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PubMed1990

Tracheotomy in the first year of life.

Much has been written concerning complications of pediatric tracheotomies, but few studies have reviewed the complication rates of tracheotomies performed in the first 12 months of life. We reviewed the records of 60 patients who underwent tracheotomy in the first year of life between 1976 and 1988. This study includes 30 full-term infants and 30 premature infants, 16 of whom were very low birth weight preterm infants (less than or equal to 32 weeks' gestation and less than 1,500 g birth weight). Overall complication rates were 3% intraoperative, 13% early postoperative, and 38% late postoperative. The early postoperative complication rate in preterm infants was nearly double that of full-term infants. The late postoperative complication rate of patients undergoing tracheotomy for airway obstruction was more than double that of patients requiring tracheotomy for pulmonary indications. Duration of tracheotomy, however, was felt to be the most important factor in the development of a late postoperative complication.

Emergencies↗
PubMed2002

Effects of tracheotomy on respiratory mechanics in spontaneously breathing patients.

Tracheotomy is a method of intubating the trachea, which is employed in several clinical settings, including the treatment of head and neck neoplasms. Tracheotomy is believed to facilitate weaning through changes in respiratory mechanics. Existing information concerning functional changes associated with tracheotomy are limited to comparisons with orotracheal intubation. In this study, respiratory mechanics were monitored in seven spontaneously breathing patients, before and after an elective tracheotomy was performed for surgical treatment of cancer. Campbell diagrams were constructed by plotting pressure, obtained with an oesophageal balloon catheter, against volume, obtained from a pneumotachograph placed at the airway opening. Work of breathing was calculated as the internal area of the Campbell diagram and was partitioned into its elastic and inspiratory and expiratory resistive components. Oesophageal pressure was also used to quantify intrinsic positive end-expiratory pressure (PEEPi) and the pressure-time product (PTP), which is considered to be proportional to the oxygen cost of breathing. PTP was divided into its resistive and elastic components. Inspiratory resistive work, PEEPi, inspiratory PTP, as well as its resistive and elastic components were significantly reduced by tracheotomy. Tracheotomy significantly reduces work of breathing and pressure-time product in spontaneously breathing patients.

Aged↗
PubMed2004

Oximetry and indications for tracheotomy for amyotrophic lateral sclerosis.

STUDY OBJECTIVE: To explore the use of oximetry as a guide for using respiratory aids and tracheotomy in the treatment of patients with amyotrophic lateral sclerosis (ALS). SETTING: A retrospective review of all ALS patients presenting to a neuromuscular disease clinic since 1996. METHODS: Patients who were symptomatic for nocturnal hypoventilation were prescribed noninvasive ventilation (NIV). Patients with assisted cough peak flows of < 300 L/min were prescribed oximeters and access to mechanically assisted coughing (MAC) to prevent or reverse decreases in baseline pulse oximetric saturation (Spo(2)) levels of < 95%. The number of decreases in baseline Spo(2) that could be normalized by any combination of NIV and MAC and the duration of normalization were recorded. When the baseline was not or could not be normalized, the time to acute respiratory failure and tracheotomy or death were recorded. RESULTS: Twenty-five patients became dependent on NIV, including 13 patients who received NIV continuously for a mean (+/- SD) period of 19.7 +/- 16.9 months, without desaturation (group 1). For another 76 patients, the daytime baseline Spo(2) level decreased to < 95% 78 times. For 41 patients, the baseline level was corrected by NIV/MAC (group 2) for a mean duration of 11.1 +/- 8.7 months before desaturation reoccurred for 27 patients. Of the latter patients, 11 underwent tracheotomy, 14 died in < 2 months, and 2 had their condition again corrected by the addition of MAC therapy. For 35 patients, the desaturation was not or could not be normalized (group 3). Thirty-three of these 35 patients required tracheotomy or died within 2 months. The only significant difference between groups 1 and 2 and group 3 was significantly poorer glottic function in the patients in group 3. CONCLUSION: Tracheotomy or death is highly likely within 2 months of a decrease in baseline Spo(2) that cannot be corrected by NIV or MAC. The long-term use of NIV and MAC, and the avoidance of tracheotomy is dependent on glottic function rather than on inspiratory or expiratory muscle failure.

