Submit your published abstract for posting on our website. In order to be considered, abstracts must be no longer than 250 words and pertain to tracheostomy topics.  Please include journal citation.

Submit abstracts to: trachs@yahoo.com

Title: Tracheostomy Care and Complications in the Intensive Care Unit

Authors: Linda L. Morris, Andrea Whitmer, and Erik McIntosh

Journal: Crit Care Nurse October 2013 33:18-30; doi:10.4037/ccn2013518

Link: http://ccn.aacnjournals.org/content/33/5/18.abstract.html

Contact: Linda L. Morris: lmorris8305@comcast.net

Abstract: 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. (Critical Care Nurse. 2013;33

[5]:18-22,24-31)

Title:  Trach tubes designed to maximize safety may increase risk to ventilated patients

Authors:  John McCracken1* and David Leasa2

Journal: Critical Care 2010, 14:1008 doi:10.1186/cc9306 Published: 8 December 2010

Abstract: Dual-cannulae tracheostomy tubes with low-pressure cuffs, such as the Shiley LPC, are widely regarded as inherently safer than single lumen tubes with low-volume cuffs. For the patient who undergoes tracheostomy for failure to wean from mechanical ventilation, however, the insertion of a tube that occupies a large amount of space within the trachea can delay subsequent efforts to liberate him from the ventilator. With an aim to promote more timely rehabilitation of ventilated patients, London Ontario’s University Hospital has been inserting the Bivona TTS, a single lumen tube with an elastic cuff, during tracheostomy. This allows caregivers to better exploit the benefits of a functional upper airway early during the weaning process, which may reduce complications associated with prolonged mechanical ventilation. We urge clinical studies to determine how the choice of initial tracheostomy tube can affect rehabilitation strategies and important patient outcomes.

Title:  Does early tracheotomy affect length of stay (LOS) and survival?

Authors:  Linda L. Morris PhD, APN, CCNS; Ricky B. Shah MD; Michael Avram PhD; Sherif Afifi MD, FCCM

Journal: Crit Care Med, 2009, 37(12 suppl): A196

Institution(s):  Northwestern Memorial Hospital, Chicago, IL; Northwestern University, Chicago, IL)

Introduction: Studies have shown benefit of early tracheotomies for critically ill patients. Most report improved patient comfort; however, there are conflicting results on mortality. We report LOS and mortality outcomes related specifically to tracheotomies performed at the bedside.

Hypothesis: Earlier tracheotomy will decrease ICU and hospital LOS and improve hospital survival.

Methods: Following IRB approval, a retrospective review examined patients who underwent bedside tracheotomies in surgical and medical ICU’s of a tertiary teaching hospital over a 12 month period. Cases performed in the operating room and those with incomplete data were excluded. Patients were categorized in 2 groups: tracheotomy < 7 days from initial intubation and tracheotomy in >7 days. ICU and hospital LOS were measured. Differences between median LOS were calculated using Mann-Whitney U test (two sided p-value). Hospital mortality was compared using Fisher’s Exact Test (p <0.05).

Results: Preliminary analysis included 147 patients who received bedside tracheotomies. Compared to patients who underwent tracheotomies >7days from intubation (N=127), patients who underwent tracheotomies <7 days (N=20) had shorter median ICU LOS (11 vs. 26, p<0.0001) and shorter median hospital LOS (25 vs. 32, p< 0.0047). However, no statistical difference in survival was noted between both groups (p=0.473).

    < 7 days > 7 days p-value
ICU LOS (median days 11 26 0.000
Hospital LOS (median days) 25 32 0.004
Survival 5% 14.2% 0.473

Title: Can we develop a protocol for the safe decannulation of tracheostomies in children less than 18 months old?  

Authors: Kubba H, Cooke J, Hartley B.

Journal: International Journal of Pediatric Otorhinolaryngology  2004; 68(7): 935-937

Abstract: Safely decannulating a tracheostomy in a very young child is challenging: in this paper we used case studies of four children successfully deacnnulated below the age of 18 months to illustrate an approach that has worked for us.

Contact: Haytham Kubba: hkubba@nhs.net

Title: Experiences of tracheocutaneous fistula closure in children: how we do it.  

