Rationale for 'early' percutaneous dilatational tracheostomy in patients with burn injuries

Several investigators have cited the numerous complications that occur with conventional tracheostomies in patients with burn injuries. However, none of these studies included the technique of percutaneous dilatational tracheostomy, which has been shown to significantly decrease operative time, cost, perioperative, and long-term sequelae as compared to conventional tracheostomy. A retrospective analysis of 36 patients with burn injuries, from 1400 burn admissions, was conducted to compare conventional tracheostomy versus percutaneous dilatational tracheostomy. In this study, percutaneous dilatational tracheostomy resulted in significantly decreased operative times and cost compared to conventional tracheostomy. There were no major operative complications in either group, and alveolar-arterial oxygen gradients were improved in 71% of the patients with a tracheostomy. Percutaneous dilatational tracheostomy is an efficacious technique for airway management in patients with burn injuries. It can be safely performed at the bedside, at one fourth the cost of a conventional tracheostomy. Percutaneous dilatational tracheostomy may also benefit the patient with severe burns by decreasing alveolar-arterial oxygen gradients. Improved ventilatory mechanics might allow for a shorter duration of mechanical ventilation, thereby decreasing patient morbidity, hospital stay, and cost.     

Bedside tracheostomy in the intensive care unit

OBJECTIVE: To prove that tracheostomy performed at the bedside in the intensive care unit is a safe, cost-effective procedure. DESIGN: Retrospective review of all adult patients undergoing elective bedside tracheostomy in the intensive care unit between January 1983 and December 1988. Two hundred four patients were identified. SETTING: A private 1200-bed tertiary care center with a 120-bed critical care facility. MAIN OUTCOME MEASURES: Major and minor perioperative complications, cost savings, and comparison of risk between bedside tracheostomy and that performed in the operating room. RESULTS: There were six major complications (2.9%): one death due to tube obstruction, two bleeding episodes requiring reoperation, one tube entrapment requiring operative removal, one nonfatal respiratory arrest, and one bilateral pneumothorax; and seven minor complications (3.4%): five episodes of minor bleeding, one tube dislodgement in a tracheostomy with a well-developed tract, and one episode of mucus plugging. One late complication (tracheal stenosis) was identified. CONCLUSIONS: Bedside tracheostomy in the intensive care unit can be performed with morbidity and mortality rates comparable to operative tracheostomy. In addition, it provides a significant cost savings for the patient.     

Operating on placental support: the ex utero intrapartum treatment procedure

While treating eight fetuses with predictable airway obstruction, the authors developed a systematic approach, the ex utero intrapartum treatment procedure, to secure the airway during delivery. Six patients had their trachea plugged or clipped in utero for treatment of congenital diaphragmatic hernia, and two patients had prenatally diagnosed cystic hygroma of the neck and oropharynx. The ex utero intrapartum treatment procedure was performed by using high doses of inhaled halogenated agents to facilitate uterine relaxation during cesarean section, securing the fetal airway while feto-placental circulation remained intact, and then dividing the umbilical cord. A variety of procedures were performed during the ex utero intrapartum treatment procedure including bronchoscopy, orotracheal intubation, tracheostomy, tracheostomy with retrograde orotracheal intubation, tracheoplasty, removal of internal tracheal plug, removal of external tracheal clip, central line placement, and instillation of surfactant. There were minimal maternal or fetal complications during the procedure. This approach requires the coordinated efforts of pediatric surgeons, obstetricians, anesthesiologists, sonographers, and neonatologists. The combination of intensive maternal-fetal monitoring, cesarean section with maximal uterine relaxation, and maintenance of intact feto-placental circulation provides a controlled environment for securing the airway in babies with prenatally diagnosed airway obstruction.     

Early prediction of prolonged ventilator dependence in thermally injured patients

BACKGROUND: Recent studies suggest that when prolonged ventilator dependence (PVD) can be predicted in trauma or intensive care unit patients, early tracheostomy may reduce hospital stay and improve utilization of resources. This study was performed to develop criteria predictive of PVD (> 14 days) in burn patients. METHODS: We reviewed burn patients aged > or =16 years admitted between 1990 and 1994 who required ventilator support for > or =3 days. Using the variables full-thickness burn size, age, inhalation injury, and worst PaO2/FiO2 on ventilator day 3, an equation predicting PVD was created using logistic regression. The equation was tested by applying it to 1995 patients. RESULTS: When a probability of >0.5 was considered predictive of PVD, the equation correctly predicted PVD in 82% of 1990 to 1994 patients (n = 110) and 90% of 1995 patients (n = 29). CONCLUSION: PVD in burn patients can be predicted using objective variables in the early postburn period. Predictions can be used to select patients for prospective studies of early tracheostomy.     