Adult↗
PubMed2000

[The timing of tracheotomy. Advantages of early timing].

Tracheotomy is widely performed in Intensive Care Units, but no general agreement exists about its correct timing in ventilated patients. Many articles examine the complications of long-term endotracheal intubation and tracheotomy; few data, however, relate these damages and ventilated patients outcome to tracheotomy timing. No universally accepted guidelines exist, but last years clinical practice prefer early tracheotomy, particularly if performed by percutaneous approach. Many authors suggest prospective and randomized clinical trials in order to evaluate tracheotomy performance correct time. At this time decision making must consider risks and benefits related to patient clinical conditions: at this regard some reports seem to advantage early tracheotomy.

Critical Care↗
PubMed2001

Overcoming the top 10 tracheotomy self-care learning barriers.

Multispecialty inpatient units are the norm in today's acute care settings. Since few units have the luxury of seasoned otorhinolaryngology (ORL) nurses, care of the postoperative patient with a tracheotomy, including discharge teaching and planning are left to the generalists. Generalist nurses and new ORL nurses may find themselves experiencing fear and anxiety along with the tracheotomy patients they care for and teach. Experienced ORL nurses are continually challenged to find ways to share their expertise with patients and less experienced nurses in effective ways. This article presents a unique approach to preparing nurses to teach self-tracheotomy care to their patients. Medical-surgical staff nurses attended a 90-minute inservice program presenting actual clinical scenarios of temporarily learning-impaired patients with tracheotomies, and were asked to role play effective interventions. The program content is designed to address the reluctance of inexperienced, busy nurses to confront learning barriers and motivate patients to accomplish early postoperative involvement in tracheotomy self care. The widespread nature of the challenges faced by nurses and patients regarding tracheotomy care has been confirmed by discussions with colleagues on a national level. It has been confirmed further by the first author's clinical experiences in a wide variety of health care settings. Recommended nursing actions and responses to learning barriers presented here are based on expert opinion and clinical experience.

Activities of Daily Living↗
PubMed2005

[Clinical significance of preoperative tracheotomy in preventing perioperative OSAHS severe complications].

OBJECTIVE: Studying the value of preoperative tracheotomy in preventing obstructive sleep apnea-hypopnea syndrome (OSAHS) severe complications in preoperative and postoperative period of UPPP/PPP and the its significance in ensuring the safety of surgical operation. METHOD: One hundred and four OSAHS severe cases were retrospective analysed from July 1998 to July 2003, and these cases were divided into tracheotomy group and non-tracheotomy group. Preoperative and postoperative complications of these cases were studied. RESULT: The incidence of complications especially severe complications endangering life in tracheotomy group was lower significantly than in non-tracheotomy group. CONCLUSION: It is very necessary to do tracheotomy preoperatively so as to preventing severe complications of OSAHS and ensuring the safety of surgical operation.

Adult↗
PubMed1991

Indications for and techniques of tracheotomy.

Although the operation has been practiced for centuries, the modern technique of tracheotomy was introduced and popularized in the beginning of the 20th century. The initial indication for tracheotomy was limited to impending airway obstruction resulting from trauma, but current indications are broader. Tracheotomy is one of four methods available to intubate the trachea and is associated with physiologic changes that are dependent on the duration of tracheotomy. Although surgical in nature, it is employed to relieve or prevent airway obstruction and to offer ventilatory support. Tracheotomy may be performed as an elective or an emergency procedure. Ideally, it is done in a controlled situation. However, when performed in an emergency setting, variations of the procedure, such as minitracheotomy or cricothyroidotomy, may be temporarily substituted. Preferably, tracheotomy is performed in an operating room; however, it may be carried out successfully in an intensive care unit as well.

