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Abstract Background Respiratory distress and failure is a complication of the coronavirus disease (COVID-19) and tracheostomy may be necessary in cases of prolonged intubation in order to reduce mechanical ventilation duration. However, according to the Canadian Society of Otolaryngology-Head and Neck Surgery guidelines, which our institution applies, patients should not undergo tracheostomy unless cleared of the virus to reduce its spread among healthcare workers because tracheostomy is an aerosolized procedure. This study aimed to identify the outcomes of prolonged intubation in patients with and without COVID-19 who underwent tracheostomy and to determine the morbidity and mortality rates in both groups. Methods This retrospective cohort study included adult patients admitted to the intensive care unit of King Fahad Hospital of the University, Alkhobar, Saudi Arabia, between March 1 and October 31, 2020. This study compared and analyzed the outcomes of delayed tracheostomy in patients with and without COVID-19 in terms of complication, morbidity, and mortality rates. Results Of the 228 study participants, 111 (48.68%) had COVID-19. The mean age of the study participants was 58.67 years (SD = 17.36, max.=93, min.=20), and the majority were males (n = 149, 65.35%). Regarding tracheostomy in patients with COVID-19, 11 (9.91%) patients underwent tracheostomy; however, four (36.36%) of them had prolonged intubation. The mean intensive care unit admission length of stay for tracheostomy patients was 37.17 days, while it was 12.09 days for patients without tracheostomy (t(226)=-9.32, p

Background: Respiratory distress and failure is a complication of the coronavirus disease (COVID-19) and tracheostomy may be necessary in cases of prolonged intubation in order to reduce mechanical ventilation duration. However, according to the Canadian Society of Otolaryngology-Head and Neck Surgery guidelines, which our institution applies, patients should not undergo tracheostomy unless cleared of the virus to reduce its spread among healthcare workers because tracheostomy is an aerosolized procedure. This study aimed to identify the outcomes of prolonged intubation in patients with and without COVID-19 who underwent tracheostomy and to determine the morbidity and mortality rates in both groups. Methods: This retrospective cohort study included adult patients admitted to the intensive care unit of King Fahad Hospital of the University, Alkhobar, Saudi Arabia, between March 1 and October 31, 2020. This study compared and analyzed the outcomes of delayed tracheostomy in patients with and without COVID-19 in terms of complication, morbidity, and mortality rates. Results: Of the 228 study participants, 111 (48.68%) had COVID-19. The mean age of the study participants was 58.67 years (SD = 17.36, max.=93, min.=20), and the majority were males (n = 149, 65.35%). Regarding tracheostomy in patients with COVID-19, 11 (9.91%) patients underwent tracheostomy; however, four (36.36%) of them had prolonged intubation. The mean intensive care unit admission length of stay for tracheostomy patients was 37.17 days, while it was 12.09 days for patients without tracheostomy (t(226)=-9.32, p < 0.001). Regarding prolonged intubation among patients with COVID-19 (n = 7, 6.31%), the complications were as follows: six people (85.71%) had dysphonia, one (14.29%) had vocal cord granuloma, and two (28.57%) had subglottic tracheal stenosis. The mortality rate among our study participants was 51.32%, and the risk was significantly higher in older people (Odds ratio = 1.04, 95% Confidence Interval [CI] = 1.02–1.06) and in delayed tracheostomy cases (OR = 2.95, 95% CI = 1.31–6.63). However, COVID-19 status was not significantly related to the risk of mortality. Conclusions: Delaying tracheostomy increases the risk of mortality. Therefore, we recommend weighing the risks and benefits for each patient to benefit both healthcare workers and patients with COVID-19. [ABSTRACT FROM AUTHOR]

Introduction The optimal time for tracheostomy changes is unknown. Most surgeons opt to wait until five to seven days postoperatively, while more recent studies suggest that changes occurring as early as two to three days postoperatively are also safe. Objective To evaluate the safety of changing the tracheostomy tube later than 14 days postoperatively. Methods The charts of patients who underwent tracheostomy placement and change at a tertiary care center from 2015 to 2019 were retrospectively reviewed, and the subjects were divided into 2 cohorts (late and very late), depending on the time of the first tracheostomy change. Results The study included 198 patients, 53 of whom aged between 0 and 18 years, and 145, aged > 18 years. The time until the first tracheostomy change was on average of 131.1 days. The most common indication for tracheostomy tube placement was prolonged intubation. Adverse events were observed in 30.8% of the cases (the most common being the formation of granulation tissue), a rate that does not differ much from the incidence reported in the literature (of 34% to 77%) when tracheostomy tubes are changed as early as 3 to 7 days postoperatively. There was no significant difference in the incidence of complications between patients undergoing late and very late changes (p = 0.688), or between pediatric and adult subjects (p = 0.36). There were no significant correlations regarding the time of the first or second change and the incidence of complications (r = −0.014; p = 0.84 for the first change; and r = −0.57; p = 0.64 for the second change). Conclusion The late first tracheostomy tube change was safe and could save resources and decrease the financial burden of frequent changes. It is always crucial to provide adequate information about home tracheostomy care for patients. [ABSTRACT FROM AUTHOR]

Airway complications that occur after anterior cervical spine surgery pose a life-threatening risk, which encompasses complications including prolonged intubation, unplanned reintubation, and/or necessity of tracheostomy. The present study aimed to identify the surgical risks associated with postoperative airway complications in neurosurgical training institutes. A retrospective, multicenter, observational review of data from 365 patients, who underwent anterior cervical spine surgery between 2018 and 2022, at three such institutes was carried out. Postoperative airway complication was defined as either the need for prolonged intubation on the day of surgery or the need for unplanned reintubation. The perioperative medical information was obtained from their medical records. The average age of the cohort was over 60 years, with males comprising approximately 70%. Almost all surgeries predominantly involved anterior cervical discectomy and fusion or anterior cervical corpectomy and fusion, with most surgeries occurring at the level of C5/6. In total, 363 of 365 patients (99.5%) were extubated immediately after surgery, and the remaining two patients were kept under intubation because of the risk of airway complications. Of the 363 patients who underwent extubation immediately after surgery, two (0.55%) required reintubation because of postoperative airway complications. Patients who experienced airway complications were notably older and exhibited a significantly lower body mass index. The results of this study suggested that older and frailer individuals are at an elevated risk for postoperative airway complications, with immediate postoperative extubation generally being safe but requiring careful judgment in specific cases.

Background: Tracheostomy procedures are performed in the intensive care unit (ICU) for prolonged intubation, unsuccessful weaning and infection prevention through either percutaneous or surgical techniques. This study aimed to outline the impact of tracheostomy timing in the ICU on mortality, need for mechanical ventilation, and complications. Methods: Patients were included in the study on the day of tracheostomy. Demographic information, tracheostomy timing, technique, complications, sedation requirement and need for mechanical ventilation at discharge were recorded by an anesthesiologist, including the pre-tracheostomy period. Results: Tracheostomy was performed on 33 patients during the first 14 days of intubation and on 54 patients on the 15th day and beyond. There was no significant difference between the tracheostomy timing and mortality, sedation requirement, or weaning from the ventilator. We observed that patients who underwent tracheostomy with the surgical technique experienced more complications, but there was no significant difference. Tracheostomy performed after the 14th day was shown to be associated with prolonged hospital stay. Conclusions: Early tracheostomy does not have any influence on the need for mechanical ventilation, sedation and mortality. The optimal timing for tracheostomy is still controversial. We are of the opinion that randomized controlled trials involving patient groups with similar survival expectations are needed. [ABSTRACT FROM AUTHOR]

Introduction The optimal time for tracheostomy changes is unknown. Most surgeons opt to wait until five to seven days postoperatively, while more recent studies suggest that changes occurring as early as two to three days postoperatively are also safe.

