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OBJECTIVE: To describe a quality improvement (QI) method to decrease pediatric accidental decannulation (AD) in the early postoperative period for children under age 3. METHODS: A retrospective chart review was conducted on children under age 3 who underwent tracheostomy at Duke University Health System from August 1, 2013 to May 1, 2023 (n = 104). A root cause analysis was used to assess factors associated with AD following pediatric tracheostomy. Based on the factors identified by the research team, retrospective data was collected before (8/1/13 - 1/31/22) and after (2/1/22 - 5/1/23) a single practice change was implemented: using twill neck ties, rather than foam neck ties, to secure newly-placed tracheostomy tubes. Twill ties were applied intraoperatively as a visual cue to signal a recent tracheostomy for the interdisciplinary care team. The primary outcome in the pre-intervention and post-intervention period was measured as 30-day incidence of AD per 10 tracheostomy cases. RESULTS: Prior to the intervention, a total of 11 ADs occurred in 9 patients across 93 pediatric tracheostomies (1.18 AD per 10 cases). Afterward, 0 ADs occurred across 11 pediatric tracheostomies (0 AD per 10 cases). CONCLUSION: This data suggests that the twill tie intervention may prevent AD and the associated morbidity. With the twill tie initiative, we describe 11 ADs and associated risk factors and present a QI intervention that may help prevent AD and improve patient safety in the early postoperative period.

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OBJECTIVES: An increasing number of pediatric patients undergo tracheostomy placement annually. Despite advances in care, these patients remain at high risk for postoperative complications, including respiratory infections. The risk factors for positive respiratory cultures and the impact of culture positivity on overall morbidity and mortality in this population is not fully characterized. STUDY DESIGN AND SETTING: Retrospective cross-sectional analysis of all patients within a single tertiary care institution who underwent tracheostomy placement from January 1, 2019 to 12/31/2021. METHODS: We collected patient demographic information, comorbidities, primary indication for tracheostomy placement, and respiratory culture information preoperatively and postoperatively. The primary outcome measure was positive bacterial respiratory culture with speciation within 1, 3, or 6 months of tracheostomy placement. The secondary outcome measure was all-cause mortality within the study period. RESULTS: A total of 180 patients with median (IQR) age of 5.2 (3.4-31.0) months at time of tracheostomy placement were included in the study. Nearly half of patients had a positive culture within 1 month (n = 81,47.4 %) while 63.7 % of patients were positive within 6 months of tracheostomy placement (n = 109). Risk factors included respiratory and/or cardiac comorbidities. Positive respiratory cultures within 6 months of surgery and cardiac and/or neurologic comorbidities were associated with increased all-cause mortality following tracheostomy placement. CONCLUSIONS: Positive respiratory cultures are common following tracheostomy placement, more so in patients with cardiac and pulmonary comorbid conditions. Positive cultures are associated with increased all-cause mortality. More work is necessary to determine optimal screening frequency and treatment protocols for positive cultures in this population.

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Neurosurgical interventions within the ventral surface of the clivus and upper cervical vertebrae in childhood are sometimes carried out through transoral approach. In this situation, tracheostomy is safer for airway protection and mechanical ventilation compared to prolonged intubation. The world experience of percutaneous dilation tracheostomy in pediatric patients is limited due to anatomical and physiological features, such as difficult orientation in anatomical landmarks, high mobility of the trachea and small tracheal lumen. Also, the trachea easily collapses when pressed in pediatric patients that complicates safe puncture of anterior wall and can lead to perforation of posterior tracheal wall. OBJECTIVE: To describe a modified technique of video-assisted percutaneous dilation tracheostomy using additional thin guide and dilator in children of primary school age. MATERIAL AND METHODS: We considered 11 patients aged 6-12 years who underwent video-assisted percutaneous dilation tracheostomy. RESULTS: There were no perioperative complications (bleeding, false course, perforation of posterior tracheal wall). Infection of tracheostomy, fistulas or tracheal stenosis was absent. CONCLUSION: Percutaneous dilation tracheostomy may be alternative to classical surgical tracheostomy for pediatric patients. Endoscopic control and certain technical changes of percutaneous tracheostomy are necessary and provide safe manipulation. Surgery time, less trauma and minimal cosmetic defect after tracheostomy are significant advantages of this technique compared to surgical tracheostomy.