Authors: Geyer M, Kubba H, Hartley B.

Journal:  Clin Otolaryngol. 2008; 33(4):367-9

This is another practical paper for surgeons, using a series of 100 children with a persistent, non-healing fistula after tracheostomy decannulation to document complications and present technical tips for success

Contact: Haytham Kubba: hkubba@nhs.net

Title: The use of the Montgomery T-tube in difficult paediatric airway surgery.

Authors: Phillips PS, Kubba H, Albert D, Hartley B.

Journal: International Journal of Pediatric Otorhinolaryngology  2006; 70: 39-44

Abstract: The Montgomery t-tube has its uses for complicated multi-level airway stenosis, as it provides an airway, a stent and a suction channel in a convenient, discreet format.  This study was an attempt to define the place of the t-tube in modern airway surgery.

Contact: Haytham Kubba: hkubba@nhs.net

In progress: Ongoing research includes a paper describing our multidisciplinary tracheostomy clinic for children and the benefits it provides for children, families and professionals (in press), and another describing our tracheostomy population, highlighting how indications for tracheostomy have changed over recent years and how a large proportion of our tracheostomised children are medically very complex (also in progress).

Contact: Haytham Kubba: hkubba@nhs.net

Title: Tracheotomy Outcomes and Complications – a National Perspective.

Authors: Shah RK, Lander L, Berry JG, Nussenbaum B, Merati A and Roberson DW.

Journal: Laryngoscope 2012; 122:25-29.

Title: Tracheotomy-related catastrophic events: results of a national survey.

Authors: Das P, Zhu H, Roberson DW, Shah RK, Berry J, Skinner ML.

Journal: Laryngoscope 2012; 122:30-37.

Title: Surveillance and management practices in tracheotomy patients. 

Authors: Zhu H, Das P, Brereton J, Roberson DW, Shah RK.

Journal: Laryngoscope 2012; 122:46-50.

Title: Managing tracheotomy risk: time to look beyond hospital discharge. 

Authors: Eibling DE and Roberson DW.

Journal: Laryngoscope 2012 122:23-24.

Abstract: This group of papers documents a significant in-house mortality after tracheostomy, primarily due to underlying disease rather than tracheostomy.  The survey on catastrophic events documents that many adverse events happen in the home rather than in hospital, and the survey on surveillance practices documents extreme variability in follow up care for tracheostomy.  The editorial calls out the need for better understanding of appropriate follow up care, and for managing risk at home as well as in the hospital.

Contact: David Roberson: davidwroberson@globaltracheostomycollaborative.org

Title: Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies.

Authors: McGrath BA, Bates L, Atkinson D, Moore JA; National Tracheostomy Safety Project.

Journal: Anaesthesia. 2012 Sep;67(9):1025-41. doi: 10.1111/j.1365-2044.2012.07217.x. Epub 2012 Jun 26.

Abstract: Adult tracheostomy and laryngectomy airway emergencies are uncommon, but do lead to significant morbidity and mortality. The National Tracheostomy Safety Project incorporates key stakeholder groups with multi-disciplinary expertise in airway management. , the Intensive Care Society, the Royal College of Anaesthetists, ENT UK, the British Association of Oral and Maxillofacial Surgeons, the College of Emergency Medicine, the Resuscitation Council (UK) the Royal College of Nursing, the Royal College of Speech and Language Therapists, the Association of Chartered Physiotherapists in Respiratory Care and the National Patient Safety Agency. Resources and emergency algorithms were developed by consensus, taking into account existing guidelines, evidence and experiences. The stakeholder groups reviewed draft emergency algorithms and feedback was also received from open peer review. The final algorithms describe a universal approach to managing such emergencies and are designed to be followed by first responders. The project aims to improve the management of tracheostomy and laryngectomy critical incidents.

Anaesthesia © 2012 The Association of Anaesthetists of Great Britain and Ireland.

Comments:

A reply. [Anaesthesia. 2013]

Algorithm for management of tracheostomy emergencies on intensive care. [Anaesthesia. 2013]

Contact: Brendan McGrath: brendan.mcgrath@nhs.net, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK.