Abstract Background The tracheo-innominate fistula is a rare and potentially life-threatening entity that occurs in approximately less than 1% of patients after a tracheostomy. It occurs when the anterior wall of the trachea erodes and comes into contact with the posterior wall of the innominate artery or brachiocephalic trunk due to excessive pressure from the hyperinflation of the cuff over the mucosa, creating a fistulous tract. Clinically, it manifests as massive tracheal bleeding that puts the patient's life at imminent risk. Case presentation We present the case of a 60-year-old Latin American male patient with a history of SARS CoV-2 pneumonia approximately 4 months earlier, who required prolonged orotracheal intubation and tracheostomy due to subglottic stenosis, which required tracheal dilations. The patient was admitted to the emergency department due to hemoptysis associated with hemodynamic instability and later on presented with massive tracheal bleeding. The chest-CT angiography evidenced a tracheo-innominate fistula that required surgical management. A concomitant Mycobacterium Tuberculosis infection was also diagnosed during his hospitalization. Conclusions There are currently many gaps in our knowledge about the tracheo-innominate fistula, mainly in terms of its incidence following the SARS-CoV-2 pandemic, as well as the role that concomitant infections and their treatments, such as tuberculosis, play in the development of these events. During the pandemic, the cases of intubated patients and patients with tracheostomies increased, giving way to new and unexpected complications, we have yet to study in depth.

Stridor is an important symptom which should not be missed, especially in a child. The etiology could be multifactorial and will require a comprehensive investigation into its management. In this case, we discuss the clinician's dilemma in reaching a diagnosis due to various factors which were present in a single patient. This rare benign laryngeal squamous polyp was eventually diagnosed in an 11-week-old boy who presented with acute stridor. The diagnostic dilemma we discuss in this case was due to multiple maternal and fetal factors. He was a premature baby, intubated at birth, there was a maternal tuberculosis infection and he also had a cutaneous hemangioma which were all part of the diagnostic dilemma faced in his management which eventually led to an acquired subglottic stenosis. Our discussion will focus on how a thorough and proper evaluation is needed especially when there are many deceptive clues or signs present in a patient. [ABSTRACT FROM AUTHOR]

Objective: In this study, we aimed to compare clinical features and outcomes of tracheotomies performed in our clinic before and during the COVID-19 pandemic, with a special focus on coronavirus disease 2019 (COVID-19) positive cases. Methods: The adult tracheotomy procedures performed in our clinic between 2018 and 2021 were retrospectively included in the study. Demographic data, indications, intubation periods, complications, and survival data were retrospectively analyzed and compared for the periods before and during the pandemic, as well as between patients with and without COVID-19. Results: In the years considered, 84 (58.7%) male and 59 (41.3%) female patients underwent tracheotomies performed by our surgical team, for a total of 143 patients. The mean age of these patients was 60.9 ± 17.2 years. The indications for tracheotomy were chronic illness requiring long-term intubation in 80 (55.9%) cases and prevention or treatment of upper airway obstruction in 63 (44.1%) cases. Four (2.8%) patients developed pneumothorax after the operation. While 86 patients were operated on during the COVID-19 pandemic (2020-2021), only 9 (10.5%) of them were polymerase chain reaction (PCR)-positive for COVID-19. No significant differences were seen between the periods before and during the pandemic regarding age, gender, indications, intubation period, complications, or survival data of the patients (P > .05). Likewise, no increased risk of complications or decreased survival was observed for patients with COVID-19 (P > .05). Conclusion: According to our findings, the COVID-19 pandemic did not significantly affect the indications, complications, or survival rates of tracheotomies performed in our clinic. Tracheotomies may be performed safely even for patients with COVID-19 after taking the necessary precautions. [ABSTRACT FROM AUTHOR]

Background: The tracheo-innominate fistula is a rare and potentially life-threatening entity that occurs in approximately less than 1% of patients after a tracheostomy. It occurs when the anterior wall of the trachea erodes and comes into contact with the posterior wall of the innominate artery or brachiocephalic trunk due to excessive pressure from the hyperinflation of the cuff over the mucosa, creating a fistulous tract. Clinically, it manifests as massive tracheal bleeding that puts the patient's life at imminent risk. Case presentation: We present the case of a 60-year-old Latin American male patient with a history of SARS CoV-2 pneumonia approximately 4 months earlier, who required prolonged orotracheal intubation and tracheostomy due to subglottic stenosis, which required tracheal dilations. The patient was admitted to the emergency department due to hemoptysis associated with hemodynamic instability and later on presented with massive tracheal bleeding. The chest-CT angiography evidenced a tracheo-innominate fistula that required surgical management. A concomitant Mycobacterium Tuberculosis infection was also diagnosed during his hospitalization. Conclusions: There are currently many gaps in our knowledge about the tracheo-innominate fistula, mainly in terms of its incidence following the SARS-CoV-2 pandemic, as well as the role that concomitant infections and their treatments, such as tuberculosis, play in the development of these events. During the pandemic, the cases of intubated patients and patients with tracheostomies increased, giving way to new and unexpected complications, we have yet to study in depth. [ABSTRACT FROM AUTHOR]

ObjectivesProlonged intubation (PI) is a frequently encountered severe complication among patients following cardiac surgery (CS). Solely concentrating on preoperative data, devoid of sufficient consideration for the ongoing impact of surgical, anesthetic, and cardiopulmonary bypass procedures on subsequent respiratory system function, could potentially compromise the predictive accuracy of disease prognosis. In response to this challenge, we formulated and externally validated an intelligible prediction model tailored for CS patients, leveraging both preoperative information and early intensive care unit (ICU) data to facilitate early prophylaxis for PI.MethodsWe conducted a retrospective cohort study, analyzing adult patients who underwent CS and utilizing data from two publicly available ICU databases, namely, the Medical Information Mart for Intensive Care and the eICU Collaborative Research Database. PI was defined as necessitating intubation for over 24 h. The predictive model was constructed using multivariable logistic regression. External validation of the model's predictive performance was conducted, and the findings were elucidated through visualization techniques.ResultsThe incidence rates of PI in the training, testing, and external validation cohorts were 11.8%, 12.1%, and 17.5%, respectively. We identified 11 predictive factors associated with PI following CS: plateau pressure [odds ratio (OR), 1.133; 95% confidence interval (CI), 1.111–1.157], lactate level (OR, 1.131; 95% CI, 1.067–1.2), Charlson Comorbidity Index (OR, 1.166; 95% CI, 1.115–1.219), Sequential Organ Failure Assessment score (OR, 1.096; 95% CI, 1.061–1.132), central venous pressure (OR, 1.052; 95% CI, 1.033–1.073), anion gap (OR, 1.075; 95% CI, 1.043–1.107), positive end-expiratory pressure (OR, 1.087; 95% CI, 1.047–1.129), vasopressor usage (OR, 1.521; 95% CI, 1.23–1.879), Visual Analog Scale score (OR, 0.928; 95% CI, 0.893–0.964), pH value (OR, 0.757; 95% CI, 0.629–0.913), and blood urea nitrogen level (OR, 1.011; 95% CI, 1.003–1.02). The model exhibited an area under the receiver operating characteristic curve (AUROC) of 0.853 (95% CI, 0.840–0.865) in the training cohort, 0.867 (95% CI, 0.853–0.882) in the testing cohort, and 0.704 (95% CI, 0.679–0.727) in the external validation cohort.ConclusionsThrough multicenter internal and external validation, our model, which integrates early ICU data and preoperative information, exhibited outstanding discriminative capability. This integration allows for the accurate assessment of PI risk in the initial phases following CS, facilitating timely interventions to mitigate adverse outcomes.