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PURPOSE: We assessed the effects of tracheostomy timing (early vs. late) on outcomes among adult patients receiving mechanical ventilation. METHODS: PubMed, Embase, Web of Science and Cochrane Library were searched to identify relevant RCTs of tracheotomy timing on patients receiving mechanical ventilation. Two reviewers independently screened the literature, extracted data. Outcomes in patients with early tracheostomy and late tracheostomy groups were compared and analyzed. Meta-analysis was performed using Stata14.0 and RevMan 5.4 software. This study is registered with PROSPERO (CRD42022360319). RESULTS: Twenty-one RCTs were included in this Meta-analysis. The Meta-analysis indicated that early tracheotomy could significantly shorten the duration of mechanical ventilation (MD: -2.77; 95% CI -5.10~ -0.44; P = 0.02) and the length of ICU stay (MD: -6.36; 95% CI -9.84~ -2.88; P = 0.0003), but it did not significantly alter the all-cause mortality (RR 0.86; 95% CI 0.73~1.00; P = 0.06), the incidence of pneumonia (RR 0.86; 95% CI 0.74~1.01; P = 0.06), and length of hospital stay (MD: -3.24; 95% CI -7.99~ 1.52; P = 0.18). CONCLUSION: In patients requiring mechanical ventilation, the tracheostomy performed at an earlier stage may shorten the duration of mechanical ventilation and the length of ICU stay but cannot significantly decrease the all-cause mortality and incidence of pneumonia.

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BACKGROUND: Tracheostomy procedures inhibit swallowing, although details of subsequent recovery of oral intake remain unknown. This retrospective cohort study aimed to investigate factors influencing dysphagia improvement in patients with subacute stroke after tracheostomy. METHODS AND RESULTS: The study included 117 patients who underwent tracheostomy after subacute stroke, cerebral hemorrhage, or endogenous subarachnoid hemorrhage and received care at 2 convalescent rehabilitation wards in urban and suburban Japan between 2015 and 2022. The primary outcome measure was the achievement of complete oral intake. Patient demographics, Functional Independence Measure scores, body mass index, food intake level scale scores, and the presence of severe white matter hyperintensities on imaging were retrospectively collected from medical records. Statistical analysis involved univariate logistic regression to identify potential predictors and multivariate logistic regression to refine the model while accounting for multicollinearity. In total, 47% of patients achieved complete oral intake on discharge. Sex, days from onset to admission, Functional Independence Measure motor and cognitive scores, body mass index, food intake level scale scores, and severe white matter hyperintensities were identified as potential predictors in the univariate analysis. However, multivariate logistic regression identified only food intake level scale scores (odds ratio [OR], 3.687 [95% CI, 1.519-8.949]; P=0.004) and severe white matter hyperintensities (OR, 0.302 [95% CI, 0.096-0.956]; P=0.042) as significant predictors of complete oral intake. CONCLUSIONS: In patients with subacute stroke undergoing tracheostomy, the level of oral intake on admission and severe white matter hyperintensities on imaging may be better predictors of complete oral intake. However, prospective studies with larger sample sizes and more comprehensive data are warranted to confirm these findings.

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BACKGROUND: Gossypiboma, a retained surgical sponge with a foreign body reaction, is an unusual but serious complication seen in open abdominal surgeries. It is exceptionally rare following head and neck surgeries. Here, we present a case of Gossypiboma of the upper airway following tracheostomy. CASE PRESENTATION: A 32-year-old male presented with stridor and difficulty breathing one-month post-tracheostomy after a severe head injury following a road traffic accident. A neck radiograph was unremarkable, and a computed tomography (CT) scan of the neck showed a well-defined homogenous curvilinear membrane extending from the hypopharynx to the upper trachea. Bronchoscopic evaluation of the larynx and upper trachea revealed a retained surgical sponge, which was retrieved. The patient's breathing improved drastically post intervention. CONCLUSION: Gossypiboma may go undetected in radiographs and may also present atypically as a homogenous membrane on a CT scan of the neck. Though rare, retained surgical items can have profound medicolegal and professional consequences on physicians. Hence, a strong clinical suspicion and vigilance for gossypiboma is necessary for patients presenting with respiratory distress post-tracheostomy.

