Innovative use of a Montgomery cannula in the bronchoscopic management of tracheal stenosis and failed tracheostomy decannulation.
ABSTRACT: Endoprosthesis are being used in the everyday clinical practice either as a permanent solution or transient. They can be used in both benign and malignant situations.We report a case in which a temporary Montgomery cannula is used in conjunction with therapeutic bronchoscopy to manage a patient with failed tracheostomy decannulation secondary to a distal complex tracheal stenosis.This innovative use of the Montgomery cannula allowed for successful management of the patient's tracheal stenosis and subsequent tracheostomy tube decannulation.
Project description:PURPOSE:COVID-19 patients requiring mechanical ventilation can overwhelm existing bed capacity. We aimed to better understand the factors that influence the trajectory of tracheostomy care in this population to facilitate capacity planning and improve outcomes. METHODS:We conducted an observational cohort study of patients in a high-volume centre in the worst-affected region of the UK including all patients that underwent tracheostomy for COVID-19 pneumonitis ventilatory wean from 1st March 2020 to 10th May 2020. The primary outcome was time from insertion to decannulation. The analysis utilised Cox regression to account for patients that are still progressing through their tracheostomy pathway. RESULTS:At the point of analysis, a median 21 days (IQR 15-28) post-tracheostomy and 39 days (IQR 32-45) post-intubation, 35/69 (57.4%) patients had been decannulated a median of 17 days (IQR 12-20.5) post-insertion. The overall median age was 55 (IQR 48-61) with a male-to-female ratio of 2:1. In Cox regression analysis, FiO2 at tracheostomy???0.4 (HR 1.80; 95% CI 0.89-3.60; p?=?0.048) and last pre-tracheostomy peak cough flow (HR 2.27; 95% CI 1.78-4.45; p?=?0.001) were independent variables associated with prolonged time to decannulation. CONCLUSION:Higher FiO2 at tracheostomy and higher pre-tracheostomy peak cough flow are associated with increased delay in COVID-19 tracheostomy patient decannulation. These finding comprise the most comprehensive report of COVID-19 tracheostomy decannulation to date and will assist service planning for future peaks of this pandemic.
Project description:Purpose: Early decannulation is considered a main rehabilitative goal in tracheostomized patients. Our aim is to evaluate whether a very early rehabilitation protocol helps to reduce the tracheostomy duration in patients affected by an Acquired Brain Injury (ABI). Methods: Data about consecutive tracheostomized patients admitted in our Neuro-Rehabilitation Unit (NRU) were retrospectively collected. We defined two groups: Early Rehabilitation Group patients came from our ICU, where they started the rehabilitative treatment; Delayed Rehabilitation Group patients arrived from external ICUs and started rehabilitation in our NRU. Primary outcome was the time from tracheostomy to decannulation. Secondary outcomes were: ICU length of stay, time from NRU admission to decannulation, Glasgow Coma Scale, Coma Recovery Scale revised and Levels of Cognitive Functioning scores at NRU discharge and the re-cannulation rate. Results: We enrolled 66 patients, 40 in the Early Rehabilitation Group and 26 in the Delayed Rehabilitation Group. 70% of patients for each group could be decannulated (p = 0.73) and were analyzed. Only one patient was re-cannulated. Early Rehabilitation Group showed a shorter tracheostomy duration (61.0 vs. 94.5 days, p = 0.013), a higher probability of occurrence of decannulation (p = 0.008) and a lower ICU length of stay (30.0 vs. 52.0 days, p = 0.001). The time to decannulation in NRU was similar between groups (30.0 vs. 45.50 days, p = 0.14). All the scale scores had a significant improvement in both groups (p < 0.0001 all). Conclusions: The present study shows that an early neuro-rehabilitation protocol helps to reduce the time to decannulation in tracheostomized patients affected by ABI.