Objective: To identify factors predictive of 30-day mortality following tracheotomy in patients with COVID-19. Methods: A retrospective chart review of patients with COVID-19 who underwent tracheotomy at a tertiary medical center between March 2020 and October 2021 was conducted. Univariate and multivariable analyses of factors correlated with 30-day post-tracheotomy mortality were performed. The outcomes of tracheotomies performed in the operating room and at bedside were compared with t-tests and multivariable analysis. Results: One hundred-twenty patients met inclusion criteria, with 48 female patients (40%). Mean age was 59.8 [12.6] years, and the 30-day mortality rate was 18.3%. On univariate analysis, age (odds ratio (OR) = 1.06; P =.015), FiO2 at the time of tracheotomy (OR = 1.06; P <.001), and bedside tracheotomy (OR = 3.21; P =.019) were associated with increased risk of 30-day mortality. After including control variables, increased FiO2 continued to predict increased odds of 30-day mortality (OR = 1.08; P =.02); specifically, patients with FiO2 > 65% were significantly more likely to pass within 30 days than those with FiO2 ≤ 40% (OR = 28.24; P <.001). There was a significant difference in the 30-day mortality rate of bedside tracheotomies (31%) and OR tracheotomies (12%; P =.02), but this association was eliminated on multivariable analysis (OR = 0.95; P =.96). Conclusion: Intubated patients with COVID-19 undergoing tracheotomy with FiO2 > 65% have 25 times greater odds of 30-day mortality than those with FiO2 ≤ 40%. There were no differences in outcomes between bedside and OR tracheotomies. [ABSTRACT FROM AUTHOR]

Many of the patients with COVID-19 have suffered respiratory distress requiring prolonged endotracheal intubation (ETI) resulting in laryngotracheal complication with an impact on breathing, phonation, and swallowing. Our aim is to describe laryngeal injuries diagnosed after ETI in patients with COVID-19 in a multicentre study. Methods: A prospective descriptive observational study was conducted from January 2021 to December 2021, including COVID-19 patients with laryngeal complications due to ETI diagnosed in several Spanish hospitals. We analyzed the epidemiological data, previous comorbidities, mean time to ICU admission and ETI, need for tracheostomy, mean time on invasive mechanical ventilation until tracheostomy or weaning, mean time in ICU, type of residual lesions, and their treatment. Results: We obtained the collaboration of nine hospitals during the months of January 2021 to December 2021. A total of 49 patients were referred. Tracheostomy was performed in 44.9%, being late in most cases (more than 7–10 days). The mean number of days of ETI until extubation was 17.63 days, and the main post-intubation symptoms were dysphonia, dyspnea, and dysphagia, in 87.8%, 34.7%, and 42.9%, respectively. The most frequent injury was altered laryngeal mobility, present in 79.6%. Statistically, there is a greater amount of stenosis after late ETI and after delayed tracheostomy, not observing the data with the immobility alterations. Conclusion: The mean number of days of ETI was long, according to the latest guidelines, with the need for several cycles of pronation. This long ETI may have had an impact on the increase of subsequent laryngeal sequelae, such as altered laryngeal mobility or stenosis. [ABSTRACT FROM AUTHOR]

Purpose: Spinal metastasis surgeries carry substantial risk of complications. PRF is among complications that significantly increase mortality rate and length of hospital stay. The risk factor of PRF after spinal metastasis surgery has not been investigated. This study aims to identify the predictors of postoperative respiratory failure (PRF) and in-hospital death after spinal metastasis surgery. Methods: We retrospectively reviewed consecutive patients with spinal metastasis surgically treated between 2008 and 2018. PRF was defined as mechanical ventilator dependence > 48 h postoperatively (MVD) or unplanned postoperative intubation (UPI). Collected data include demographics, laboratory data, radiographic and operative data, and postoperative complications. Stepwise logistic regression analysis was used to determine predictors independently associated with PRFs and in-hospital death. Results: This study included 236 patients (average age 57 ± 14 years, 126 males). MVD and UPI occurred in 13 (5.5%) patients and 13 (5.5%) patients, respectively. During admission, 14 (5.9%) patients had died postoperatively. Multivariate logistic regression analysis revealed significant predictors of MVD included intraoperative blood loss > 2000 mL (odds ratio [OR] 12.28, 95% confidence interval [CI] 2.88–52.36), surgery involving cervical spine (OR 9.58, 95% CI 1.94–47.25), and ASA classification ≥ 4 (OR 6.59, 95% CI 1.85–23.42). The predictive factors of UPI included postoperative sepsis (OR 20.48, 95% CI 3.47–120.86), central nervous system (CNS) metastasis (OR 10.21, 95% CI 1.42–73.18), lung metastasis (OR 7.18, 95% CI 1.09–47.4), and postoperative pulmonary complications (OR 6.85, 95% CI 1.44–32.52). The predictive factors of in-hospital death included postoperative sepsis (OR 13.15, 95% CI 2.92–59.26), CNS metastasis (OR 10.55, 95% CI 1.54–72.05), and postoperative pulmonary complications (OR 9.87, 95% CI 2.35–41.45). Conclusion: PRFs and in-hospital death are not uncommon after spinal metastasis surgery. Predictive factors for PRFs included preoperative comorbidities, intraoperative massive blood loss, and postoperative complications. Identification of risk factors may help guide therapeutic decision-making and patient counseling. [ABSTRACT FROM AUTHOR]

Acquired tracheoesophageal fistula (TEF) is a rare and severe complication of intubation and tracheostomy, which can lead to serious comorbidities and high mortality. In this case report, we present a case with TEF in addition to multiple systemic diseases and infections, the patient's clinical fetures, diagnosis, and management. This case highlights the importance of considering acquired TEF as a potential sequelle of prolonged intubation and the need for prompt detection and treatment to prevent potentially life-threatening complications, including death. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to characterize the risk factors for posterior glottic injury (PGI) in patients with coronavirus disease 2019 (COVID‐19) who underwent prolonged intubation. Study Design: This was a case‐control study designed to assess the risk factors associated with development of PGI in COVID‐19 patients who underwent prolonged intubation. Setting: This single‐center study was conducted at a tertiary care academic hospital in a metropolitan area. Methods: We retrospectively reviewed patients who underwent prolonged intubation (≥7 days) for COVID‐19 and compared those with PGI to those without. Patient demographics, comorbidities, and intubation characteristics were compared. Factors associated with PGI development among COVID‐19 patients were assessed using multivariate regression. Results: We identified 56 patients who presented with PGI following prolonged intubation for COVID‐19 and 60 control patients who underwent prolonged intubation for COVID‐19 but did not develop PGI. On univariate analyses, the number of reintubations due to failed extubation efforts was significantly associated with development of PGI (odds ratio [OR], 2.9; 95% CI, 1.4‐6.2). On multivariate analyses, patients with cardiovascular disease (OR, 3.3; 95% CI, 1.2‐9.0); non–COVID‐19 respiratory illnesses, which included obstructive sleep apnea and asthma (OR, 5.9; 95% CI, 2.0‐17.8); and diabetes mellitus (OR, 11.6; 95% CI, 3.7‐36.6) were more likely to develop PGI. Conclusion: Our results represent the largest case‐control study investigating risk factors for PGI in the setting of prolonged intubation specific to COVID‐19. Our study suggests a significant role of comorbidities associated with poor wound healing with development of PGI. [ABSTRACT FROM AUTHOR]