Tracheostomy: acute and long-term mortality and morbidity in very low birth weight premature infants

Thirty-six very low birth weight premature infants (VLBW-PT) born at 24 to 32 weeks gestation and with birth weights 635 to 1,360 g who had tracheostomies performed for acquired subglottic stenosis or for prolonged mechanical ventilation were followed in relation to acute and long-term mortality and morbidity. Mortality due to the tracheostomy occurred in 4 patients (11%); mortality from all other causes was 25%. Death after hospital discharge was associated with the nonuse of prescribed cardiorespiratory monitors. Complications < 1 week postsurgery occurred in 31% of infants and complications > or = 1 week postsurgery occurred in 64% of infants. Fifty percent of infants required tracheostomy for > 2 years and/or extensive reconstructive surgery of the airway. Parents should be counselled that VLBW-PT infants with a tracheostomy may require extended medical and home care. An effective home care program requires parental training in tracheostomy care, the use of ancillary equipment, and infant cardiopulmonary resuscitation.     

Early tracheostomy tube change in children

OBJECTIVE: To review the safety of early tracheostomy tube change in children. DESIGN: Retrospective case series. SETTING: Pediatric tertiary care hospital. PATIENTS: Twenty-one consecutive pediatric patients undergoing routine tracheotomy. INTERVENTION: First tracheostomy tube change performed at patient's bedside at 3 (n = 15) or 4 (n = 5) days after surgery. OUTCOME MEASURE: The ability to safely change a tracheostomy tube at the patient's bedside 3 or 4 days after surgery. RESULTS: The first tracheostomy tube change was safely performed at 3 or 4 days after surgery in 20 patients. All changes were accomplished without complication or difficulty on the first attempt. The patients' ages ranged from 4 days to 16 years. The smallest child weighed 1.6 kg. Early tracheostomy tube change was not attempted in one obese 10-year-old girl whose pediatric tracheostomy tube became dislodged and formed a false tract 2 days after surgery. CONCLUSIONS: Most pediatric tracheostomy tubes can be safely changed at the patient's bedside approximately 3 days after surgery. Clinical applications of early tracheostomy tube change may include facilitating better hygiene, earlier completion of family caregiver tracheotomy education, and shorter hospital stays. It appears safe and advantageous for surgeons to consider early initial tracheostomy tube change for pediatric patients.     

Vocal cord laterofixation as early treatment for acute bilateral abductor paralysis after thyroid surgery

Bilateral vocal cord palsy due to a lesion of the recurrent laryngeal nerves is a serious complication of thyroid operations, with the airway obstruction usually necessitating tracheostomy. In the cases presented, a stable airway was ensured with endolaryngeal cord laterofixation instead of tracheostomy. The operation was performed with the endo-extralaryngeal needle carrier instrument devised by Lichtenberger. During the operation, only minor surgical trauma occurred in the larynx. The fixing thread was then removed following recovery of contralateral vocal cord function, resulting in an improvement in the voice. Four patients are described who suffered bilateral recurrent laryngeal nerve palsy after thyroid gland operations. During the follow-up period of 3-12 months, airway stability was demonstrated by regular spirometric measurements. The simple method recommended spares patients the possible complications of tracheostomy.     