Project description:<h4>Background</h4>Removal of a tracheostomy tube in critically ill neurologic patients is a critical issue during intensive care treatment, particularly due to severe dysphagia and insufficient airway protection. The "Standardized Endoscopic Evaluation for Tracheostomy Decannulation in Critically Ill Neurologic Patients" (SESETD) is an objective measure of readiness for decannulation. This protocol includes the stepwise evaluation of secretion management, spontaneous swallowing, and laryngeal sensitivity during fiberoptic endoscopic evaluation of swallowing (FEES). Here, we first evaluated safety and secondly effectiveness of the protocol and sought to identify predictors of decannulation success and decannulation failure.<h4>Methods</h4>A prospective observational study was conducted in the neurological intensive care unit at Münster University Hospital, Germany between January 2013 and December 2017. Three hundred and seventy-seven tracheostomized patients with an acute neurologic disease completely weaned from mechanical ventilation were included, all of whom were examined by FEES within 72 h from end of mechanical ventilation. Using regression analysis, predictors of successful decannulation, as well as decannulation failure were investigated.<h4>Results</h4>Two hundred and twenty-seven patients (60.2%) could be decannulated during their stay according to the protocol, 59 of whom within 24 h from the initial FEES after completed weaning. 3.5% of patients had to be recannulated due to severe dysphagia or related complications. Prolonged mechanical ventilation showed to be a significant predictor of decannulation failure. Lower age was identified to be a significant predictor of early decannulation after end of weaning. Transforming the binary SESETD into a 4-point scale helped predicting decannulation success in patients not immediately ready for decannulation after the end of respiratory weaning (optimal cutoff ≥1; sensitivity: 64%, specifity: 66%).<h4>Conclusions</h4>The SESETD showed to be a safe and efficient tool to evaluate readiness for decannulation in our patient collective of critically ill neurologic patients.
Project description:<h4>Objectives</h4>To evaluate the clinical outcomes and perioperative complications associated with complete percutaneous decannulation of femoral venoarterial extracorporeal membrane oxygenation (VA-ECMO) with the MANTA closure device.<h4>Methods</h4>This is a retrospective analysis of a single surgeon consecutive series of 14 patients at a single center who underwent decannulation from VA-ECMO, 10 of whom underwent a percutaneous method of femoral cannula removal.<h4>Results</h4>After a mean duration of VA-ECMO support of 7.4 ± 3.8 days, all 10 patients, with arterial cannulas ranging in size from 17 to 21 Fr, underwent percutaneous decannulation with the MANTA closure device, with immediate hemostasis. One patient had acute lower limb ischemia that was recognized intraoperatively and successfully treated with suction embolectomy. Two patients had a pseudoaneurysm at the distal perfusion catheter site recognized on perioperative imaging studies, one resolving with observation and the other necessitating thrombin injection. One patient had a hematoma that resolved with observation.<h4>Conclusions</h4>Percutaneous decannulation from VA-ECMO using the MANTA large-bore vascular closure device is feasible and results in immediate hemostasis with excellent angiographic results.
Project description:PURPOSE:A single institutions experience with various surgical options in the treatment of severe suprastomal collapse (SSC). METHODS:The study included 18 tracheostomized children with SSC treated between January 2012 and December 2018. Data included: patient demography, initial airway lesions, comorbidities, indication and age at tracheostomy, prior airway surgery, stomal demography, type of surgery, postoperative management, complications and treatment outcomes. RESULTS:Four techniques were used to correct SSC. The surgical choice was dependent on stoma demography and associated airway lesions. Excision was done in eight patients and rib cartilage augmentation in five. Three patients had single stage tracheal resection and anastomosis. Two patients received stomal rigidification and temporary placement of Montgomery T tube. Three patients with anterior rib graft augmentation required additional lateral tracheal wall rigidification. Three patients (two with cartilage augmentation, and one with stomal rigidification) developed minimal granulation tissue in the postoperative period. Complete SSC resolution was seen in all except two patients who had a partial response to the treatment. All patients were successful decannulated and are currently asymptomatic. CONCLUSION:Decannulation failures may be due to severe suprastomal collapse that could be either unique or associated with obstructing laryngotracheal lesions. Therefore, it is essential to select the most appropriate surgical treatment to obtain overall favorable outcomes.
Project description:Improvements in cannula removal techniques, and in particular a standardized decannulation technique with a suitable closure device, are needed to further improve patients' outcomes after percutaneous cannulation. The decannulation techniques described so far are neither sufficiently standardized nor proven enough to be used in the large group of venoarterial extracorporeal membrane oxygenation patients. To meet this challenge, we have established a highly standardized and safe decannulation technique based on the Perclose ProGlide closure system (Abbott Vascular, Lake Bluff, IL). Design:Establishment of a highly standardized and safe decannulation technique based on the Perclose ProGlide closure system, which is described in detail with comprehensive instructions for the executive clinician and first application in the context of a pilot study. Measurements and Main Results:So far our technique has already been used successfully in seven patients since January 2019 as a standard procedure on our ICU with only one minor complication occurred after the first procedure, that is, a small pseudoaneurysm likely originating from antegrade perfusion puncture site which was sealed by thrombin injection. Conclusions:Our crossed ProGlide technique using a hemostasis valve Y connector ensuring no blood loss seems to be a very promising decannulation technique.