Abstract Objective The acute treatment and complications of the novel COVID‐19 virus have been well studied, but the implications of this novel virus for swallowing function continue to be investigated. The goal of this study is to retrospectively assess airway and swallowing outcomes for those patients who required intensive care unit(ICU)‐level care for COVID‐19 infection. Study Design Comparison of swallowing outcomes through diet change in COVID‐19 patients in the Ochsner‐Louisiana State University (LSU) Hospital ICU. Setting Ochsner‐LSU Hospital (Shreveport, Louisiana). Methods A retrospective chart review was performed from March 2020 to May 2022 to identify patients with a primary diagnosis of COVID‐19. Variables analyzed include age, gender, length of intubation, length of ventilation, airway interventions, use of extracorporeal membrane oxygenation, and diet prior to, during, and after hospitalization for COVID‐19 infection. Results Two hundred and seven patients fit the inclusion criteria. There was a significant difference in discharge diet between those patients who were intubated and those who were not (P = .007). Thirty percent of patients were discharged on a different diet than their baseline with patients on a nonregular diet significantly more likely to discharge to a facility (P = .043). Negative vaccine status was associated with prolonged ICU stay, prolonged duration of intubation, and prolonged duration of ventilation. Conclusion COVID‐19 continues to present novel challenges with new implications and outcomes being discovered in the third year of the pandemic. Further research is necessary to determine the most effective treatment approaches with respect to optimized speech and swallow outcomes.

OBJECTIVE: The optimal timing of tracheostomy in nonneurologically injured mechanically ventilated critically ill adult patients is uncertain. We conducted a systematic review of randomized controlled trials to evaluate the effect of early versus late tracheostomy or prolonged intubation in this population. DATA SOURCES: We searched MEDLINE, Embase, CENTRAL, CINAHL, and Web of science databases for randomized controlled trials comparing early tracheostomy (<10 d of intubation) with late tracheostomy or prolonged intubation in adults. DATA SELECTION: We selected trials comparing early tracheostomy (defined as being performed less than 10 d after intubation) with late tracheostomy (performed on or after the 10th day of intubation) or prolonged intubation and no tracheostomy in nonneurologically injured patients. The primary outcome was overall mortality. Secondary outcomes included ventilator-associated pneumonia, duration of mechanical ventilation, ICU, and hospital length of stay. DATA EXTRACTION: Two reviewers screened citations, extracted data, assessed the risk of bias, and classification of Grading of Recommendations, Assessment, Development, and Evaluation independently. DATA SYNTHESIS: Our search strategy yielded 8,275 citations, from which nine trials (n = 2,457) were included. We did not observe an effect on the overall mortality of early tracheostomy compared with late tracheostomy or prolonged intubation (risk ratio, 0.91, 95% CI, 0.82–1.01; I 2 = 18%). Our results were consistent in all subgroup analyses. No differences were observed in ICU and hospital length of stay, duration of mechanical ventilation, incidence of ventilator-acquired pneumonia, and complications. Our trial sequential analysis showed that our primary analysis on mortality was likely underpowered. CONCLUSION: In our systematic review, we observed that early tracheostomy, as compared with late tracheostomy or prolonged intubation, was not associated with a reduction in overall mortality. However, we cannot exclude a clinically relevant reduction in mortality considering the level of certainty of the evidence. A well-designed trial is needed to answer this important clinical question. [ABSTRACT FROM AUTHOR]

Objective: The aim is to use a simulation lung model to assess the possibility of performing bronchoscopy through endotracheal tubes (ETT) less than 8.0‐mm while appropriately ventilating patients with normal and ARDS lungs in the setting of SARS‐CoV‐2. Methods: Five SHERIDAN® ETTs were used to ventilate SimMan® 3G under respiratory compliance levels representing normal and severe ARDS lungs. Baseline measurements of peak pressure, plateau pressure, and auto‐positive end expiratory pressure (auto‐PEEP) were recorded at four different inspiratory times (Ti). Three different‐sized disposable bronchoscopes were inserted, and all measurements were repeated. Results: Normal lung model: Slim bronchoscopes in 6.0‐mm ETTs resulted in plateau pressures <30 cm H2O, and increasing Ti to minimize peak pressure resulted in low auto‐PEEP. Regular bronchoscopes in 7.0‐mm ETTs had similar results. Large bronchoscopes in 7.5‐mm ETTs generated plateau pressures ranging from 28 to 35 cm H2O with modest auto‐PEEP. Severe ARDS lung model: Slim bronchoscopes in 6.0‐mm ETTs resulted in plateau pressures of 46 and an auto‐PEEP of 5 cm H2O. Regular bronchoscopes in 7.0‐mm ETTs generated similar results. Large bronchoscopes in 8.0‐mm ETTs displayed plateau pressures of 44 and an auto‐PEEP of 2 cm H2O. Conclusion: To mitigate risk of laryngeal injury, larger ETTs during bronchoscopy should be avoided. Our data show bronchoscopy with any ETT causes auto‐PEEP and high plateau pressures, especially in lungs with poor compliance; however, ETT less than 7.5 mm can be used when considering several factors. Our data also suggest similar studies in patients with varying degrees of ARDS would be informative. Level of Evidence: NA Laryngoscope, 133:147–153, 2023 [ABSTRACT FROM AUTHOR]

The aim of this study was to retrospectively evaluate all pediatric tracheotomies that had been performed at Sanliurfa Training and Research Hospital From September 2016 to July 2019. A retrospective study was performed on pediatric patients who had undergone tracheostomy during the three-year study period. Patient data were reviewed for the following variables: age, gender, age at the time of tracheostomy, primary indication for tracheostomy, length of stay in intensive care unit before and after tracheostomy, complications, mortality and cause of death. The primary indication for tracheostomy was categorized into 4 separate groups: congenital disease, traumatic injury, prolonged intubation and other causes. The study group consisted of 138 children. Seventy-one (51.4%) of the children were male, 67 (48.6%) were female and the mean age of tracheostomy was 13.30 (0.03–192.27) months, and 44.2% were younger than 1 year when tracheotomy was performed. The median age at the time of tracheostomy was highest in children who underwent tracheostomy for traumatic injury. The indication for tracheostomy was prolonged intubation in 73.2% of the children. Complications were observed in 13 (9%) children; bleeding (69.2%) was the most common. Complications were most frequent in children who underwent tracheostomy for prolonged intubation. The overall mortality ratewas 30.4% with cardiac arrest being the most common cause. At our center, the most common indication for tracheostomy in children was long-term intubation, possibly due to our center being a tertiary healthcare institute. Bleeding was the most common complication, while cardiac arrest was the most common cause of death. [ABSTRACT FROM AUTHOR]