Airway Obstruction↗
PubMed1999

The impact of preoperative tracheotomy on T3 transglottic carcinomas of the larynx.

To evaluate the impact of the practice of a preoperative tracheotomy and different prognostic factors reported in the literature in patients with transglottic carcinoma of the larynx, a retrospective study was performed in the Instituto Nacional de Cancerologia, Mexico City. In all, 90 cases with T3 transglottic squamous cell carcinoma requiring a total laryngectomy as primary treatment were studied. Prognostic factors such as the Karnofsky index, tumor differentiation, surgical margins and preoperative tracheotomy were analyzed by a Cox's proportional hazards model. The Kaplan-Meier method and log rank test were used to evaluate the disease-free intervals and survival curves. Thirty-two patients had preoperative tracheotomies, while 58 did not. Eighty percent of the patients in the non-preoperative tracheotomy group were alive after 5 years versus 20% of those with preoperative tracheotomies (P < 0.001). Although possibly controversial, our findings indicate that a pretreatment tracheotomy should be avoided in T3 transglottic obstructive lesions. In patients with these lesions and a subglottic extension < or = 3 cm we recommend an emergency total laryngectomy when possible to increase survival and decrease surgical morbidity.

Adult↗
PubMed1998

Starplasty: a new technique of pediatric tracheotomy.

OBJECTIVE: To report a new technique of pediatric tracheotomy that reduces the problems of pneumothorax and recannulation after accidental decannulation in a recently performed tracheotomy. DESIGN: Retrospective chart review for 1990-1997. PATIENTS: Sixty-eight children aged between 2 days and 14 years. METHOD: The starplasty procedure is based on the geometry of a 3-dimensional Z-plasty. The technique of the procedure is described and illustrated in detail. RESULTS: There were 27 short-term complications, including 4 accidental decannulations. There were no instances of pneumothorax or tracheotomy-related deaths. There were 25 long-term minor complications. There were no instances of tracheotomy-related death, suprastomal collapse, or tracheal stenosis. Thirty-eight children remain tracheotomy tube dependent, 17 underwent decannulation, 7 died of primary disease, and 6 were lost to follow-up. All 17 children who underwent decannulation have a persistent tracheocutaneous fistula. CONCLUSIONS: I conclude that starplasty reduces the incidence of major complications and death. Its only drawback seems to be persistent tracheocutaneous fistula.

Adolescent↗
PubMed2003

The impact of pediatric tracheotomy on parental caregiver burden and health status.

OBJECTIVE: To explore the effects of the placement of a pediatric tracheotomy tube on the degree of caregiver burden and overall health status of parents using general and disease-specific instruments. METHODS: Between January and July 2001, the Medical Outcomes Study Short Form 12 (SF-12) and the Pediatric Tracheotomy Health Status Instrument (PTHSI) were administered to 154 families of children requiring tracheotomy. Summary scores were generated for each of the 2 scales of the SF-12 (the Physical Component Score [PCS] and the Mental Component Score [MCS]) as well as for the 4 previously established domains of the PTHSI: domain 1, physical symptoms of the child (7 items); domain 2, medical visits and cost (7 items); domain 3, parental rating of the child's psychological health status (3 items); and domain 4, parental rating of their own caregiver burden (17 items). Correlations between responses from the individual domains and between domain 4 of the PTHSI (reflecting caregiver burden) and the SF-12 were performed. RESULTS: The mean +/- SD summary scores for the 4 domains of the PTHSI were domain 1, 22.7 +/- 5.3; domain 2, 24.9 +/- 6.2; domain 3, 10.5 +/- 4.4; and domain 4, 48.3 +/- 9.5 (lower scores reflect "poorer" health status). The mean +/- SD summary scores of PCS and MCS were 50.5 +/- 11.3 and 35.8 +/- 11.4, respectively. There existed a significant correlation between parental caregiver burden (as expressed by domain 4) and the child's physical health status (domain 1) (0.32; P<.001) as well as between parental caregiver burden and increasing economic costs associated with this care (0.27; P<.001). A strong correlation was found between the domain measuring parental caregiver burden (domain 4) and the MCS-12 (r = 0.43; P<.001), while a poor correlation existed with the PCS-12 (r = -0.17; P =.14). Nevertheless, in contrast to caregiver burden, the health status of the caregivers as measured by the SF-12 did not alter according to the severity of illness for the children (P =.17). CONCLUSIONS: Parents caring for children with tracheotomy tubes experience significant caregiver burden. These parents appear to experience increased burden with respect to the child's severity of illness and increased costs associated with caring for their children. Overall, the mental health status for an adult caring for a child with a tracheotomy tube is significantly reduced and appears to be more affected than physical health status.