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BACKGROUND: Tracheostomy-related acquired pressure injuries (TRPIs) are one of the hospital-acquired conditions. We hypothesize that an uneven ventilator circuit load, leading to non-neutral tracheostomy tube positioning in the immediate post-tracheostomy period, leads to an increased incidence of TRPIs. Does switching the ventilator circuit load daily, in addition to standard post-tracheostomy care, lead to a decreased incidence of TRPIs? METHODS: This is a prospective quality improvement study. Study was conducted at two academic hospital sites within tertiary care hospitals at Emory University in different ICUs. Consecutive patients undergoing bedside percutaneous tracheostomy by the interventional pulmonary service were included. The flip the ventilator circuit (FLIC) protocol was designed and implemented in selected ICUs, with other ICUs as controls. RESULTS: Incidence of TRPI in intervention and control group were recorded at post-tracheostomy day 5. A total of 99 patients were included from October 22, 2019, to May 22, 2020. Overall, the total incidence of any TRPI was 23% at post-tracheostomy day 5. Incidence of stage I, stage II, and stages III-IV TRPIs at postoperative day 5 was 11%, 12%, and 0%, respectively. There was a decrease in the rate of skin breakdown in patients following the FLIC protocol when compared with standard of care (13% vs. 36%; p = 0.01). In a multivariable analysis, interventional group had decreased odds of developing TRPI (odds ratio, 0.32; 95% CI, 0.11-0.92; p = 0.03) after adjusting for age, albumin, body mass index, diabetes mellitus, and days in hospital before tracheostomy. CONCLUSIONS: The incidence of TRPIs within the first week following percutaneous tracheostomy is high. Switching the side of the ventilator circuit to evenly distribute load, in addition to standard bundled tracheostomy care, may decrease the overall incidence of TRPIs.

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Posttransplant lymphoproliferative disorder is a life-threatening complication after solid-organ transplants. In adults, recipients of heart transplants have the highest risk, whereas renal transplant recipients have the lowest risk among all solid-organ transplants. The most common site for posttransplant lymphoproliferative disorders are gastrointestinal tract followed by the graft itself. Airway involvement in posttransplant lymphoproliferative disorder is rarely encountered. We report a case of a 26-year-old renal allograft recipient who presented to the emergency room with airway obstruction necessitating an emergency tracheostomy. Imaging revealed a left tonsillar mass extending into the nasopharynx and retropharyngeal space causing complete oropharyngeal occlusion. Endoscopic biopsy from nasopharyngeal mass showed a diffuse large B-cell lymphoma and was Ebstein-Barr virus positive. Reduction in immunosuppression and treatment with posttransplant lymphoproliferative disorder-1 risk-stratified approach resulted in complete remission.

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OBJECTIVE: Traditionally, pediatric tracheostomy has been viewed as a technically demanding procedure with a high complication rate, requiring the routine use of a formal operating room. Pediatric bedside tracheostomy in an intensive care unit (ICU) setting has not been widely reported, in contrast to the widespread adult bedside ICU tracheostomy. Transport of these critically ill, multiple life support systems dependent patients can be technically difficult, labor intensive, and potentially risky for these patients. Our study aimed to demonstrate the safety and efficacy of bedside tracheostomy in the pediatric ICU. MATERIALS AND METHODS: A retrospective analysis of all pediatric patients undergoing tracheostomy at a tertiary care center, between 1st of January 2013 and 31st of December 2019. RESULTS: During the study period, 117 pediatric patients underwent tracheostomy, 57 (48.7%) were performed bedside while 60 (51.3%) were performed in the operating room. Patients' ages ranged from 2 weeks to 17 years of age, with a median age of 16 months. No case of bedside tracheostomy necessitated a shift to the operating room. There was no difference in 30-day morbidity and mortality between the 2 groups. CONCLUSIONS: Our results suggest that pediatric open bedside tracheostomy in an ICU setting is a safe procedure, with similar complications and outcomes compared to tracheostomy performed in the operating room.