Objective: To examine the impact of increased body mass index (BMI) on (1) tracheotomy timing and (2) short-term surgical complications requiring a return to the operating room and 30-day mortality utilizing data from the Multi-Institutional Study on Tracheotomy (MIST)., Methods: A retrospective analysis of patients from the MIST database who underwent surgical or percutaneous tracheotomy between 2013 and 2016 at eight institutions was completed. Unadjusted and adjusted logistic regression analyses were used to assess the impact of obesity on tracheotomy timing and complications., Results: Among the 3369 patients who underwent tracheotomy, 41.0% were obese and 21.6% were morbidly obese. BMI was associated with higher rates of prolonged intubation prior to tracheotomy accounting for comorbidities, indication for tracheotomy, institution, and type of tracheostomy (p = 0.001). Morbidly obese patients (BMI ≥35 kg/m 2 ) experienced a longer duration of intubation compared with patients with a normal BMI (median days intubated [IQR 25%-75%]: 11.0 days [7-17 days] versus 9.0 days [5-14 days]; p < 0.001) but did not have statistically higher rates of return to the operating room within 30 days (p = 0.12) or mortality (p = 0.90) on multivariable analysis. This same finding of prolonged intubation was not seen in overweight, nonobese patients when compared with normal BMI patients (median days intubated [IQR 25%-75%]: 10.0 days [6-15 days] versus 10.0 days [6-15 days]; p = 0.36)., Conclusion: BMI was associated with increased duration of intubation prior to tracheotomy. Although morbidly obese patients had a longer duration of intubation, there were no differences in return to the operating room or mortality within 30 days., Level of Evidence: 3 Laryngoscope, 134:4674-4681, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: The purpose of this retrospective study is to evaluate the outcome of Montgomery T-tube insertion in our institution (AIIMS, Raipur). This study also throws light on its indications and complications. Methods: This is a retrospective study of 10 patients who presented with laryngotracheal stenosis and managed by Laryngofissure with Montgomery Tube insertion in the Department of Otorhinolaryngology, Head and Neck Surgery atAll India Institute of Medical Sciences (AIIMS) Raipur, India, during the period of January 2018- JUNE 2020. Results: The most common cause of laryngotracheal stenosis was prolonged intubation as seen in 80% patients.Majority of patients (40%) in this study were in the 3rd decade. In this study all the patients underwent tracheostomy prior to treatment for stenosis. The most common complication seen was surgical emphysema in post-operative period seen in 6 patients (60%) followed by crusting in 4 patients (40%), secondary granulation tissue formation in 4 patients (40%). Montgomery tube reinsertion had to be done in 2 patients (20%). Conclusions: Laryngotracheal stenosis (LTS) has always been and will remain a challenge to the otolaryngologistsand a multidisciplinary approach is required to tackle it.A multitude of surgeries have been described for the management of Laryngotracheal stenosis ranging from Endoscopic dilatation and cricotracheal resection with anterior and posterior grafting and anastomosis but many of them require specialized training and expertise,prolonged ICU care and have morbidity and mortality. ‘Laryngofissure and Montgomery Tube stenting provides a safe and easy treatment option which can be done at most centres provided appropriate case selection has been done. [ABSTRACT FROM AUTHOR]

Abstract Background Tracheal stenosis following prolonged intubation is a relatively rare but serious problem. This condition is usually managed by surgical or endoscopic interventions. Bronchoscopic balloon dilatation for tracheal stenosis is considered a valuable tool used for the management of tracheal stenosis. In this article, we try to evaluate the role of balloon tracheoplasty in the management of tracheal stenosis and to assess the number of dilatation sessions usually needed as well as the short to midterm outcome. Results This study involved 40 patients with tracheal stenosis diagnosed by computed tomography (neck and chest) and bronchoscopy at the Security Force Hospital in Riyadh, KSA, between January 2013 and August 2018. Patients’ data were retrospectively reviewed and analyzed. Patients’ age ranged between 18 and 60 years. Thirty patients were males (75%); those patients underwent balloon tracheoplasty via dilatation of areas of narrowing using catheter balloon insufflation guided by fiber-optic bronchoscope. Ninety-five percent of the patients had initial success with acceptable dilatation of the stenotic area and improvement of the symptoms. There were no technical or major problems which resulted from the procedure, and no patient complained of severe pain or severe discomfort after the procedure. From the total of 81 BBD sessions, no in-hospital mortality is related to the procedure itself, and ICU stay ranged between 1 and 5 days post-procedure. Among those 40 patients, 16 patients (40%) needed one session, 10 patients (25%) needed two sessions, 8 patients (20%) needed three sessions, and 6 patients (15%) needed more than three sessions of balloon dilatation. Conclusion Balloon tracheoplasty is a simple, safe method and could be a promising and effective approach that offers immediate symptomatic relief for tracheal stenosis in cases with a history of prolonged intubation. It is worth mentioning that BBD is considered as a temporary measure, and most of the cases will need definitive or additional treatment either resection or stent placement.

Many of the patients with COVID-19 have suffered respiratory distress requiring prolonged endotracheal intubation (ETI) resulting in laryngotracheal complication with an impact on breathing, phonation, and swallowing. Our aim is to describe laryngeal injuries diagnosed after ETI in patients with COVID-19 in a multicentre study. Methods: A prospective descriptive observational study was conducted from January 2021 to December 2021, including COVID-19 patients with laryngeal complications due to ETI diagnosed in several Spanish hospitals. We analyzed the epidemiological data, previous comorbidities, mean time to ICU admission and ETI, need for tracheostomy, mean time on invasive mechanical ventilation until tracheostomy or weaning, mean time in ICU, type of residual lesions, and their treatment. Results: We obtained the collaboration of nine hospitals during the months of January 2021 to December 2021. A total of 49 patients were referred. Tracheostomy was performed in 44.9%, being late in most cases (more than 7–10 days). The mean number of days of ETI until extubation was 17.63 days, and the main post-intubation symptoms were dysphonia, dyspnea, and dysphagia, in 87.8%, 34.7%, and 42.9%, respectively. The most frequent injury was altered laryngeal mobility, present in 79.6%. Statistically, there is a greater amount of stenosis after late ETI and after delayed tracheostomy, not observing the data with the immobility alterations. Conclusion: The mean number of days of ETI was long, according to the latest guidelines, with the need for several cycles of pronation. This long ETI may have had an impact on the increase of subsequent laryngeal sequelae, such as altered laryngeal mobility or stenosis.

Abstract Background Persistent swallowing disorders (SD) are non-pulmonary complications of mechanical ventilation (MV). However, there are few clinical studies on persistent SD in critically ill patients undergoing tracheal intubation for MV. The aim of the present study was to assess the incidence and characteristics of clinical manifestations associated with persistent SD. Methods We prospectively evaluated in patients requiring more than 7 days of invasive MV the incidence and characteristics of clinical manifestations related to persistent SD. For this purpose, quality of swallowing was assessed within 24 h after extubation by an experienced physical therapist not directly involved in patient management. Swallowing assessment consisted in a specific standardized test combining a swallowing test and a full clinical evaluation of the cranial nerves involved in swallowing. In patients with SD on the first test, a second test was done within 48 h in order to discriminate between transient and persistent SD. Results Among the 482 patients mechanically ventilated more than 7 days, 138 were enrolled in this study. The first test performed 24 h after extubation revealed SD in 35 patients (25%). According to the second test performed 48 h later, SD were considered transient in 21 (15%) and persistent in 14 (10%) cases. Patients with persistent SD were older (66 ± 16 vs 58 ± 15 years), had lower bodyweight at admission (76 ± 15 vs 87 ± 23 kg) and received less often neuromuscular blocking agents (36% vs 66%) compared to patients without or with only transient SD. Patients with persistent SD had longer duration of Intensive Care Unit (ICU) stay after first extubation and longer delay to oral feeding than patients without or with only transient SD, respectively, 11 ± 9 vs 7 ± 6 days and 23 ± 33 vs 5 ± 7 days. Conclusions Based on a specific standardized clinical test, 25% of patients mechanically ventilated more than 7 days exhibited clinical manifestations of SD. However, SD were considered as persistent after extubation in only 10% of them. Persistent SD were associated with longer duration of ICU stay after extubation and longer time of enteral feeding. Trial registration: The study is registered with Clinical Trials (NCT01360580).