Carotid endarterectomy with shortened hospital stay

OBJECTIVE: To review the outcome of a consecutive series of patients undergoing carotid endarterectomy with a focus on length of stay. DESIGN: Retrospective case review. SETTING: Six hundred-bed community hospital. PATIENTS: During a 40-month period, we performed 266 carotid endarterectomies. Ages of patients ranged from 49 to 91 years (mean, 71.2 years). Seventy-two percent were hypertensive, 55% were smokers, 24% were diabetic, and 22% had symptomatic heart disease. Indications for operation included asymptomatic stenosis in 48% of patients, transient ischemia attack in 23%, stroke in 24%, and nonhemispheric symptoms in 5%. OUTCOME MEASURES: Perioperative complications and conditions precluding early hospital discharge were noted. In patients discharged within 48 hours of operation, problems requiring readmission within 30 days were recorded. RESULTS: Five patients (1.9%) experienced perioperative strokes, of which three were permanent and two temporary. There was one perioperative death. Hospital stays ranged from 1 to 9 days (mean 1.7 days). Sixty-three percent of the patients were discharged within 24 hours and 88% within 48 hours of operation. Patients staying in the hospital more than 48 hours were significantly older (P = .008). Other factors did not correlate with length of stay. Readmission was required in five patients. CONCLUSIONS: Patients having an uneventful course following carotid endarterectomy may be safely discharged within 48 hours of operation. Complications occurring after this time are infrequent and often unpredictable. It is unlikely that lengthening patient stay would decrease or eliminate these complications.     

The dietitian''s role in developing and implementing the first federal obesity guidelines

OBJECTIVE: To determine possible indications for tracheotomy in the burned child based on bronchoscopic and laryngoscopic findings. DESIGN AND SETTING: A retrospective case study of all patients admitted to a tertiary children's burn center. PARTICIPANTS: All children admitted with burn inhalation injury between 1990 and 1995 (n = 211). INTERVENTION: All patients underwent laryngoscopy and bronchoscopy and 19 underwent tracheotomy, with 5 tracheotomy tubes placed emergently. MAIN OUTCOME MEASURES: Observations during laryngoscopy and bronchoscopy included erythema, edema, carbonaceous material, ulcerations, and bronchial mucous casts. The supraglottis, glottis, and subglottis were analyzed separately, when possible. Any sepsis resulting from tracheotomy was determined. Complications, such as glottic webs, subglottic stenosis, and tracheomalacia, were noted. RESULTS: Indications for tracheotomy included 6 for airway obstruction, 6 for prolonged intubation, 6 for pulmonary cleansing, and 1 for endotracheal tube complications (subglottic stenosis). When examined by bronchoscopy and laryngoscopy, 17 of 19 children had significant airway edema, 10 had carbonaceous material in the airway, and 3 had ulcerations in the airway. CONCLUSIONS: Tracheotomy is indicated in the burned child when significant airway edema is present. Failure to place a tracheotomy tube in these cases leads to a high incidence of immediate tracheotomies (26%). There was no evidence of clinically significant infection attributable to tracheotomy. The number of airway complications due to tracheotomy was no higher than from endotracheal intubation.     

Use of alternative health care practitioners by Canadians

Non-invasive acoustic airway monitoring was evaluated in an experimental study. Recording amplitude and travel time of acoustic pulse response, an area-distance function of the cross sectional dimensions of the endotracheal tube and the adjacent airway was calculated to obtain an acoustic pattern of the airway. Measurements on models and excised human cadaver lungs were performed to discover whether displacement or obstruction of the artificial airway can be detected in the acoustic equivalent. Regression analysis revealed a close correlation between displacement of tracheostomy tubes and the shifting of the acoustic area-distance function (corr. coeff. 0.97-1). Dispersion analysis confirmed reasonable reliability (coeff. of variation 0.6-2.1%). Location and amount of obstruction could likewise be identified. Thus acoustic mapping provides an adequate approximation of the true geometry of tracheostomy and endotracheal tubes. We conclude that acoustic monitoring may provide a powerful tool to achieve primary prevention of airway disturbances in intubated and mechanically ventilated patients, as geometrical changes of airway configuration can be detected even before they cause substantial effects on respiratory metabolism.     

Spiral computed tomographic scanning of the chest with three dimensional imaging in the diagnosis and management of paediatric intrathoracic airway obstruction