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Increasing use of tracheal expandable metallic hybrid stents will lead to common encounters with these devices in emergency airway management. The presence of these stents qualifies any patient as a challenge when an emergency tracheostomy is needed. We report an unorthodox technique of tracheostomy with concomitant removal of tracheal stent, without any major complications. Although the combined approach with bronchoscopy and tracheostomy has been reported in similar cases, we present a safe procedure when rigid bronchoscopy is not available.

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INTRODUCTION: Percutaneous dilatational tracheostomy (PDT) is a safe and cost-effective alternative to surgical tracheostomy. Cirrhotic patients often require ICU admission and prolonged mechanical ventilation. Patients with liver cirrhosis (LC) are known to have coagulopathy and relatively safe and simple procedures such as tracheostomy may be associated with high complication rates, specifically high bleeding rates. Current guidelines are unable to make a specific recommendation on the safety of PDT among cirrhotic patients. We aimed to evaluate the safety of PDT in critically ill patients with LC. METHODS: A retrospective chart review identified critically ill patients who underwent PDT between January 2012 and March 2023. The study group was defined as all patients with a diagnosis of LC. The primary outcome was early (7-day) bleeding, categorized as minor or major. Secondary outcomes were PDT-related and 30-day all-cause mortality. Propensity score matching was performed to adjust the imbalances between the groups. RESULTS: A total of 1,628 were included in the analysis. Thirty-three of them (2.0%) had LC. In the LC group, only 1 patient (3.0%, 95% CI: 0.0-15.8%) developed early bleeding. Intra-operative, early, late bleeding, and PDT-related mortality rates did not differ significantly between those with LC and those without. CONCLUSION: This retrospective cohort study indicates that PDT can be safely performed in critically ill cirrhotic patients, without significantly increasing the risk of bleeding complications.

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BACKGROUND: Tracheostomies provide many advantages for the care of patients who are critically ill but may also result in complications, including tracheostomy-related pressure injuries. Research efforts into the prevention of these pressure injuries has resulted in specialized clinical care teams and pathways. These solutions are expensive and labor intensive, and fail to target the root cause of these injuries; namely, pressure at the device-skin interface. Here we measure that pressure directly and introduce a medical device, the tracheostomy support system, to reduce it. METHODS: This was a cross-sectional study of 21 subjects in the ICU, each with a tracheostomy tube connected to a ventilator. A force-sensing resistor was used to measure baseline pressures at the device-skin interface along the inferior flange. This pressure was then measured again with the use of the tracheostomy support system in the inactive and active states. Resultant pressures and demographics were compared. RESULTS: Fifteen male and 6 female subjects, with an average age of 47 ± 14 (mean ± SD) years, were included in this study. Average pressures at the tracheostomy-skin interface at baseline in these 21 ICU subjects were 273 ± 115 (mean ± SD) mm Hg. Average pressures were reduced by 59% (median 62%, maximum 98%) with the active tracheostomy support system to 115 ± 83 mm Hg (P < .001). All the subjects tolerated the tracheostomy support system without issue. CONCLUSIONS: Despite best clinical practice, pressure at the tracheostomy-skin interface can remain quite high. Here we provide measures of this pressure directly and show that a tracheostomy support system can be effective at minimizing that pressure.