Objectives: To evaluate coronavirus disease 2019 (COVID-19) patient tracheostomy outcomes. Methods: All COVID-19 patients at the National Guard Hospital, Riyadh, Saudi Arabia, were retrospectively recruited. Those who had tracheostomies between April and December 2020 were included. Results: The population was 45 patients, of which 30 (66.7%) were males, 15 (33.3%) were females and the mean age was 66.76±12.74 years. The tracheostomy indications were anticipated prolonged weaning in 40 (88.9%) and failed extubation in 5 (11.1%) of the patients. The mean intubation to tracheostomy duration was 20.62±7.21 days. Mortalities were high, with most attributed to COVID-19. Mortality and a pre-tracheostomy C-reactive protein (CRP) uptrend were significantly related (p=0.039). Mortality and intubation to tracheostomy duration were not significantly related. The mean post-tracheostomy time to death was 10.64±6.9 days. Among the survivors, 20 (44.4%) males and 11 (24.4%) females were weaned off mechanical ventilation; 9 (20%) remained on ventilation during the study. The mean ventilation weaning time was 27.92±20 days. Conclusion: The high mortality rate was attributed to COVID-19. Mortality and a pre-tracheostomy CRP uptrend were significantly related; uptrend patients experienced far more mortalities than downtrend patients. Unlike previous findings, mortality and intubation to tracheostomy duration were not significantly related. [ABSTRACT FROM AUTHOR]

Laryngeal granuloma development can be a postoperative complication of laryngeal trauma or irritation resulting from general anesthesia and endotracheal intubation. These rare benign lesions are located primarily over the cartilaginous portions of the larynx, particularly the vocal processes of the arytenoids. Airway manipulation during the intubation process and prolonged intubation periods can be contributing factors to intubation-related laryngeal granulomas, which may manifest 1 to 4 months after intubation. The patient in this case was a female who returned with complaints of throat pain without hoarseness or sensations of a "lump in her throat" 3 months following surgery, during which she was intubated with a 7.0-mm nasotracheal tube for 30 hours, likely contributing to her bilateral laryngeal granulomas. The patient underwent successful conservative medical management consisting of a proton pump inhibitor and an inhaled corticosteroid. [ABSTRACT FROM AUTHOR]

Airway complications that occur after anterior cervical spine surgery pose a life-threatening risk, which encompasses complications including prolonged intubation, unplanned reintubation, and/or necessity of tracheostomy. The present study aimed to identify the surgical risks associated with postoperative airway complications in neurosurgical training institutes. A retrospective, multicenter, observational review of data from 365 patients, who underwent anterior cervical spine surgery between 2018 and 2022, at three such institutes was carried out. Postoperative airway complication was defined as either the need for prolonged intubation on the day of surgery or the need for unplanned reintubation. The perioperative medical information was obtained from their medical records. The average age of the cohort was over 60 years, with males comprising approximately 70%. Almost all surgeries predominantly involved anterior cervical discectomy and fusion or anterior cervical corpectomy and fusion, with most surgeries occurring at the level of C5/6. In total, 363 of 365 patients (99.5%) were extubated immediately after surgery, and the remaining two patients were kept under intubation because of the risk of airway complications. Of the 363 patients who underwent extubation immediately after surgery, two (0.55%) required reintubation because of postoperative airway complications. Patients who experienced airway complications were notably older and exhibited a significantly lower body mass index. The results of this study suggested that older and frailer individuals are at an elevated risk for postoperative airway complications, with immediate postoperative extubation generally being safe but requiring careful judgment in specific cases.

Objectives: Prolonged intubation (PI) is a frequently encountered severe complication among patients following cardiac surgery (CS). Solely concentrating on preoperative data, devoid of sufficient consideration for the ongoing impact of surgical, anesthetic, and cardiopulmonary bypass procedures on subsequent respiratory system function, could potentially compromise the predictive accuracy of disease prognosis. In response to this challenge, we formulated and externally validated an intelligible prediction model tailored for CS patients, leveraging both preoperative information and early intensive care unit (ICU) data to facilitate early prophylaxis for PI., Methods: We conducted a retrospective cohort study, analyzing adult patients who underwent CS and utilizing data from two publicly available ICU databases, namely, the Medical Information Mart for Intensive Care and the eICU Collaborative Research Database. PI was defined as necessitating intubation for over 24 h. The predictive model was constructed using multivariable logistic regression. External validation of the model's predictive performance was conducted, and the findings were elucidated through visualization techniques., Results: The incidence rates of PI in the training, testing, and external validation cohorts were 11.8%, 12.1%, and 17.5%, respectively. We identified 11 predictive factors associated with PI following CS: plateau pressure [odds ratio (OR), 1.133; 95% confidence interval (CI), 1.111-1.157], lactate level (OR, 1.131; 95% CI, 1.067-1.2), Charlson Comorbidity Index (OR, 1.166; 95% CI, 1.115-1.219), Sequential Organ Failure Assessment score (OR, 1.096; 95% CI, 1.061-1.132), central venous pressure (OR, 1.052; 95% CI, 1.033-1.073), anion gap (OR, 1.075; 95% CI, 1.043-1.107), positive end-expiratory pressure (OR, 1.087; 95% CI, 1.047-1.129), vasopressor usage (OR, 1.521; 95% CI, 1.23-1.879), Visual Analog Scale score (OR, 0.928; 95% CI, 0.893-0.964), pH value (OR, 0.757; 95% CI, 0.629-0.913), and blood urea nitrogen level (OR, 1.011; 95% CI, 1.003-1.02). The model exhibited an area under the receiver operating characteristic curve (AUROC) of 0.853 (95% CI, 0.840-0.865) in the training cohort, 0.867 (95% CI, 0.853-0.882) in the testing cohort, and 0.704 (95% CI, 0.679-0.727) in the external validation cohort., Conclusions: Through multicenter internal and external validation, our model, which integrates early ICU data and preoperative information, exhibited outstanding discriminative capability. This integration allows for the accurate assessment of PI risk in the initial phases following CS, facilitating timely interventions to mitigate adverse outcomes., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Wang, Zhu, Liu, Zhao, Zhang, Luo, Liu, Guo, Zhang and Yu.)

