Use of the pro-seal laryngeal mask airway facilitates percutaneous dilatational tracheostomy in an intensive care unit

Purpose:

To study the feasibility of using the pro-seal laryngeal mask airway (LMA) for airway maintenance during bronchoscopic-guided percutaneous tracheostomy.

Materials and Methods:

Observational study of 60 patients in a 16-bed intensive care unit. The patient’s tracheal tube was exchanged for a pro-seal LMA before undertaking percutaneous tracheostomy.

Results:

Inspiratory pressure and tidal volumes achieved during the procedure were recorded. The median peak inspiratory pressure was 25 (standard deviation 4.4) cm H2O. There was no loss of tidal volume in 30 patients, a loss of less than 100 mL/breath in 27, and loss of more than 100 mL in 3 patients. A pro-seal LMA successfully maintained the airway and allowed adequate ventilation during per-cutaneous tracheostomy in all 60 patients. In all patients, fiber optic bronchoscopy through the pro-seal LMA provided a clear view of the cords and trachea and there was no laryngeal or tracheal soiling at any stage of the procedure.

Conclusion:

The pro-seal LMA provides a reliable airway and allows effective ventilation during percutaneous tracheostomy. The passage of a fiberscope through the pro-seal LMA and glottis is easy and provides a clear view of the upper trachea.     

Safety and Feasibility of Percutaneous Tracheostomy Performed by Neurointensivists

Introduction  We evaluated the effects of a change from routine surgical tracheostomy (ST), performed primarily by ENT surgeons, to bedside percutaneous tracheostomy (PT) performed by neurointensivists. Methods  The first 67 PT procedures performed by neurointensivists were retrospectively reviewed, and compared with 68 consecutive ST procedures performed during the previous year. Demographics, severity of illness, procedural complications, incidence of ventilator-associated pneumonia (VAP), duration of mechanical ventilation (DMV), length of stay (LOS), and hospital charges were evaluated. Results  Age, race, gender, neurological diagnoses, comorbid illnesses, and Glasgow coma scale on admission and the day of tracheostomy were similar. Procedural complications occurred in 8% of PT patients and 9% of ST patients, including clinically significant bleeding, transient loss of the airway, ICP rise requiring treatment, or acute lung injury (P = 0.3). PT was performed earlier than ST (median [interquartile range] ventilator day 8 [4–11] vs. 12 [8–18], P = 0.001). Median DMV was shorter in the PT cohort (19 [10–27] vs. 24 [16–33] days, P = 0.02), as was median ICU LOS (15 [9–21] vs. 19 [12–27] days, P = 0.01). ICU charges (US dollars) were lower in the PT cohort (median $123,404 vs. $156,311, P = 0.01). Trends toward less VAP, shorter hospital LOS, and lower total hospital charges among patients receiving PT did not achieve significance. Conclusions  PT performed by neurointensivists was safe compared to ST. Timely PT by neurointensivists may offer significant advantages in terms of ventilator weaning, ICU LOS, and the cost of care.     

纤维支气管镜下经皮扩张气管切开术在口腔颌面外科的应用

目的:探讨纤维支气管镜引导下经皮扩张气管切开术在口腔颌面外科的应用价值。方法:选择因手术需要行预防性气管切开的口腔颌面外科患者60例,随机分为3组(n=20):经典手术气管切开组(A组)、经皮扩张气管切开组(B组)、纤维支气管镜引导下经皮扩张气管切开组(C组)。观察并记录3组的气管切开操作时间、出血量、一次性置管成功率、血氧饱和度(SpO2)变化和并发症的差异。采用SPSS 17.0软件包对数据进行统计学分析。结果:与经典手术A组相比,B组和C组在气管切开中的操作时间显著缩短,出血量和并发症减少,一次性置管成功率显著提高(P<0.05)。与B组相比,C组在操作时间上显著减少,一次性置管成功率显著提高(P<0.05)。结论:纤维支气管镜引导下经皮扩张气管切开术安全有效,在口腔颌面外科手术中有较高的应用价值。     

Fatal inhalation injury caused by airway fire during tracheostomy

A 45-year-old man needed emergency tracheostomy and cranioplasty. He was intubated with a cuffed oral polyvinylchloride endotracheal tube and ventilated with 100% oxygen before tracheal incision. During opening of the trachea using diathermy, a popping sound was heard and flames originating from the tracheal incision were observed. The endotracheal tube was charred and its lumen had melted. Immediately after the incident, bronchofibroscopic examination revealed inhalation injury. After remaining for 8 weeks in hospital, the patient was transferred to a health care centre, where he was found dead in his bed.     

Repeat percutaneous dilatational tracheostomy in an awake and unintubated patient

Bedside percutaneous dilatational tracheostomy (PDT) has become an accepted method for securing airways in patients requiring prolonged ventilatory support. Repeat PDT in patients who have had a tracheostomy earlier is considered a relative contraindication as a result of distorted anatomy. Three case series have been reported supporting the safety of repeat bedside PDT in experienced hands, but there is no previously published data regarding repeat PDT in awake and unintubated patients. We report a case in which a repeat PDT was done on an awake 20-year-old female patient with cerebral palsy and kyphoscoliosis admitted owing to pneumonia and respiratory failure. This facilitated tracheal toilet in this patient without resorting to general anaesthesia and mechanical ventilation. In conclusion, both repeat PDT and awake PDT, both separately or together, can be very useful in the management of critical care and pre-critical care patients and merit wider use.     