Adult↗
PubMed1995

Early tracheotomy in neutropenic, mechanically ventilated patients: rationale and results of a pilot study.

Despite substantial advances in the management of such patients, the prognosis of ventilated neutropenic patients remains grim. The objective of our study was to evaluate the benefit of tracheotomy in this category of patients, in terms of mortality while they were in the intensive-care unit and nosocomial pneumonias. The charts of 53 consecutive, ventilated, neutropenic patients, or those destined to be imminently neutropenic, admitted to our intensive-care unit during a 4-year period, have been retrospectively reviewed. Tracheotomy was performed at the bedside or in the operating room: 20 patients underwent tracheotomy within 48 h of mechanical ventilation (ET group), while 33 were tracheotomized later or remained intubated (INT group). The two groups were comparable with regard to the underlying disease, respiratory failure, mechanical ventilation patterns and severity scores, but neutropenia was more profound in the ET group. Mortality while in the intensive-care unit was similar (ET: 70%; INT: 78.8%). However, the survival curves showed a trend towards longer survival in the ET group, even after adjustment for the degree of neutropenia (log-rank test: P = 0.07). The incidence of pneumonias was similar in both groups. No major complications of tracheotomy were reported. These findings suggest that a tracheotomy could be proposed for neutropenic patients requiring mechanical ventilation, in order to prolong their survival beyond the end of the neutropenic period. A prospective study is underway to confirm these preliminary results.

Adolescent↗
PubMed1998

Tracheotomy tube occlusion status and aspiration in early postsurgical head and neck cancer patients.

The purpose of the present study was to investigate tracheotomy tube occlusion status and prevalence of aspiration utilizing videofluoroscopy. A prospective study was done of 16 consecutive, early, postsurgical head and neck cancer patients with tracheotomy. Selection criteria included the ability to tolerate tracheotomy tube occlusion prior to and during the modified barium swallow procedure, oral and/or pharyngeal surgical resection, no history of neurological disease or stroke, and medical clearance to begin oral feeding. There was 100% agreement among the independent reviewers on ratings of the presence or absence of aspiration. It was found that occlusion status of the tracheotomy tube did not influence the prevalence of aspiration in the immediate postoperative period. No trends were observed when comparing bolus consistency, type of tracheotomy tube, or presence/absence of a nasogastric tube and the ratings of aspiration.

Adult↗
PubMed2005

Percutaneous tracheotomy in bone marrow transplant patients with severe thrombocytopenia.