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BACKGROUND: Airway bleeding events are a rare incident in SARS-CoV-2-infected patients after tracheostomies. We aimed to explore the correlation between airway bleeding and SARS-CoV-2 infection and evaluate the consistency of SARS-CoV-2 RNA test results in the upper and lower airway samples from patients after tracheostomies. METHODS: Forty-four patients after temporary or permanent tracheostomy were divided into a positive group (29 patients) and a negative group (15 patients) based on the SARS-CoV-2 RNA test results of their oropharyngeal swabs. The oropharyngeal and tracheal swabs of the positive group were re-collected for SARS-CoV-2 RNA detection. Demographic and clinical characteristics and airway bleeding events were recorded for all enrolled patients. RESULTS: Airway bleeding was reported in eleven patients of the positive group (11/29), with seven displaying bloody sputum or hemoptysis, and four featuring massive sputum crust formation in the trachea that resulted in dyspnea, and only one patient in the negative group (1/15), with a significant difference in the airway bleeding rate (37.9% vs. 6.7%, p < 0.05). The SARS-CoV-2 RNA test results showed a statistical difference in cycle threshold (Ct) values between oropharyngeal swabs and tracheal swabs (p < 0.05). CONCLUSIONS: After tracheostomies, patients are more susceptible to airway bleeding if they are infected with SARS-CoV-2. The findings signify that in addition to droplet transmission through tracheostoma, SARS-CoV-2 may infect the oropharynx by airborne and close contact transmission, and that given the higher viral load and longer infection time in the trachea, tracheal swabs are more reliable for SARS-CoV-2 detection in these patients.

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INTRODUCTION: Bone flap replacement after a decompressive craniectomy is a low complexity procedure, but with complications that can negatively impact the patient's outcome. A better knowledge of the risk factors for these complications could reduce their incidence. PATIENTS AND METHODS: A retrospective review of a series of 50 patients who underwent bone replacement after decompressive craniectomy at a tertiary center over a 10-year period was performed. Those clinical variables related to complications after replacement were recorded and their risk factors were analyzed. RESULTS: A total of 18 patients (36%) presented complications after bone flap replacement, of which 10 (55.5%) required a new surgery for their treatment. Most of the replacements (95%) were performed in the first 90 days after the craniectomy, with a tendency to present more complications compared to the subsequent period (37.8% vs 20%, p > 0.05). The most frequent complication was subdural hygroma, which appeared later than infection, the second most frequent complication. The need for ventricular drainage or tracheostomy and the mean time on mechanical ventilation, ICU admission, or waiting until bone replacement were greater in patients who presented post-replacement complications. Previous infections outside the nervous system or the surgical wound was the only risk factor for post-bone flap replacement complications (p = 0.031). CONCLUSIONS: Postoperative complications were recorded in more than a third of the patients who underwent cranial bone flap replacement, and at least half of them required a new surgery. A specific protocol aimed at controlling previous infections could reduce the risk of complications and help establish the optimal time for cranial bone flap replacement.

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OBJECTIVES: To describe the epidemiology, surgical complications, and long-term outcomes after tracheostomy in pediatric oncology and/or hematopoietic stem cell transplantation (HSCT) patients in U.S. Children's Hospitals. DESIGN: Retrospective cohort from the Pediatric Health information System (PHIS) database, 2009-2020. SETTING: The PHIS dataset incorporates data from 48 pediatric hospitals in the Children's Hospital Association. PATIENTS: Patients 0-21 years old with an oncologic diagnosis and/or underwent HSCT, received a tracheostomy, and were discharged from hospital between January 1, 2009, and December 31, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 1061 patients included in the dataset, and 217 (20.5%) had undergone HSCT. The annual prevalence in tracheostomy usage did not change over the study period. The majority of patients (62.2%) underwent tracheostomy early (< 30 d) in the admission and those who underwent the procedure later (> 90 d) had a significant increase in mortality (52.6% vs. 17.6%; p < 0.001) and mechanical ventilation (MV) at discharge (51.9% vs. 24.5%; p < 0.001) compared with the early tracheostomy patients. Complications reported included tracheostomy site bleeding (< 1%) and infection (24%). The overall rate of MV at discharge was 32.6% and significantly associated with chronic lung (adjusted odds ratio [OR], 1.54; 95% CI, 1.03-2.32) and acute lung disease (OR, 2.18; 95% CI, 1.19-3.98). The overall rate of mortality was 19.6% within the cohort and significantly associated with HSCT (OR, 5.45; 95% CI, 3.88-7.70), diagnosis of sepsis (OR, 2.09; 95% CI, 1.28-3.41), and requirement for renal replacement therapy (OR, 2.76; 95% CI, 1.58-4,83). CONCLUSIONS: This study demonstrated a static prevalence of tracheostomy placement in the cohort population relative to the increasing trends in other reported groups. Regardless of underlying diagnosis, the study patients incurred substantial morbidity and mortality. However, tracheostomy specific complication rates were comparable with that of the general pediatric population and were not associated with increased odds of mortality within this population.