The use of cognitive task analysis to improve the learning of percutaneous tracheostomy placement

OBJECTIVE: The purpose of the current study was to determine the effectiveness of using cognitive task analysis (CTA) to develop a curriculum to teach the behavioral skills and the cognitive strategies of a percutaneous tracheostomy (PT) placement. METHODS: Postgraduate 2, 3, and 4 general surgery residents were randomly assigned to either the CTA group (N = 9) or the control group (N = 11). The CTA group was taught percutaneous tracheostomy placement using the CTA curriculum. The control group received the traditional curriculum. RESULTS: The CTA group performed significantly higher on the PT procedure at 1 month (CTA: 43.5 +/- 3.7, control 35.2 +/- 3.9, P = .001) and at 6 months post-instruction (CTA: 39.4 +/- 4.2, control: 31.8 +/- 5.8, P = .004). In addition, the CTA group demonstrated superior cognitive strategies than the control group (CTA: 25.4 +/- 5.3, control: 19.2 +/- 2.0, P = .004). CONCLUSIONS: The use of CTA was effective in improving the cognitive processes and technical skills of performing a PT for surgical residents.     

Frequency of nocturnal sudden death in patients with multiple system atrophy

Sudden death has been reported in patients with multiple system atrophy (MSA), although the frequency of this event has not been well delineated. We investigated the frequency and potential causes of sudden death in patients with MSA. During the 5-year observation period, 10 of 45 patients with probable MSA died. The causes of death included sudden death of unknown etiology (seven patients), aspiration pneumonia (one patient), asphyxia after vomiting (one patient), and lung cancer (one patient). The mean survival time of patients with sudden death was 63.0 ± 24.7 months (range, 39–116 months). Among seven patients who experienced sudden death, six were found to have died during sleep. Among these patients, two had been treated with tracheostomy and three with continuous positive airway pressure (CPAP) or noninvasive positive pressure ventilation (NPPV) during sleep, suggesting that these treatments do not always prevent sudden death in patients with MSA. Nocturnal sudden death should be recognized as the most common mechanism of death in patients with MSA.     

Survival of a child without sequelae after tracheoarterial fistula

Tracheoarterial fistula (TAF) involves erosion through the tracheal wall into the innominate artery resulting in bleeding. It is a rare but lethal complication of tracheostomy. Mortality is 100% without operative interference. Even with appropriate management, a survival rate of only 14.3% has been reported. We report a case of TAF in a child, where rapid institution of resuscitative and operative measures resulted in survival. Initial temporary control of bleeding was achieved by hyperinflation of cuff. Computed tomography (CT) angiography confirmed the diagnosis. The damaged segment of the eroded artery was resected and ligated. This case highlights the role of early diagnosis and prompt aggressive therapy for management of this potentially lethal complication.     

Palliative care approaches to neonates with chronic respiratory failure

Neonates with chronic respiratory failure have uncertain prognosis and can face significant treatment burden. As the trajectory of the illness becomes more concerning, consultation with a pediatric palliative service should be considered, especially as therapeutic options shift from standard to “innovative.” Benefits include as follows: supporting emotionally conflicted providers and parents, maintaining transparency in determination of goals, and balancing medical progress with each individual patient’s and family’s best interests.     

Prediction of prolonged mechanical ventilation in patients in the intensive care unit A cohort study

Introduction:

There are no established guidelines for selecting patients for early tracheostomy. The aim was to determine the factors that could predict the possibility of intubation longer than 7 days in critically ill adult patients.

Methods:

This is cohort study made at a general intensive care unit. Patients who required at least 48 hours of mechanical ventilation were included. Data on the clinical and physiologic features were collected for every intubated patient on the third day. Uni- and multivariate statistical analyses were conducted to determine the variables associated with extubation.

Results:

163 (62%) were male, and the median age was 59±17 years. Almost one-third (36%) of patients required mechanical ventilation longer than 7 days. The variables strongly associated with prolonged mechanical ventilation were: age (HR 0.97 (95% CI 0.96-0.99); diagnosis of surgical emergency in a patient with a medical condition (HR 3.68 (95% CI 1.62-8.35), diagnosis of surgical condition-non emergency (HR 8.17 (95% CI 2.12-31.3); diagnosis of non-surgical-medical condition (HR 5.26 (95% CI 1.85-14.9); APACHE II (HR 0.91 (95% CI 0.85-0.97) and SAPS II score (HR 1.04 (95% CI 1.00-1.09) The area under ROC curve used for prediction was 0.52. 16% of patients were extubated after day 8 of intubation.

Conclusions:

It was not possible to predict early extubation in critically ill adult patients with invasive mechanical ventilation with common clinical scales used at the ICU. However, the probability of successfully weaning patients from mechanical ventilation without a tracheostomy is low after the eighth day of intubation.