Background: In recent years, obese patients presenting with acute thoracic aortic dissection have not been uncommon and there are often pulmonary complications among them. Whether a higher body mass index (BMI) is associated with more pulmonary complications or even a higher mortality rate has yet to be determined. This study aimed to evaluate the effects of higher BMI on pulmonary complications and other surgical outcomes.Methods: A total of 404 patients who underwent acute thoracic aortic dissection surgery were retrospectively studied. They were divided into three groups based on their BMI: normal weight (BMI 18.5 to <25 kg/m2, n=173), overweight (BMI 25 to <30 kg/m2, n=145) and obese (BMI ≥30 kg/m2, n=86). Clinical data were collected and analysed among groups.Results: No statistical significance was detected among the groups for postoperative complications, in-hospital mortality and hospital or ICU stay, except for prolonged intubation, the proportion of which was highest in the obese group followed by the overweight and normal groups (40.7% vs 29% vs 11%, respectively; p<0.001). Furthermore, logistic regression analysis showed that postoperative renal failure (OR=16.984) and cardiopulmonary bypass time (OR=1.013) were independent risk factors for in-hospital mortality, while higher BMI (OR=7.148 for BMI ≥25 and 18.967 for BMI ≥30), transfused red blood cells (OR=1.004), and postoperative renal failure (OR=7.386) were independent risk factors for prolonged ventilation (p<0.05).Conclusion: Body mass index had no effect on in-hospital mortality but may be closely correlated with prolonged intubation for patients undergoing aortic dissection surgery. This finding suggests that these patients should receive more aggressive pulmonary management. [ABSTRACT FROM AUTHOR]

Objective: To examine the effect of including obesity with parameters of the I-TRACH scale in predicting the need for prolonged mechanical ventilation.Study Design: A retrospective cohort study.Setting: Tertiary care academic medical center.Subjects and Methods: Consecutive patients were identified retrospectively over a 45-month period based on need for mechanical ventilation in the medical intensive care unit. Chart review was performed to collect demographic information as well as clinical data, including duration of mechanical ventilation, body mass index (BMI), and I-TRACH parameters (heart rate >110, serum urea nitrogen >25, serum pH <7.25, serum creatinine >2, serum bicarbonate <20). Statistical analysis was performed to identify any predictors of prolonged mechanical ventilation, defined as ≥14 days and as ≥10 days.Results: In total, 455 patients were identified, with an average duration of mechanical ventilation of 10.4 days (range, 0-248 days). On univariate and multivariate regression analysis, only BMI >30 reached statistical significance with respect to prolonged mechanical ventilation (P < .05). The I-TRACH parameters-either alone or in combination-were not significantly predictive.Conclusion: This study challenges previous findings regarding the I-TRACH scale and the relation of its parameters to prolonged mechanical ventilation. Furthermore, BMI >30 alone was predictive of prolonged intubation. Inclusion of BMI in predictive models could assist current decision making in determining the likelihood of prolonged mechanical ventilation in medical intensive care unit patients going forward, and obesity should be considered a predictor of prolonged mechanical ventilation. [ABSTRACT FROM AUTHOR]

Purpose: Prolonged endotracheal intubation may lead to laryngeal damage, with stridor being the most relevant clinical symptom. Our objective was to determine the incidence of post-extubation stridor and their clinical consequences in children within a tertiary referral center and to identify contributing factors. Methods: 150 children, aged 0–16 years, intubated for more than 24 h were prospectively enrolled until discharge of the hospital. Potential relevant factors, thought to mediate the risk of laryngeal damage, were recorded and analyzed. Results: The median duration of intubation was 4 days, ranging from 1 to 31 days. Stridor following extubation occurred in 28 patients (18.7%); 3 of them required reintubation due to respiratory distress and in 1 child stridor persisted for which a surgical intervention was necessary. In multivariate analyses, we found the following independent predictors of stridor: intubation on the scene, the use of cuffed tubes and lower age. Conclusion: Despite a high incidence for post-extubation stridor, only few children need reintubation or surgical intervention as a result of post-extubation lesions. Intubation on the scene, the use of cuffed tubes and young age are associated with a significant increased risk of post-extubation stridor. Awareness of these factors gives the possibility to anticipate on the situation and to minimize laryngeal injury and its possible future consequences. [ABSTRACT FROM AUTHOR]

Vocal fold motion impairment (VFMI) is a potential consequence of intubation. Studies describing the natural course of this complication are largely case reports. This study aims to evaluate outcomes for a cohort of patients who endured varying degrees of vocal fold immobility or hypomobility post-intubation. Retrospective chart review. Upon excluding known causes of VFMI, such as surgeries and tumors involving the head and neck, VFMI cases (ICD-9 diagnosis code 478.3) were identified from 2008 to 2014 at a regional healthcare institution. A total of 2,387 were identified and of those, 25 were intubation-induced VFMI cases. This cohort was then examined for notable features. With a mean prolonged intubation duration of 6.55 days, 68% of cases resulted in left unilateral, 8% right unilateral, and 24% bilateral VFMI. Overall, 80% of patients experienced a recovery outcome (voice improvement or restoration of vocal fold mobility). Median recovery time was 4.31 months (mean, 6.51 months; range, 19-715 days). In cases of unilateral VFMI, 95% of cases had a recovery outcome. In cases of bilateral VFMI, 33% of cases had a recovery outcome. Additionally, bilateral cases showed a statistically significant association with an approximately 36-fold lower odds of recovery than unilateral cases (odds ratio, 0.0278; 95% confidence interval, 0.0020-0.3868; P value, 0.0077). Intubation-induced VFMI is rare. In this cohort, most cases resulted from prolonged intubation. While spontaneous recovery was the most common outcome, full remission was not guaranteed in every case. A sizable proportion of cases revealed bilateral motion impairment which was less likely to resolve. Our results are informative for tracheostomy decision-making and differential diagnoses for post-intubation laryngeal symptomatology. [ABSTRACT FROM AUTHOR]

Abstract Since we started seeing post‐COVID pneumonia patients in our clinics, tracheo‐laryngeal stenosis should be kept in mind as an important sequela of prolonged intubation (>7 days) particularly in those who are persistently symptomatic.

Introduction: Iatrogenic injury to the larynx, particularly the vocal cords from prolonged intubation, has been well-studied; however, tracheal injuries are rarely reported. This study investigates the effectiveness of cuffed, high-volume, low-pressure endotracheal tubes in preventing the development of tracheal ulcers in intubated subjects., Methods: A retrospective, IRB-approved review was performed on 1355 subjects who underwent percutaneous tracheostomy from 2002 to 2018. The presence and severity of tracheal ulcers were collected using documentation and photos during percutaneous tracheostomy placement. Primary outcome measures included: the length of time on a ventilator until tracheostomy (LOVT), length of hospitalization (LOH), and mortality in relationship to the severity of the tracheal injury. Data was reported as n (%) and median (IQR). The differences in means between groups were analyzed by ANOVA and Chi-square test with an alpha of 0.05., Results: 206 subjects met the inclusion criteria; 65 subjects had an absence of tracheal injury, and 141 subjects developed tracheal ulcers. Subjects with tracheal ulcers were grouped by the following severity scale: no ulcer; mild ulcer (minimal mucosal erosion with exudate); moderate ulcer (mucosal erosion); and severe (tracheal ring exposure). There were no statistically significant differences in age (p = 0.99), gender (p = 0.83), BMI (p = 0.44), LOH (p = 0.88), LOVT (p = 0.93), and mortality (p = 0.306) between subjects with differing severity of ulcers. The average annual incidence of clinically significant ulcers (moderate and severe) was 2.2 %., Conclusions: The lack of statistical correlation between the duration of intubation and tracheal ulcer severity, along with a low annual incidence of tracheal ulcers, supports the improved safety of high-volume, low-pressure cylindrical, cuffed endotracheal tubes. This study is among the first to specifically focus on injuries at the level of the cuff and tip of endotracheal tubes with implications in preventive measures and potential product design changes., Competing Interests: Declaration of competing interest The authors declare there is no conflict of interest., (Copyright © 2023. Published by Elsevier Inc.)