BACKGROUND: The usefulness of spiral computed tomographic (CT) scans of the chest with three dimensional imaging (3D-CT) of intrathoracic structures in the diagnosis and management of paediatric intrathoracic airway obstruction was assessed. METHODS: A retrospective review was made of five consecutive cases (age range six months to four years) admitted to the paediatric intensive care unit and paediatric radiology division of a tertiary care children's hospital with severe respiratory decompensation suspected of being caused by intrathoracic large airway obstruction. Under adequate sedation, the patients underwent high speed spiral CT scanning of the thorax. Non-ionic contrast solution was injected in two patients to demonstrate the anatomical relationship between the airway and the intrathoracic large vessels. Using computer software, three-dimensional images of intrathoracic structures were then reconstructed by the radiologist. RESULTS: In all five patients the imaging results were useful in directing the physician to the correct diagnosis and appropriate management. In one patient, who had undergone repair of tetralogy of Fallot with absent pulmonary valve, the 3D-CT image showed bilateral disruptions in the integrity of the tracheobronchial tree due to compression by a dilated pulmonary artery. This patient underwent pulmonary artery aneurysmorrhaphy and required continued home mechanical ventilation via tracheostomy. In three other patients with symptoms of lower airway obstruction the 3D-CT images showed significant stenosis in segments of the tracheobronchial tree in two of them, and subsequent bronchoscopy established a diagnosis of segmental bronchomalacia. These two patients required mechanical ventilation and distending pressure to relieve their bronchospasm. In another patient who had undergone surgical repair of intrathoracic tracheal stenosis three years prior to admission the 3D-CT scan ruled out restenosis as the reason for her acute respiratory decompensation. CONCLUSIONS: 3D-CT scanning is a useful additional diagnostic tool for intrathoracic airway obstruction in paediatric patients.     

Microscopic measurement of cellular infiltration in the rheumatoid arthritis synovial membrane: a comparison of semiquantitative and quantitative analysis

BACKGROUND: A significant proportion of burn patients with inhalation injuries incur difficulties with airway protection, dysphagia, and aspiration. In assessing the need for intubation in burn patients, the efficacy of fiberoptic laryngoscopy was compared with clinical findings and the findings of diagnostic tests, such as arterial blood gas analysis, measurement of carboxyhemoglobin levels, pulmonary function tests, and radiography of the lateral aspect of the neck. OBJECTIVE: To determine if these patients were at risk for aspiration or dysphagia, barium-enhanced fluoroscopic swallowing studies were performed. DESIGN: Prospective study. SETTINGS: Burn intensive care unit in an academic tertiary referral center. MAIN OUTCOME MEASURES: Need for endotracheal intubation and potential for aspiration. RESULTS: Six (55%) of 11 patients had clinical findings and symptoms that indicated, under traditional criteria, endotracheal intubation for airway protection. Visualization of the upper airway with fiberoptic laryngoscopy obviated the need for endotracheal intubation in all 11 patients. These patients also failed to evidence an increased risk of aspiration or other swallowing dysfunction. CONCLUSIONS: In comparison with other diagnostic criteria, fiberoptic laryngoscopy allows differentiation of those patients with inhalation injuries who, while at risk for upper airway obstruction, do not require intubation. These patients may be safely observed in a monitored setting with serial fiberoptic examinations, thus avoiding the possible complications associated with intubation of an airway with a compromised mucosalized surface. In these patients, swallowing abnormalities do not manifest.     

Airway resistance and work of breathing in tracheostomy tubes

Recommendations for sizing of tracheostomy tubes are generally based on anatomic considerations with the largest fitting tube most commonly placed. Once in the tracheostomy site, the tube assumes the new role of the upper airway. Consideration of the airway resistance of each tracheostomy tube and change in work of breathing are important in maintaining the respiratory system homeostasis. The airflow dynamics of neonatal, pediatric, and adult tracheostomy tubes were studied. Flow rates were plotted against change in pressure for inspiratory and expiratory flows and resistances for each tube were calculated. The expiratory resistances were larger for the neonatal tubes and pediatric tubes 0 and 00, while inspiratory resistances were the limiting factor in the adult tubes and the larger pediatric tubes. Comparison of calculated resistances of the tracheostomy tubes was made with known physiologic airway resistances. Adult tubes 8 and 10 most closely simulated the upper airway resistance of adults and neonatal tube 0 appeared most appropriate for the newborn. Work of breathing was determined for each tracheostomy tube. Increasing tube diameter as well as decreasing tidal volume and respiratory rate decreased the amount of work required to maintain a given flow.     

