty with maintaining mechanical ventilatory support. STUDY DESIGN: The present report is of an observational study of a newly implemented policy that required regular changing of tracheostomy tubes. Comparable groups of patients were compared before and after this procedural change to document complications. Data collection consisted of chart reviews of all admissions for 1 year before the policy change and the subsequent 2 years. Complication rates were compared using standard statistical techniques. METHODS: A policy change was instituted that required all tracheostomy tubes to be changed every 2 weeks in conjunction with a detailed evaluation of the tracheostomy stoma. Charts were reviewed the year before the change in policy and in the subsequent 2 years to determine the incidence of granulation tissue requiring operative intervention. RESULTS: The number of patients requiring surgical intervention secondary to granulation tissue showed a statistically significant decrease (P =.02). A review of policies and procedures from the six largest hospitals in southeastern Michigan had no recommendations for routine tracheostomy tube changes. CONCLUSIONS: A policy requiring a routine change of tracheostomy tubes results in fewer complications from granulation tissue. Tracheostomy tube changes to prevent granulation tissue and its complications.

Adult↗

PubMed1995

Occurrence of infection in anterior cervical fusion for spinal cord injury after tracheostomy.

STUDY DESIGN: This study retrospectively reviewed the outcomes of 11 patients treated for a cervical spine injury with a tracheostomy placed before anterior cervical spine surgery. OBJECTIVES: The primary goal was to show that anterior cervical spine surgery in the setting of spinal cord injury is a viable option in patients with previous tracheostomy. SUMMARY OF BACKGROUND DATA: Respiratory failure after cervical cord injury commonly requires tracheostomy, possibly increasing the risk of soft tissue or bony infection in patients at high risk for morbidity after surgery. Although numerous studies have explored the risk of infection after tracheostomy or anterior cervical spine surgery, no study has been performed to explore the risk of infection in patients with previous tracheostomy at the time of anterior cervical spine surgery. METHODS: A retrospective review of the clinical data of 1800 spinal cord injury patients seen from 1979 to the present at the Regional Spinal Cord Injury Center of the Delaware Valley of Thomas Jefferson University with affiliated institutions of Thomas Jefferson University Hospital and Magee Rehabilitation Hospital was performed. Eleven patients were found who had existing tracheostomy at the time of anterior cervical spine surgery. Clinical follow-up period averaged 28 months with a range of 6-51 months, and radiographic analysis averaged 7 months with a range of 1-51 months. Autogenous iliac crest graft was used in all patients, consisting of an intervertebral graft after a discectomy or a strut graft after a complete corpectomy. Anterior instrumentation was used in more than 50% of the patients. RESULTS: After all patient interviews and review of all radiographs for evidence of infection, no patient was noted to have evidence of a cervical soft tissue or bony infection after surgery. The tracheostomy complications were minor and resolved quickly. CONCLUSIONS: The authors concluded that in patients with cervical cord damage resulting from nonpenetrating trauma, tracheostomy was not found to increase the risk of infection in subsequent anterior cervical surgery. Careful preparation of the skin and placement of the second surgical incision lateral to the tracheostomy site is recommended. Anterior cervical spine surgery remains a viable treatment option in this severely injured patient population.

Adult↗

PubMed2006

Variations in rates of tracheostomy in the critically ill trauma patient.

OBJECTIVE: The utility of tracheostomy to expedite weaning and prevent complications in patients with acute respiratory failure is actively debated, with many physicians holding strong opinions regarding the value and timing of this intervention. We postulated that these opinions would be reflected in significant variation in tracheostomy rates across centers. Thus, we set out explore the extent and potential sources of this variation among injured patients cared for in trauma centers in the United States. DESIGN: This is a retrospective cohort study. We used stratification and hierarchical multivariate analysis to evaluate the effect of patient and institutional characteristics on tracheostomy rates and variance decomposition to determine the proportion of variance across institutions explained by patient characteristics. SETTING: Intensive care units within trauma centers participating in the National Trauma Databank. PATIENTS: Injured patients admitted over the years 2001-2003, age >/=16 yrs, with an Injury Severity Score >/=9 and a diagnosis of acute respiratory failure, excluding patients with burn injuries and those with a severe injury to the face or neck who might require tracheostomy for maintenance of an airway. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 17,523 patients meeting inclusion criteria: 4,146 (24%) underwent tracheostomy. The mean tracheostomy rate across centers was 19.6 per 100 hospital admissions with a range of 0-59. This variation persisted after stratification by age, injury mechanism, and severity. Although several patient and injury characteristics were predictive of tracheostomy, there were no identifiable institutional characteristics associated with tracheostomy. Patient characteristics accounted for only 14% of the variance across centers. CONCLUSIONS: There is significant unexplained variation in the rates of tracheostomy in critically injured patients with acute respiratory failure. This variation might reflect preconceived notions of efficacy among physicians practicing in the absence of evidence to guide care. The variation provides evidence of equipoise and emphasizes the need for a well-conducted randomized controlled trial to evaluate the utility of this procedure.