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Children with tracheostomies have multiple challenges with respect to achieving normal deglutition. These children may have underlying neurologic or genetic conditions that can predispose to dysphagia, but even in children without underlying comorbidities, the presence of a tracheostomy tube impacts the mechanics of swallowing, leading to difficulty with different consistencies as well as management of normal oral secretions. Intubation prior to tracheostomy also impacts sensation in the upper aerodigestive tract increasing the risk of aspiration. Occlusion of the tracheostomy with a speaking valve or cap improves outcomes in swallow and prognosis for oral feeding.

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OBJECTIVE: The number of tracheostomies performed annually in resource-rich countries is estimated at 250,000. While an essential procedure, approximately 20% to 30% of patients will experience at least 1 tracheostomy-related adverse event. Within tracheostomy care and across wider health care environments, quality improvement (QI) programs have been shown to reduce patient harm and improve outcomes. Herein we report on a 5-year long, tracheostomy QI initiative aimed at improving patient experience and reducing the frequency and severity of adverse events. METHODS: A 5-year (ongoing) QI initiative led by the Cardiff and Vale University Health Board tracheostomy team, within a tertiary, 1000-bedded hospital in South Wales, United Kingdom. The QI initiative has focused on 3 main themes: (1) Education and training; (2) Clinical oversight and decision making; and (3) improved data collection. Data were collected from existing tracheostomy databases. RESULTS: Over the past 5 years, we have observed a sustained reduction in both the frequency and severity of adverse events, with less than 1 patient per 100 experiencing a moderate or severe adverse event. This has resulted in improvements in patient experience and a cost reduction of £GBP364,726 per annum. DISCUSSION: Our 5-year ongoing tracheostomy QI initiative has resulted in improved outcomes with increased achievement of tracheostomy weaning markers and sustained reductions in both the frequency and severity of adverse events. IMPLICATIONS FOR PRACTICE: A continuous focus on QI is associated with improved patient and service outcomes. These improvements can be spread and scaled to benefit more patients and organizations.

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INTRODUCTION: With its introduction in 1986, the use of metal tracheal stents gained favor due to relative ease of deployment and reduced risk of stent migration and mucus plugging. However, adverse events associated with metal stenting led the FDA to publish a recommendation against its use for benign airway stenosis in 2005. We present a case which illustrates the difficulty in removal of a metal stent from the airway. CASE REPORT: Our patient is a 47-year-old woman with a history of postintubation tracheal stenosis. She underwent multiple interventions with Thoracic Surgery at an outside facility, including stenting with an Ultraflex expandable metal stent. Her course was complicated by recurrent intraluminal granulation tissue, which led to placement of additional metal stents, as well as a tracheostomy due to obstructive proximal granulation tissue. On presentation at our institution, removal of the stents was recommended due to recurrent tracheitis and proximity of stent fragments to the innominate artery on CT imaging. She underwent direct microlaryngoscopy and bronchoscopy, and stent fragments were removed using a hemostat through the trach stoma. Postoperative imaging has confirmed retained stent fragments, and additional procedures have been required for further removal. DISCUSSION/CONCLUSION: Removal of metal stents from the trachea is challenging for several reasons. Neoepithelization of respiratory mucosa makes identification of fragments difficult. Furthermore, growth of granulation tissue through the metal lattice framework, as well as the stents' tendency to fracture, complicates extraction. This case illustrates the dangers of metal stenting for benign airway stenosis. Laryngoscope, 134:3977-3980, 2024.

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