Laryngotracheal stenosis (LTS) is a life threatening airway problem that is mainly caused by prolonged intubation. The authors intend to assess whether there was variability in the risk factors depending on age, and to determine which risk factors and comorbidities were more important in the development of LTS at older or younger ages. Fifty-two LTS patients were evaluated for comorbidities and risk factors retrospectively. The LTS etiologies, demographics, and medical and surgical histories of the patients were determined by the medical records. The patients under 40 years old were defined as group 1, and the patients 40 years of age or older were defined as group 2. Our study revealed that with regard to GERD, hypertension, DM2, and pulmonary infection, there was a statistically significant difference between group 1 and group 2 (p = 0.025, p = 0.0005, p = 0.002, and p = 0.000, respectively). Those patients ≥ 40 years old exhibited higher rates of GERD, hypertension, DM2, and pulmonary infection. However, there were no statistically significant differences between the groups with regard to smoking, alcohol consumption, COPD/asthma, immunological disease, and obesity (BMI > 30). There was a statistically significant difference between the groups for all the risk factors except a previous tracheotomy (p = 0.115). The risk factors and comorbidities thought to be involved in the development of LTS could show age-related variability. Therefore, in patients over 40 years of age with comorbidities (GERD, hypertension, DM2, and pulmonary infection), it is necessary to take precautions before the development of LTS. Prolonged intubation and tracheotomy history are the main risk factors for all patients, regardless of age. [ABSTRACT FROM AUTHOR]

Dr Ian Hamilton McDonald (1923-2019) was a pioneer of paediatric anaesthesia and intensive care at the Royal Children's Hospital, Melbourne. He first started working at the hospital in the 1940s, later doing further training from 1953-1955 at the Nuffield Department of Anaesthesia in Oxford under Sir Robert Macintosh. McDonald returned to Melbourne as assistant director supporting Dr Margaret (Gretta) McClelland as the director of anaesthesia, together pioneering the development of a major paediatric anaesthesia department. McDonald, along with Dr John Stocks (1930-1974), was intimately involved in pioneering prolonged nasotracheal intubation in children, following on from earlier work by Dr Bernard Brandstater (an Australian working in Beirut), and Drs Tom Allen and Ian Steven in Adelaide. Ian McDonald was an influential, highly respected and greatly loved paediatric anaesthetist who had a profound influence on the early days of paediatric anaesthesia in Australia. [ABSTRACT FROM AUTHOR]

Background: Patients undergoing abdominal wall reconstruction (AWR) are at an increased risk of developing respiratory complications. Previous studies have demonstrated that postoperative findings, such as an increase in plateau pressure greater than 6 cm H2O following fascial closure, creates an increased risk of postoperative respiratory complications. The purpose of this study is to determine if specific preoperative characteristics are an indicator for postoperative respiratory failure.Methods: The 2005-2013 ACS-NSQIP participant use data were reviewed to evaluate post-operative intubation status following AWR procedures for ventral hernias. Prolonged intubation, defined as intubation up to 48 h post-operatively, was evaluated. Multivariable logistic regression was used to control for patient demographics and comorbidities. Odds ratios and 95% confidence intervals were reported as appropriate using SPSS.Results: 4378 patients were identified. Majority (51%) of patients were female. 2.96% of patients experienced a prolonged intubation. Factors such as a history of severe COPD, ASA 3 or 4, current smoker within 1 year, and a BMI of 40 were all found to have a significant association with a prolonged intubation.Conclusions: Post-operative prolonged intubation is a known complication of AWR. We have demonstrated that pre-operative factors, such as a history of COPD, ASA 3 or 4, current smoker, and a BMI > 40 kg/m2 are factors associated with a prolonged intubation. Optimization of each may allow for a reduction in the risk of prolonged intubation in patients undergoing AWR. [ABSTRACT FROM AUTHOR]

Tracheal transection is a rare, life-threatening complication after tracheal injury. Most commonly, tracheal transection presents after blunt trauma, but iatrogenic tracheal transection after tracheotomy has not been well described. Here, we present a case without a history of trauma that presented with signs of symptoms of tracheal stenosis. She was taken to the operating room for tracheal resection and anastomosis and was incidentally found to have a complete tracheal transection intraoperatively. [ABSTRACT FROM AUTHOR]

Subglottic stenosis is a known complication of a traumatic and prolonged intubation. In a child, subglottic area is narrower and more prone to damage by an oversized or overinflated endotracheal tube. The stenosis can present with complaints of change in voice, croup, or respiratory obstruction. Those presenting with respiratory obstruction require immediate diagnosis under direct laryngoscopy and timely corrective intervention under general anesthesia. A 4-year-old child came to the emergency department with severe respiratory obstruction. His medical history revealed invasive ventilatory management for aspiration pneumonitis 2 months back. Under direct laryngoscopy, we found severe narrowing of the subglottic area due to subglottic web. Since the subglottic area was so stenosed, intubation was impossible. Hence, emergency tracheostomy was performed to secure patient airway, followed by microlaryngeal surgery to remove the subglottic web. Acquired subglottic stenosis in a child can be a life-threatening situation which requires immediate airway management. It should be suspected in any child in severe respiratory obstruction with a history of prolonged intubation.

We present a unique case of complete tongue necrosis caused by a compression of an endotracheal tube (ETT). A 39-year-old female underwent endotracheal intubation secondary to respiratory failure following sudden altered mental status. Tongue swallowing developed and worsened with obvious pallor on examination. Extensive ischemic changes with tongue necrosis developed dramatically due to the compression during her prolonged intubation. This case of tongue necrosis highlights the importance of proper ETT sizing and positioning during prolonged intubation in ICU patients., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: The acute treatment and complications of the novel COVID-19 virus have been well studied, but the implications of this novel virus for swallowing function continue to be investigated. The goal of this study is to retrospectively assess airway and swallowing outcomes for those patients who required intensive care unit(ICU)-level care for COVID-19 infection., Study Design: Comparison of swallowing outcomes through diet change in COVID-19 patients in the Ochsner-Louisiana State University (LSU) Hospital ICU., Setting: Ochsner-LSU Hospital (Shreveport, Louisiana)., Methods: A retrospective chart review was performed from March 2020 to May 2022 to identify patients with a primary diagnosis of COVID-19. Variables analyzed include age, gender, length of intubation, length of ventilation, airway interventions, use of extracorporeal membrane oxygenation, and diet prior to, during, and after hospitalization for COVID-19 infection., Results: Two hundred and seven patients fit the inclusion criteria. There was a significant difference in discharge diet between those patients who were intubated and those who were not ( P  = .007). Thirty percent of patients were discharged on a different diet than their baseline with patients on a nonregular diet significantly more likely to discharge to a facility ( P  = .043). Negative vaccine status was associated with prolonged ICU stay, prolonged duration of intubation, and prolonged duration of ventilation., Conclusion: COVID-19 continues to present novel challenges with new implications and outcomes being discovered in the third year of the pandemic. Further research is necessary to determine the most effective treatment approaches with respect to optimized speech and swallow outcomes., Competing Interests: None., (© 2023 The Authors. OTO Open published by Wiley Periodicals LLC on behalf of American Academy of Otolaryngology–Head and Neck Surgery Foundation.)