Application of the laryngeal mask for elective percutaneous dilatation tracheotomy

Percutaneous dilatational tracheostomy is an increasingly accepted procedure for bed-side tracheostomy. The exact positioning of the endotracheal tube, the localization of the point for puncturing the trachea and damage to the endotracheal tube and the cuff as well as to the bronchoscope due to the puncturing process are technical problems which can endanger the course of the operation. In a prospective randomized study, we examined whether use of the laryngeal mask airway (LMA) is a real alternative to the endotracheal tube during tracheostomy. Of 48 consecutive patients only 43 fulfilled all criteria for this study: PaO2 > 100 mmHg, PaCO2 < 45 mmHg (in patients with head injury < 35 mmHg) under intermittent positive pressure ventilation (IPPV) with a mean ventilation pressure of < 25 mmHg and an FiO2 of 1.0. Patients with intestinal obstruction, hemorrhages of the mouth and nose and unfavourable anatomic conditions were not included in this study. Three more patients had to be excluded from the study because of technical problems. In 21 patients tracheostomy was performed using an endotracheal tube (ET group) and in 19 patients using a LMA (LM group). After positioning of the endotracheal tube or the LMA, tracheostomy was performed in the usual way. Arterial blood gases (PaO2 and PaCO2) were investigated before positioning of the endotracheal tube or the LMA, five minutes after this procedure and five minutes after the end of tracheostomy. Mean arterial pressure (MAP), heart frequency (HF) and peripheral oxygen saturation (SpO2), endexpiratory CO2 partial pressure (PetCO2) and minute ventilation volume (MVV) were registered every 60 seconds. The ET group and LM group did not differ regarding basic diseases, age and severity of illness. Before the beginning of tracheostomy, there were no differences in MAP, HF, SpO2, PetCO2 and PaCO2 between the two groups. Before tracheostomy, only PaO2 was significantly higher in the LM group than in the ET group. Immediately before the insertion of the tracheal cannula and five minutes after the end of tracheostomy, there were no differences in the measured parameters of the two groups. An increase in PetCO2 and a decrease in minute ventilation volume were observed in both groups. Regarding technical complications, the LMA is a safe alternative to the endotracheal tube. The choice of method should depend on the basic disease and the patient's ventilation requirements at the time of tracheostomy, while there is still a call for safe instruments guaranteeing sufficient sealing of the respiratory tract during the dilatational tracheostomy and simultaneous avoidance of technical problems during puncturing of the trachea and widening of the point of puncturing.     

The laryngeal mask in pediatric anesthesia

We carried out a perspective study in order to assess the ease of insertion, the type and the incidence of perioperative complications connected with the use of the Laryngeal Mask Airway (LMA). We examined 300 consecutive patients, M/F 261/39, average age 4.2 yrs. (range 0.1-16), ASA I-II, who underwent surgical operations of short or average length not involving the pleural, the oropharyngeal or the peritoneum cavity. The choice about anesthesia was left to the discretion of the anesthesiologist. In 27 cases the position of the LM was controlled through a flexible fiberoptics. In 269 patients (89.6%) the LMA was correctly positioned during the first attempt. In 27 patients (9%), 2 or more attempts were necessary, and in 4 patients (1.4%) it was not possible to set the LMA. No differences of statistical significance were noticed between the different size of LMA, with regards to the facility of insertion. The control through fiberoptics showed a correct position, from an anatomical point of view, in 11 patients (41%), whereas in 13 patients (48%) some signs of partial obstruction were noticed (epiglottis interposing between the opening of LMA and larynx) and in 3 patients (11%) vocal cords are not visible. The following complications took place: laryngeal spasm on induction (2.3%), cough or movements on positioning (2.3%), hypoxia (4.3%), obstruction (1%), laryngeal spasm on awakening (1.7%), trauma (5%) and vomiting (0.3%). No connections were found between the size of LMA and total complications. Nevertheless, cough or movement during positioning and laryngeal spasm on awakening were significantly more frequent with LMA n. 3. In our experience, the LMA proved to be effectual and safe in the control of the airway during elective operations in pediatric surgery.     

Respiratory failure in Guillain-Barré syndrome: a 6-year experience

Seventy-nine patients with acute Guillain-Barré syndrome were seen during a 6-year period. Twenty-one were admitted to a respiratory intensive care unit, where they remained for 58 +/- 26 days (range 14 to 105 days). Thirteen patients required nasotracheal intubation followed by tracheostomy and mechanical ventilation. The tracheostomy tube was in place for an average of 50 +/- 27 days (range 10 to 104 days). Four patients had complications of tracheostomy; two of these were significant, and one of them led directly to the patient's death. There were no complications due to mechanical ventilation, from which 11 patients were successfully weaned after a mean period of 37 +/- 29 days (range 7 to 93 days). Three of the 79 patients (3.8%) died of complications of their disease or its treatment. Respiratory failure in this condition is protracted and its complications are mainly those of prolonged endotracheal intubation with a tracheostomy tube.     