Acute Disease↗

PubMed2007

Tracheostomy does not improve the outcome of patients requiring prolonged mechanical ventilation: a propensity analysis.

OBJECTIVE: To examine the association between the performance of a tracheostomy and intensive care unit and postintensive care unit mortality, controlling for treatment selection bias and confounding variables. DESIGN: Prospective, observational, cohort study. SETTING: Twelve French medical or surgical intensive care units. PATIENTS: Unselected patients requiring mechanical ventilation for > or =48 hrs enrolled between 1997 and 2004. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Two models of propensity scores for tracheostomy were built using multivariate logistic regression. After matching on these propensity scores, the association of tracheostomy with outcomes was assessed using multivariate conditional logistic regression. Results obtained with the two models were compared. Of the 2,186 patients included, 177 (8.1%) received a tracheostomy. Both models led to similar results. Tracheostomy did not improve intensive care unit survival (model 1: odds ratio, 0.94; 95% confidence interval, 0.63-1.39; p = .74; model 2: odds ratio, 1.12; 95% confidence interval, 0.75-1.67; p = .59). There was no difference whether tracheostomy was performed early (within 7 days of ventilation) or late (after 7 days of ventilation). In patients discharged free from mechanical ventilation, tracheostomy was associated with increased postintensive care unit mortality when the tracheostomy tube was left in place (model 1: odds ratio, 3.73; 95% confidence interval, 1.41-9.83; p = .008; model 2: odds ratio, 4.63; 95% confidence interval, 1.68-12.72, p = .003). CONCLUSIONS: Tracheostomy does not seem to reduce intensive care unit mortality when performed in unselected patients but may represent a burden after intensive care unit discharge.

APACHE↗

PubMed1992

Tracheostomy in pediatric patients.

From 1978 to 1987, tracheostomy was performed on 33 children, 13 boys and 20 girls, with a male to female ratio of 0.65:1. The mean age at the time of tracheostomy was 726 days, 76% of the children being under the age of two years. The incidence of pediatric tracheostomy per hospital admissions was 0.05%. Subglottic stenosis (13 children) and respiratory distress syndrome with prolonged endotracheal ventilation (11 children) were the most common indications for tracheostomy. The mean duration of prolonged endotracheal intubation before tracheostomy was 64 days, and that of tracheostomy treatment 117 days. During the tracheostomy period, five children died, but only one death was related to tracheostomy. The total rate of complications was 30%. We emphasize the importance of strict indications for pediatric tracheostomy.

Adolescent↗

PubMed2004

Tracheostomy placement in patients with complete cervical spinal cord injuries: American Spinal Injury Association Grade A.

