Tracheostomy

PURPOSE: To develop a method of differential diagnosis to drowning, due to analysis of the alveolar macrophages quantitative, in rats submitted to induced drowning in fresh water and salty water. METHODS: Were used 15 male adult rats Wistar EPM-1, weight 360g (SD=21,3), randomized in three groups: G1- Control; G2- Fresh water; G3- Salty water, each one with n=5. The animals have been anesthetized and tracheostomized to insert a cannula inside the trachea, for drowning induction. The lungs have been removed, weighed, prepared for histology and colored by immunohistochemistry. The macrophages have been counted in both lungs (right and left) of each animal. The statistical test used was ANOVA (SPSS.10) with p<0,05. RESULTS: The amount of macrophages was G3>G2>G1 with p=0,0001 in each comparison. The weight of lungs of G3 and G2 was higher than G1, with p>0,0001, however G3 and G2 do not possess difference statistics in the weight of lungs. CONCLUSION: The developed diagnost...

Supraglottic stenosis/collapse is an uncommon condition. It can be difficult to detect and may be a cause of failed decannulation following tracheostomy. We present a novel technique to correct supraglottic stenosis/collapse. We performed a retrospective analysis of the records of patients in whom attempts at decannulation had failed at our center between 2003 and 2007. A subgroup with supraglottic stenosis/collapse with posterior displacement of the base of the epiglottis was identified. Our epiglottic repositioning procedure was performed in these patients. Through an external incision, the epiglottis was divided above the anterior commissure and attached to the superior border of the thyroid cartilage. Eight decannulation failures out of 36 attempted decannulations were identified. Three of these 8 cases involved supraglottic stenosis/collapse due to posterior displacement of the base of the epiglottis. Correction of the supraglottic stenosis/collapse led to successful decannulat...

A plan to progress a tracheostomy toward decannulation should be initiated unless the tracheostomy has been placed for irreversible conditions. In most cases, tracheostomy progression can begin once a patient is free from ventilator dependence. Progression often begins with cuff deflation, which frequently results in the patient’s ability to phonate. A systematic approach to tracheostomy progression involves assessing (1) hemodynamic stability, (2) whether the patient has been free from ventilator support for at least 24 hours, (3) swallowing, cough strength, and aspiration risk, (4) management of secretions, and (5) toleration of cuff deflation, followed by (6) changing to a cuffless tube, (7) capping trials, (8) functional decannulation trials, (9) measuring cough strength, and (10) decannulation. Critical care nurses can facilitate the process and avoid unnecessary delays and complications.

Our objective was to characterize sleep-disordered breathing in 88 children with achondroplasia aged 1 month to 12.6 years. At the time of their initial polysomnography, five children had previously undergone tracheostomy, and seven children required supplemental oxygen. Initial polysomnography demonstrated a median obstructive apnea index of 0 (range, 0 to 19.2 apneas/hr). The median number of central apneas with desaturation per study was 0.5 (0 to 49), the median oxygen saturation nadir was 91% (50% to 99%), and the median peak end-tidal pCO2 was 47 mm Hg (36 to 87 mm Hg). Forty-two children (47.7%) had abnormal initial study results, usually caused by hypoxemia. Two children with severe obstructive sleep apnea eventually required continuous positive airway pressure therapy, and three additional children required tracheostomies. (1) Children with achondroplasia often have sleep-related respiratory disturbances, primarily hypoxemia. (2) The majority do not have significant obstructive or central apnea; however, a substantial minority are severely affected. (3) Tonsillectomy and adenoidectomy decreases the degree of upper airway obstruction in most but not all children with achondroplasia and obstructive sleep apnea. (4) Restrictive lung disease can present at a young age in children with achondroplasia.

Tracheotomy is a common procedure in intensive care units, and nurses must provide proper care to tracheostomy patients to prevent complications. One of the most important considerations is effective mobilization of secretions, and a suction catheter is the most important tool for that purpose. Each bedside should be equipped with a functional suctioning system, an oxygen source, a manual resuscitation bag, and a complete tracheostomy kit, which should accompany patients wherever they go in the hospital. Complications include infection, tracheomalacia, skin breakdown, and tracheoesophageal fistula. Tracheostomy emergencies include hemorrhage, tube dislodgement and loss of airway, and tube obstruction; such emergencies are managed more effectively when all necessary supplies are readily available at the bedside. This article describes how to provide proper care in the intensive care unit, strategies for preventing complications, and management of tracheostomy emergencies.

Little is known about the school experience of children with tracheostomy tubes. These children may represent a population that qualifies for special services in school. Understanding how tracheostomy affects school-aged children may provide information needed to develop programs that provide these children with invaluable experiences. To understand what children with tracheostomies experience in school as it relates to tracheostomy care and how their condition affects academic achievement and social adjustment. We identified a cohort of 38 eligible school-aged children with indwelling tracheostomy tubes for ongoing upper airway obstruction through the North Carolina Children's Airway Center. A questionnaire was developed to assess support of their medical condition throughout the school day. Twenty-three patients responded to the questionnaire. School experience for a child with a tracheostomy varied. Approximately half the children attended special needs classes, the other hal...

For most mechanically ventilated patients, weaning can be accomplished quickly and easily. However, there is a smaller group of ventilated patients who fail to wean and remain ventilator-dependent. These patients account for a significant amount of health care costs and pose a great challenge for clinicians. Detailed knowledge of the etiology and pathophysiology of weaning failure is very important for the “treatment” of difficult to wean patients, and is thoroughly presented in this article. Based on this physiological background, strategies and techniques are proposed that are useful for the gradual transition to spontaneous ventilation.