OBJECTIVE: Evaluation of percutaneous tracheotomy in bone marrow transplant patients with severe thrombocytopenia. DESIGN: A retrospective outcome study. PATIENTS: A retrospective study of 26 percutaneous tracheotomies was performed at the Bone Marrow Transplant Unit, Rambam Medical Center, Haifa, Israel. Age, sex, underlying disease, reason for intubation, complete blood count, coagulation profile, and the incidence of renal failure were collected. All patients received 6 units of platelets one hour prior to the procedure. RESULTS: The mean platelets count was 14,300 +/- 5500. Twenty-five of the 26 percutaneous tracheotomies were completed successfully, without any intraoperative complications. One patient suffered from moderate bleeding during the procedure, which was immediately stopped and converted to open tracheotomy. In the postoperative period 4 patients suffered from mild bleeding around the stoma, which was managed conservatively. No other late complications were encountered. CONCLUSIONS: Percutaneous tracheotomy can be safely performed in patients with severe thrombocytopenia when the surgeon and anesthesiologist are experienced in the procedure, and platelets are given perioperatively.

Adult↗
PubMed1997

Congenital airway abnormalities requiring tracheotomy: a profile of 56 patients and their diagnoses over a 9 year period.

We reviewed the 9 year experience at the Children's Hospital of Philadelphia with patients requiring tracheotomy for a diagnosis of congenital airway abnormalities. Of the 56 patients, 28 (50%) had cardiovascular, or chromosomal abnormalities, neurologic conditions, or congenital syndromes, 24 (43%) were born prematurely, and 13 (23%) were found to have gastroesophageal reflux. Only 18 (32%) went on to eventual decannulation of their tracheotomy with a mean tracheotomy duration of 1.75 years. The majority of patients (75%) had multiple presenting signs. Stridor was the most common (54%), followed by accessory respiratory effort (39%), cyanosis (30%), apnea (29%), and failure to thrive (23%). Twenty eight patients (50%) had multiple airway abnormalities contributing to their need of a tracheotomy for airway protection orr ventilator dependence. Laryngeal abnormalities were found in 71% of patients, tracheal abnormalities in 48% of patients, bronchial abnormalities in 11%, and upper airway obstruction in 14%. Of the laryngeal abnormalities, laryngomalacia was the most common, followed by subglottic stenosis, glottic web, and vocal cord paralysis. Tracheomalacia was the most common tracheal abnormality. The relatively large percentage of patients with cardiovascular or other major malformations, and prematurity, accounts for comorbid factors in the need for prolonged tracheotomy (and low early decannulation rate). Although gastroesophageal reflux was found in a recognizable portion off the patients, it is unclear whether this represents a comorbid condition.

Abnormalities, Multiple↗
PubMed1995

Olfactory disturbance in pediatric tracheotomy.

Several studies have described hyposmia after laryngectomy. The most common mechanism invoked is a reduction in nasal airflow, leading to elevated olfactory detection thresholds. Children with nasal obstruction have been shown to also have elevated olfactory detection thresholds linked to reduced nasal airflow. A child with a tracheotomy is in some degree similar to a laryngectomee. These patients will have variable amounts of nasal airflow reduction proportional to the degree of suprastomal obstruction. Our concern was that this alteration in nasal airflow may cause hyposmia. Furthermore, if the olfactory system requires adequate early stimulation for normal development (as is the case with vision and hearing), tracheotomy would be suspected to cause persistent hyposmia even after decannulation. Thus decreased olfactory sensitivity, delayed olfactory experience, or both could interfere with a child's ability to recognize and identify odor stimuli. We studied children aged 4 to 16 years with upper airway obstruction requiring tracheotomy and compared their abilities to identify familiar odorants with those of a large group of normal control children. None of the children had intrinsic mucosal or olfactory pathology. Statistical analysis of the early data shows a significant reduction in olfactory identification scores in the patients with tracheotomies, both by Student's t test and by the Wilcoxon rank sum test. Analysis of covariance confirmed age as an independent prognostic variable for identification ability. We therefore conclude that tracheotomy can reduce a child's ability to identify familiar odorants.

Adolescent↗
PubMed2000

Chest radiographs after dilatational percutaneous tracheotomy: are they necessary?