Project description:INTRODUCTION:Surgical and percutaneous tracheostomy remains a commonly performed procedure in the intensive care unit (ICU). Given the unique patient population in the Middle East we decided to perform a review of the procedures performed in our hospital over a two-year period. METHODS:Single centre, retrospective observational study. All tracheostomies performed between January 2016 and January 2018 were included in the study. The primary outcome was the rate of tracheostomy complications. Multivariate logistic regression analysis was used to identify the independent factors associated with complications and decannulations. RESULTS:One hundred sixty-four patients were included in the study. Percutaneous tracheostomy was performed in 99 patients (60.4%). Complications occurred in thirty-eight patients (23%). Higher Left ventricular ejection fraction (OR = 0.94, 95%CI: [0.898-0.985]) and percutaneous tracheostomy (OR = 0.107, 95%CI: [0.029-0.401]) were associated with lower complications. Good Eastern Cooperative Oncology Group (ECOG) performance status (OR = 4.1, 95%CI: [1.3-13.3]) and downsized tracheostomy tube (OR = 6.5, 95%CI: [2.0-21.0]) were associated with successful decannulations. Successful decannulation was associated with lower hospital mortality when compated to those who could not be decannulated (3.2% vs 33.3% p < 0.0001). CONCLUSION:In our older population with high comorbidities, percutaneous tracheostomies were associated with less complications than surgical tracheostomies. Patients with poor premorbid functional status and those who could not have their tracheostomy tube sucessfuly downsized were less likely to be decannulated, and had a higher mortality. This data enables physicians to inform the families of the added risks involved with tracheostomy in this patient group.
Project description:BACKGROUND:This case highlights challenges in the assessment and management of the "difficult airway" patient in the SARS-CoV-2 (COVID-19) pandemic era. METHODS:A 60-year-old male with history of recent transoral robotic surgery resection, free flap reconstruction, and tracheostomy for p16+ squamous cell carcinoma presented with stridor and dyspnea 1 month after decannulation. Careful planning by a multidisciplinary team allowed for appropriate staffing and personal protective equipment, preparations for emergency airway management, evaluation via nasopharyngolaryngoscopy, and COVID testing. The patient was found to be COVID negative and underwent imaging which revealed new pulmonary nodules and a tracheal lesion. RESULTS:The patient was safely transorally intubated in the operating room. The tracheal lesion was removed endoscopically and tracheostomy was avoided. CONCLUSIONS:This case highlights the importance of careful and collaborative decision making for the management of head and neck cancer and other "difficult airway" patients during the COVID-19 epidemic.
Project description:BACKGROUND:Outcome of infants with tracheostomy have not been well described in the literature. Our objective was to describe the respiratory, growth, and survival outcomes of infants with tracheostomy. METHODS:A retrospective study was conducted on 204 infants born between 2005 and 2015 with tracheostomy at <1 year of age and follow-up in the Infant Tracheostomy and Home Ventilator Clinic up to 4 years of age. RESULTS:The mean age at tracheostomy was 4.5 months with median age of 3 months. Median age of decannulation was 32 months. The time from tracheostomy placement to complete discontinuation of mechanical ventilation was 15.4 months and from tracheostomy to decannulation was 33.8 months. Mortality rate was 21% and median age of death was 18 months. Preterm infants with acquired airway and lung disease (BPD) and born at <28 weeks' gestation had a significantly higher survival rate compared to term infants. The z-scores for weight and weight for length improved from the time of discharge (mean chronological age 6.5 months) to first year and remained consistent through 3 years. CONCLUSIONS:Premature infants had a higher rate of discontinuation of mechanical ventilation and decannulation compared to term infants. These infants showed consistent growth and comparable survival rate. IMPACT:Infants with tracheostomy and ventilator dependence followed in a multidisciplinary clinic model may have improved survival, growth, and earlier time to decannulation. Preterm infants with acquired airway and lung disease (BPD) with tracheostomy had a higher survival rate compared to term infants with various tracheostomy indications. The age at tracheostomy in infants was 4.5 months and of decannulation was 37 months. Time from tracheostomy to complete discontinuation of mechanical ventilation was 15.4 months. Addition of this data to the sparse literature will be crucial in counseling the families and education of medical staff.