Weaning from mechanical ventilation represents one of the main challenges facing ICU physicians. Difficult weaning affects about 25% of critical patients undergoing mechanical ventilation. Its duration correlates on one hand with pathophysiological aspects of the underlying disease and, on the other hand, with other factors such as the development of neuromyopathy of the critically ill patient, prolonged use of sedative-hypnotic drugs and, most of all, physicians' reluctance to identify the correct timing of therapeutic steps for weaning and subsequent extubation. The goal of adopting weaning protocols is to overcome problems due to an exclusively clinical opinion. Protocols have to be used together with daily clinical evaluation of the patient and the procedure must be carried out by an ICU team of both medical and nursing staff. Attempts to wean a patient from a ventilator and extubate him should be made through a spontaneous breathing trial (SBT) with T-tube or pressure suppo...

Tracheostomy with invasive ventilation (TIV) may be required for the survival of patients at advanced stages of amyotrophic lateral sclerosis (ALS). In Japan it has been shown that a proactive approach toward TIV may prolong the survival of ALS patients by over 10 years by preventing the lethal respiratory failure that generally occurs within 3-5 years of the onset of the disease. Measures to prolong life expectancy without foregoing quality of life have produced better results in Japan than in other developed countries. This ‘Japanese bias’ has been attributed to socio-cultural and religious factors as well as to the availability of material resources in Japan. In this article, we use the concepts of onozukara in kadō (Japanese traditional flower art, also called ikebana ) and amae (passive love) to illuminate features of patient care that may contribute to this ‘Japanese bias’.

This study investigated whether air leaks from the upper airway during assisted ventilatory support are associated with persistent hypercapnia (PaCO(2) >45 mmHg) in patients with neuromuscular disorders. A rehabilitation hospital. The study was performed in 95 neuromuscular patients; 52 were tracheostomized with a cuffless tracheostomy tube (invasive ventilation), and 43 received noninvasive ventilation. The volume of air leaked (VL) and arterial carbon dioxide (PaCO(2)) were routinely measured during mechanical ventilation; PaCO(2) was also measured during spontaneous breathing. VL, expressed as a percentage of tidal volume, was higher in the hypercapnic group (32+/-14%, n=20) than the nonhypercapnic group ( vs. 20+/-14%). PaCO(2) during mechanical ventilation was correlated with both VL and the duration of ventilatory support per day; PaCO(2) during spontaneous breathing was correlated only with the volume of air leaked. In stepwise multiple regression analysis, air leaks contr...

The objectives were to compare the duration of use of polymeric tracheostomy tubes, i.e., silicone (Si), polyvinyl chloride (PVC), and polyurethane (PU), and to determine whether surface changes in the materials could be observed after 30 days of patient use. Data were collected from patient and technical records for all tracheostomized patients attending the National Respiratory Center in Sweden. In the surface study, 19 patients with long-term tracheostomy were included: six with Bivona TTS Si tubes, eight with Shiley PVC tubes, and five with Trachoe Twist PU tubes. All tubes were exposed in the trachea for 30 days before being analyzed by scanning electron microscopy (SEM) and attenuated total reflectance Fourier transform infrared spectroscopy (ATR-FTIR). New tubes and tubes exposed in phosphate-buffered saline were used as reference. Si tubes are used for longer periods of time than those made of PVC (P<.0001) and PU (P=.021). In general, all polymeric tubes were used longer than the recommended 30-day period. Eighteen of the 19 tubes exposed in patients demonstrated, in one or more areas of the tube, evident surface changes. The morphologic changes identified by SEM correlate well with the results obtained by ATR-FTIR. Si tracheostomy tubes are in general used longer than those made of PVC and PU. Most of the tubes exposed in the trachea for 30 days suffered evident surface changes, with degradation of the polymeric chains as a result.

Aim.  Implement and evaluate an inter-disciplinary team approach to tracheostomy management in non-critical care.Background.  Trends towards early tracheostomy in intensive care units (ICU) have led to increased numbers of tracheostomy patients. Together with the push for earlier discharge from ICU, this poses challenges across disciplines and wards. Even though tracheostomy is performed across a range of patient groups, tracheostomy care is seen as the domain of specialist clinicians in critical care. It is crucial to ensure quality care regardless of the patient’s destination after ICU.Design.  A mixed method evaluation incorporating quantitative and qualitative approaches.Method.  Data collection included pre-implementation and postimplementation clinical audits and staff surveys and a postimplementation tracheostomy team focus group. Descriptive and inferential analysis was used to identify changes in clinical indicators and staff experiences. Focus group data were analysed using iterative processes of thematic analysis.Results.  Findings revealed significant reductions in mean hospital length of stay (LOS) for survivors from 50–27 days (p < 0·0001) and an increase in the number of tracheostomy patients transferred to non-critical care wards in the postgroup (p = 0·006). The number of wards accepting patients from ICU increased from 3–7 and there was increased staff knowledge, confidence and awareness of the team’s role.Conclusion.  The team approach has led to work practice and patient outcome improvements. Organisational acceptance of the team has led to more wards indicating willingness to accept tracheostomy patients. Improved communication has resulted in more timely referral and better patient outcomes.Relevance to clinical practice.  This study highlights the importance of inter-disciplinary teamwork in achieving effective patient outcomes and efficiencies. It offers a model of inter-disciplinary practice, supported by communication and data management that can be replicated across other patient groups.