BACKGROUND: The efficacy of routinely obtaining chest radiographs after standard open tracheotomy has been questioned. Recent literature would suggest that after a routine, uncomplicated tracheotomy, chest radiography is a low-yield procedure that incurs unnecessary expense. Percutaneous dilatational tracheotomy (PDT) is rapidly replacing open tracheotomy as the intensive care unit procedure of choice for airway management. Complication rates are equivalent between the two procedures. OBJECTIVE: We examined the value and cost-effectiveness of routine postoperative chest radiographs in patients undergoing PDT. STUDY DESIGN AND SETTING: The study was a prospective analysis of 54 consecutive PDTs performed at a tertiary care academic institution. RESULTS: Eighteen (33%) patients had chest radiographs obtained within 1 hour of PDT (6 at the request of the otolaryngology service); 35 (66%) underwent radiography more than 2 hours later at the request of the intensive care unit for reasons other than PDT. There were no incidents of pneumothorax, pneumomediastinum, or tracheotomy tube malposition in any patient. Patients undergoing chest radiography within 1 hour of the PDT also had chest radiographs within 12 hours at the request of ICU staff for their underlying disease. CONCLUSIONS: Routine chest radiography after PDT is of low yield. Because most of these patients require chest radiographs for their underlying disease within 12 hours, a cost savings of approximately $13,500 would be realized in this patient population. SIGNIFICANCE: Routine chest radiography after PDT is unwarranted in most cases.

Cost Savings↗
PubMed2001

Lack of utility of postoperative chest radiograph in pediatric tracheotomy.

OBJECTIVE: To assess the incidence of pulmonary complications after nonemergent pediatric tracheotomy and to determine whether obtaining a routine postoperative chest radiograph is warranted. STUDY DESIGN: Retrospective review of the records of 107 consecutive patients (age 1 month to 18 years) who underwent tracheotomy from October 1994 to June 2000. Main outcome measures included frequency of pulmonary complications and use of information obtained from postoperative chest radiograph for intervention. SETTING: Tertiary care university children's hospital. RESULTS: No pneumothoraces or significant pulmonary complications were detected in the immediate postoperative period. No management changes were undertaken as a result of information obtained from any chest radiograph in this period. CONCLUSIONS: The incidence of significant pulmonary complications after pediatric tracheotomy is low. Little information is obtained from chest radiograph after tracheotomy, and this information does not change management. SIGNIFICANCE: Routine postoperative chest radiograph after pediatric tracheotomy is not indicated in all patients.

Adolescent↗
PubMed2002

Tracheal stenosis after percutaneous dilational tracheotomy.

OBJECTIVE: In many critical care units percutaneous dilational tracheotomy (PDT) has become an alternative to open tracheotomy. Although significant tracheal stenosis after PDT has been reported, the exact incidence is unknown. We report our findings on endoscopic laryngotracheoscopy for a group of patients who had undergone PDT more than 6 months before their examination. STUDY DESIGN AND SETTING: We did a retrospective review of 108 trauma patients who underwent PDT at least 6 months before enrollment in the study. Twenty-eight patients were either deceased or ineligible. Participation requests were mailed to the last recorded address of 80 patients. Thirty-four of those patients were contacted by phone, and 14 indicated their willingness to participate. Only 10 patients were able to make it to the clinic for examination. After transorally anesthetizing the hypopharynx and larynx with 4% lidocaine, each patient underwent flexible laryngotracheoscopy. Findings were categorized as normal or tracheal stenosis (<25%, 25% to 50%, or >50%). RESULTS: The tracheotomy site was virtually undetectable in 5 patients. In 4 patients, a scar was visible at the tracheotomy site, but there was no decrease in cross-sectional area. In 1 patient there was a 25% to 50% stenosis. All patients were completely asymptomatic with regard to airway and voice quality. CONCLUSION: One out of 10 patients in our series had a significant but asymptomatic stenosis after PDT. The risk of tracheal stenosis in PDT appears to be the same as that of open tracheotomy.

Adult↗