OBJECT: The authors sought to identify variables that predispose patients with acute American Spinal Injury Association (ASIA) Grade A cervical spinal cord injury (SCI) to require tracheostomies for ventilator support or airway protection. METHODS: A retrospective analysis was performed of 178 consecutive patients with a cervical ASIA Grade A SCI who were admitted through the Delaware Valley SCI Center at Thomas Jefferson Hospital during a 6-year period. Exclusion criteria included injury occurring more than 48 hours prior to admission, death within 14 days of admission or nontraumatic SCI. Twenty-two patients were excluded based on these criteria. Parameters evaluated in the remaining population (156 patients) included demographics, cervical vertebral ASIA level, tracheostomy placement, pneumonia, premorbid pulmonary disease, smoking history, evidence of direct thoracic/lung trauma, operative intervention, associated appendicular trauma, and preexisting medical comorbidities. The ASIA classification of the 156 patients included in this analysis were C-2 (eight), C-3 (11), C-4 (64), C-5 (36), C-6 (20), C-7 (13), and C-8 (four). Tracheostomies were performed in 107 of these 156 patients. Statistical analysis revealed a significant relationship between tracheostomy and patient age (p = 0.0048), preexisting medical conditions (p = 0.0417), premorbid lung disease (p = 0.0177), higher cervical ASIA level (p < 0.0001), and the presence of pneumonia (p < 0.0001). No patient with a C-8 ASIA A injury required tracheostomy, whereas all C-2 and C-3 ASIA A-injured patients underwent tracheostomies. Patients older than 45 years of age with ASIA A levels between C-4 and C-7 more commonly required tracheostomy (p < 0.005) than patients younger than 45 years of age. CONCLUSIONS: Several risk factors were identified that corresponded to the frequent tracheostomy placement in the acute injury phase after complete cervical SCI. Early tracheostomy may be considered in patients with multiple risk factors to reduce duration of stay in the intensive care unit and facilitate ventilatory weaning.

Adolescent↗

PubMed2006

Care of the chronic tracheostomy.

A minority of patients with neuromuscular disease require placement of a tracheostomy, usually for the purpose of providing mechanical ventilation. Often the tracheostomy is performed during a hospital admission for an acute illness. The debate about the appropriate timing of tracheostomy in critically ill patients has not been resolved; however, the weight of evidence now favors performing a tracheostomy early (within 7 d of translaryngeal intubation) if the period of mechanical ventilation is likely to be prolonged beyond 3 weeks. For patients with chronic progressive weakness who develop respiratory difficulty, the consensus of opinion is that tracheostomy should be performed in patients with severe bulbar involvement, inability to effectively cough up secretions despite mechanical aids for secretion clearance, or for those who are unable to tolerate or fail noninvasive ventilation. The decision to perform tracheostomy in patients with chronic neuromuscular weakness involves consideration of several factors, including complications, resources, quality of life, ethical issues, cosmetic issues, and cost. Complications from tracheostomy and physician-perceived poor quality of life often lead to a negative bias, such that some patients may be denied this life-saving procedure. Special training is needed to provide long-term tracheostomy care, and an organized approach should be followed to decannulate patients who recover from their acute illness. Appropriate and skilled care could significantly improve the longevity and quality of life of those patients with neuromuscular disease who have a tracheostomy for long-term ventilation.

Acute Disease↗

PubMed1995

[Analysis of tracheostomy for patients after thoracic esophageal cancer resection].

Tracheostomy is an available method for respiratory management, but a consensus has not been reached with regard to the significance of postoperative respiratory management. So, we analyzed postoperative tracheostomy patients of esophageal cancer and clarified its significance. We analyzed 26 patients from among 85 who underwent resection for thoracic esophageal cancer between April 1989 and December 1992. We divided them into 3 groups according to the indications of tracheostomy, group I: cases with postoperative pulmonary complications (n: 17), group II: cases of prophylaxis against pulmonary complications (n: 5) and group III: cases with dyspnea deriving from postoperative recurrent nerve palsy (n: 4). Tracheostomy was most often performed between 3 and 4 POD in group I, up to 1 POD in group II and from 5 POD to 7 POD in group III. Long-term respiratory support was needed in 13 cases in group I and 2 cases in group II. The rate of tracheostomy was higher in the case who had postoperative recurrent nerve palsy and received preoperative chemoradiotherapy. All cases excluding a case of MOF had a good clinical course after tracheostomy. We were able to clarify the significance of tracheostomy by dividing tracheostomy patients into 3 groups according to the indications for the procedure. It was concluded that tracheostomy is a very useful technique in the respiratory management of resected thoracic esophageal cancer patients.

Dyspnea↗

PubMed1981

Tracheostomy in neonates and small infants: problems and pitfalls.