Short-term outcome of laparoscopic paraesophageal hernia repair. A case series of 58 consecutive patients

BACKGROUND: The purpose of this study is to determine the morbidity, mortality, and short-term outcomes associated with laparoscopic paraesophageal hernia repair (LPHR). METHODS: A series of 58 consecutive LPHRs performed by the author were reviewed with an average 1-year follow-up. Morbidity and mortality rates were compared with historical series of open repairs. Anatomy and technical considerations pertinent to LPHR were reviewed. RESULTS: There were no procedure-related or perioperative deaths in this series of patients undergoing LPHR. Four major complications occurred (7%), two of which required reoperation, all in urgently repaired patients. One patient required conversion to laparotomy (1. 7%). Based on symptoms, there were no reherniations. No patients had long-term dysphagia worse than preoperatively. Preoperative symptoms of chest pain, esophageal obstruction, hemorrhage, and reflux were resolved in all patients. CONCLUSIONS: LPHR is safe, effective, and compares favorably to historical series of open paraesophageal hernia repair.     

Activation of p70 S6 protein kinase is necessary for angiotensin II-induced hypertrophy in neonatal rat cardiac myocytes

Infants with mandibular hypoplasia are at risk of sudden death from cardiorespiratory arrest secondary to upper airway obstruction. To evaluate diagnostic difficulties that may occur at autopsy in such infants, the autopsy files at the Adelaide Children's Hospital (ACH) for 36 years, 1959 to 1994, were reviewed. Eight cases were identified (age range, 2 days to 10 months; mean age, 2.2 months; male/female ratio, 5:3). In all cases, death was considered most likely due to airway obstruction related to mandibular hypoplasia or its treatment. Although death occurred in the hospital in five cases, one infant suddenly collapsed at home while feeding and died, and two infants were unexpectedly found dead in their cribs at home. Three infants had defined genetic syndromes. Although all the infants had histories of antemortem airway obstruction, one infant had normal oxygen saturation studies before hospital discharge, and one infant had a tracheostomy. Acute bronchopneumonia was an exacerbating factor in one case. Assessment of mandibular size is important in any infant who dies unexpectedly; and if hypoplasia is found, careful review of the clinical details for evidence of airway obstruction is necessary to help distinguish these cases from sudden infant death syndrome (SIDS). Sudden death may, however, occur in infants with mandibular hypoplasia in spite of apparent clinical stability before death with no significant recent episodes of oxygen desaturation.     

Effects of blood transfusion on left ventricular output in premature babies

Tracheostomy tube insertion is periodically performed when patients with acquired immunodeficiency syndrome (AIDS) require prolonged mechanical ventilation. In this population, bedside percutaneous tracheostomy may be a better technique than conventional operating room tracheostomy because it reduces procedural cost, requires no patient transport, and requires few sharp instruments, thereby potentially decreasing risk to surgical staff. A retrospective review was conducted in the Department of Medical Records at St. Vincents Hospital and Medical Center of New York City. Nine consecutive patients diagnosed with AIDS and undergoing percutaneous tracheostomy from January 1, 1992, to December 31, 1996, were identified. All patients were males (mean age 32.1 +/- 4 years, CD4 count average 145) and were ventilator-dependent for mean of 24 +/- 3 days. The procedure was successful and without complications in all patients. Follow-up was 27 months (range 1-42 months) and in-hospital mortality was 77 per cent. The average length of survival for those patients who died in the hospital was 29 days (range, 3-120). Two patients survived the hospitalization after undergoing decannulation on postoperative days 29 and 52, respectively. Despite the poor prognosis after tracheostomy in patients with AIDS this procedure allows better oral care and may improve patient comfort. Bedside percutaneous tracheostomy can be performed with less risk to surgical personnel and patient when compared to conventional surgery. This minimally invasive procedure safely and efficiently provides prolonged tracheal access in patients with AIDS.