Title: Improving tracheostomy management through design, implementation and prospective audit of a care bundle: how we do it

Authors: Hettige R, Arora, A, Ifeacho S & Narula A.

Journal: Clinical Otolaryngology 2008 33, 472–494

Abstract: Occurrence of significant numbers of ‘severe’ tracheostomy-related critical incidents at our institution highlighted shortcomings and inconsistencies in the standard of tracheostomy care provision.

  • A tracheostomy care bundle was developed as the gold standard to which all healthcare professionals managing a tracheostomised patient must adhere.
  • An ENT-led programme of ward-based education was devised and implemented, and ongoing support was provided by a nurse specialist. This resulted in increased compliance with the care bundle from 43% in 2003⁄2004 to 58% during the second cycle audit (chi-squared test: P-value <0.05).
  • A reduction from 27% to 10% in the proportion of ‘severe’ tracheostomy-related clinical incidents was seen during a similar time-frame (chi-squared test: P-value <0.05), despite the overall increase in clinical incident reporting.
  • Ongoing education and continuous audit is required to increase compliance with care bundles, and to improve the care of tracheostomised patients trust-wide.

Contact: Asit Arora, asitarora@doctors.org.uk

Title: Driving standards in tracheostomy care: a preliminary communication of the St Mary’s ENT-led multi disciplinary team approach

Authors: Arora A, Hettige R, Ifeacho S & Narula A.

Journal: Clinical Otolaryngology 2008 33, 596–599

Abstract: Objectives: To assess tracheostomy care and improve standards following the introduction of an ENT-led multidisciplinary tracheostomy ward round service. Design: Prospective third cycle audit.

SETTING: Tertiary academic London hospital serving an inner city population of multi-ethnic background (St Mary’s Hospital, Paddington, London).

PARTICIPANTS: Patients with a tracheostomy discharged from ITU to general wards.

IMPLEMENTED ACTIONS:

  • Establishment of an ENT-led Tracheostomy Multidisci- plinary Team (TMDT).
  • Weekly TMDT ward round to manage patients with a tracheostomy.
  • ENT-led educational and training sessions for allied healthcare professionals.

MAIN OUTCOME MEASURES: Compliance with local tracheostomy care guidelines (St Mary’s tracheostomy care bundle) and time to tracheostomy tube decannulation.

RESULTS: Preliminary results of 10 patients show improved compliance with tracheostomy care guidelines, established in 2004, rising to 94%. Average time to decannulation was significantly reduced from 21 to

5 days (P-value = 0.0005, Mann Whitney Wilcoxon Test). The mean total tracheostomy time was reduced from 34 to 24 days although this was not statistically significant (P-value = 0.13, Mann Whitney Wilcoxon Test).

CONCLUSIONS: The introduction of regular ENT-led multidisciplinary input for patients with a tracheostomy significantly improved compliance with nursing care standards. There was also a reduction in the total length of time tracheostomy tubes remain in situ, with time to decannulation significantly reduced.

Contact: Asit Arora, asitarora@doctors.org.uk

Title: Improving tracheostomy care: a prospective study of the multidisciplinary approach

Authors: Cetto R, Arora A, Hettige R, Nel M, Benjamin L, Gomez C.M.H, Oldfield W.L.G & Narula A.A.

Journal: Clinical Otolaryngology 2011 36, 482–488

Abstract: Objectives: Suboptimal standards in tracheostomy care have been highlighted as a growing concern in view of the increasing demands for intensive care services. Our objective is to assess the impact of our model for tracheostomy care on patients with short-term tracheostomies (<4 months in situ) following their discharge from the intensive care unit. The model has three components: The St Mary’s tracheostomy care bundle checklist, a dedi- cated tracheostomy multidisciplinary team and an educational programme.

DESIGN: A 38-month prospective cohort study.

SETTING: A London Teaching Hospital.

PARTICIPANTS: A total of 102 patients with tracheostomy within the 19-month pre-intervention cohort and 95 patients in the 19-month post-intervention cohort.

MAIN OUTCOME MEASURES: The number of clinical incidents, mean time taken for decannulation, mean total tracheostomy time and total number of days spent in the intensive care unit were assessed before and after the intervention.