Newborn babies and small infants who require tracheostomy often follow a complicated clinical course characterized by frequent sepsis, altered ventilatory dynamics, and eventual respiratory decompensation. Many of these problems are avoidable with use of a properly placed endotracheal tube during tracheostomy, a special surgical technique in the performance of the tracheostomy, and silicone rubber tracheostomy tubes. Seventy-four babies underwent tracheostomy at our Children's Center between 1963 and 1976. A review of this experience demonstrates the benefits of unhurried, standardized technique and management. In the 48 newborns requiring tracheostomy, no technical difficulties were encountered, and no complications occurred as a result of the tracheostomy. In the group of 26 older infants, however, there were significant complications, especially in children undergoing emergency tracheostomy without a previously placed endotracheal tube. Although there were no deaths directly related to tracheostomy, one case of pirulent tracheitis and one case of interstitial thyroid hemorrhage were noted at autopsy. Among survivors, there was one case of bilateral pneumothoraces, two cases of severe subcutaneous emphysema, and three cases of postoperative bleeding. Review of the long-term complications in this series demonstrates the benefits of the silicone rubber polymer tube. Since its routine use, problems with stomal granulation have almost disappeared. There have been no problems in extubating the very young babies. Our operative technique and intensive care management of these babies will be emphasized as the keys to the improved outcome.

Airway Obstruction↗

PubMed2003

Tracheostomy in preterm infants: current trends.

OBJECTIVE: To study the indications for and outcomes of tracheostomy in a population of preterm infants. DESIGN: Retrospective analysis of case records. SETTING: Two university-affiliated tertiary care children's hospitals. Patients We identified premature infants who required tracheostomies from January 1, 1997, through January 31, 2001. Information on weight, gestational age, comorbid conditions, indication for tracheostomy, and outcomes was collected. Infants were divided by birth weight into group 1 (<1000 g; n = 19 [very low birth weight]) and group 2 (> or =1000 g; n = 14). Comorbid conditions were scored and a total score was calculated for each patient. RESULTS: Group 1 had a higher incidence of patent ductus arteriosus, bronchopulmonary dysplasia, intraventricular hemorrhage, and retinopathy of prematurity. The incidence of congenital or genetic defects was equal in groups 1 and 2 (11 infants [58%] and 8 infants [57%], respectively). Group 1 had a higher average number of failed extubations (5.17 vs 3.18) and a higher oxygen requirement (48.7% vs 30.3%) compared with group 2. Weight at tracheostomy was essentially equal in groups 1 and 2 (3.6 vs 3.7 kg). Subglottic stenosis and laryngotracheomalacia were equally common findings in groups 1 and 2. The average comorbidity score for group 1 was higher than that for group 2 (6.7 vs 2.8). The most common indication for tracheostomy was ventilatory dependence (n = 24 [73%]), compared with airway obstruction (n = 6 [18%]) and pulmonary toilet (n = 3 [9%]). Overall, 6 patients (18%) had a complication related to the tracheostomy. CONCLUSIONS: Severity of pulmonary disease was the most significant factor associated with the need for tracheostomy in preterm infants. A tracheostomy can safely be performed in these infants with minimal morbidity.

Birth Weight↗

PubMedDate not supplied

Effect of the Passy-Muir Valve on aspiration in patients with tracheostomy.

OBJECTIVE: To assess potential benefit of a Passy-Muir Speaking Valve (PMV) in decreasing aspiration in patients with a tracheostomy. BACKGROUND: Many patients with tracheostomy exhibit clinically significant aspiration. It has been previously noted that aspiration can often be reduced or eliminated by plugging or removing the tracheostomy tube. Some patients, however, do not tolerate removal or plugging of their tracheostomy tube, which then leads to persistent aspiration. We postulated that a one-way speaking valve may restore more normal subglottic and glottic air flow and reduce aspiration. METHODS: Alert patients with a tracheostomy and clinical evidence of aspiration were eligible for study. Eleven patients with tracheostomy and known aspiration were studied with a modified barium swallow. Radiographic examination was used to evaluate the presence and amount of aspiration while patients swallowed both with and without a PMV in place on their tracheostomy tube. RESULTS: Aspiration was reduced (or eliminated) during swallowing in all 11 patients when they wore a PMV, when compared to swallowing with an open (unvalved) tube. This improvement was achieved with liquids, semisolids, and pureed consistencies. CONCLUSION: This study demonstrates that a Passy-Muir speaking valve facilitated swallow and reduced aspiration in patients with a tracheostomy and known aspiration.

Adult↗