RESULTS: Time to decannulation following intensive care unit discharge decreased from 21 to 11 days, as did the mean total tracheostomy time, from 34 to 25 days (both statistically significant with a P < 0.0001 Mann–Whitney U-test). The number of critical incidents, which included all patients prior to exclusion, substantially declined following the introduction of intervention from 58 to 7 in the second year after intervention.

CONCLUSIONS: A multidisciplinary care model significantly expedited the decannulation process and reduced the overall time that a tracheostomy was in situ. The intervention was associated with a reduction in clinical incidents and shorter intensive care unit admissions, which can be associated with significant monetary savings.

Contact: Asit Arora, asitarora@doctors.org.uk

Title: Patient safety incidents associated with tracheostomies occurring in hospital wards: a review of reports to the UK National Patient Safety Agency.

Authors: McGrath BA, Thomas AN.

Journal: Postgrad Med J. 2010 Sep;86(1019):522-5. doi: 10.1136/pgmj.2009.094706. Epub 2010 Aug 13.

Abstract:

BACKGROUND: Tracheostomies are increasingly common in hospital wards due to the rising use of percutaneous and surgical tracheostomies in critical care and bed pressures in these units. Hospital wards may lack appropriate infrastructure to care for this vulnerable group and significant patient harm may result.

OBJECTIVES: To identify and analyse tracheostomy related incident reports from hospital wards between 1 October 2005 and 30 September 2007, and to make recommendations to improve patient safety based on the recurrent themes identified. The study was performed between August 2008 and August 2009.

METHODS: 968 tracheostomy related critical incidents reported to the National Patient Safety Agency over the 2 year period, identified by key letter searches, were analysed. Incidents were categorised to identify common themes, and root cause analysis attempted where possible.

RESULTS: In the 453 incidents where patients were directly affected, 338 (75%) were associated with some identifiable patient harm, of which 83 (18%) were associated with more than temporary harm. In 29 incidents (6%) some intervention was required to maintain life, and in 15 cases the incident may have contributed to the patient’s death. Equipment was involved in 176 incidents and 276 incidents involved tracheostomies becoming blocked or displaced.

CONCLUSIONS: By identifying and analysing themes in incident reports associated with tracheostomies, recommendations can be made to improve safety for this group of patients. These recommendations include improvements in infrastructure, competency and training, equipment provision, and in communication.

PMID: 20709764 [PubMed – indexed for MEDLINE]

Contact: Brendan McGrath, brendan.mcgrath@nhs.net, University Hospital of South Manchester, Wythenshawe, Manchester, UK.

Title: Tracheostomy care and complications in the ICU.

Authors: Morris, LL, Whitmer, A, McIntosh, E.

Journal: Critical Care Nurse (in press)

Abstract: Tracheotomy has become a common procedure in the ICU and nurses need to provide proper care in order to prevent complications. One of the most important considerations for any tracheostomy patient is effective mobilization of secretions, and this consists of adequate hydration, vigorous physical activity, and removal of secretions. The suction catheter is your most important tool. Each bedside should be equipped with a functional suction system, oxygen source, and manual resuscitation bag, as well as a complete tracheostomy kit, which should accompany patients wherever they go in the hospital. Cuff pressure should be between 20-25 cm H2O, and cuffs should be deflated as soon as possible. Tracheomalacia is a common complication of tracheostomies and can be prevented by proper attention to cuff pressure and minimizing traction against the tube. Tracheostomy emergencies generally include hemorrhage, obstruction, or dislodgement/decannulation and a plan is presented for management of emergencies.

Contact: Linda L. Morris:  lmorris8305@comcast.net

Title: The importance of tracheostomy progression in the ICU

Authors: Morris, LL, McIntosh, E, Whitmer, A

Journal: Critical Care Nurse (in press)

Abstract: Unless a tracheostomy has been placed for irreversible conditions, there should be a plan to progress a patient toward decannulation. 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. This paper provides a systematic approach to tracheostomy progression and discusses how the critical care nurse can facilitate the process.

Contact: Linda L. Morris: lmorris8305@comcast.net