Incidence and determinants of malpositioning tracheostomy tubes in critically ill adult patients

Tracheostomy tubes are chosen primarily based on their internal diameter; however, the length of the tube may also be important. We performed a prospective clinical audit of 30 critically ill patients following tracheostomy to identify the type of tracheostomy tube inserted, the incidence of malpositioning and the factors associated with the need to change the tracheostomy tube subsequently. Anthropometric neck measurements, distance between the skin and tracheal rings and the position of the tracheostomy cuff relative to the tracheal stoma were recorded and analysed. Malpositioning of the tracheostomy tube was noted in 20%, with a high riding cuff being the most common cause of malpositioning, resulting in an audible leak and a need to change the tracheostomy tube subsequently. A high riding cuff was more common when a small tracheostomy tube (e.g. Portex (Smiths Medical Australasia, Macquarie Park, NSW) ≤8.0 mm internal diameter with length <7.5 cm) was used, with risk further increased when the patient’s skin to trachea depth was greater than 0.8 cm. Identifying a high riding cuff relative to the tracheal stoma confirmed by a translaryngeal bronchoscopy strongly predicted the risk of air leak and the need to change the tracheostomy tube subsequently. Our study suggests that when a small (and short) tracheostomy tube is planned for use, intraoperative translaryngeal bronchoscopy is warranted to exclude malpositioning of the tracheostomy tube with a high riding cuff.

Tracheostomy tube infection in children: a systematic review of the literature

BACKGROUND. Currently, health professionals face the management of artificial airways in paediatric groups. This action requires delicate care and a lot of attention to detect, establish and manage pressing situations, in these cases being a greater risk of tracheo-pulmonary bacterial infections. OBJECTIVE. To identify and evaluate the scientific publications on infections in paediatric patients with tracheostomy tubes. MATERIAL AND METHODS. A systematic review of the years 2015-2020 was carried out, using the Elsevier, PubMed, Google Academic and Scielo databases, considering the population aged between 0-20 years who used a tracheostomy tube. RESULTS. From 322 articles distributed in the databases, 13 articles that met the inclusion criteria were selected. Comorbidities that were described as most frequently associated with infection of the tracheostomy tube in children were: neuromuscular disease, prematurity, ventilator use, congenital anomalies, chronic lung disease, obstruction airway, cystic fibrosis, and heart disease. The factors associated with length of stay (LOS) were the age from 30 days to 12 months, with a greater probability of re-entering the hospital and the presence of 4 or more complex chronic diseases. Regarding respiratory infections in patients with tracheostomy, P. aeruginosa was the most frequent bacteria present in cultures (90%), followed by Staphylococcus aureus. CONCLUSION. Although there are currently clinical criteria, risk factors and laboratory tests associated with infections of the post-tracheostomy tube in paediatric patients, further research is required to define clinical guidelines for the management in medical decision-making cases.

Biofilm Formation of Clinical Klebsiella pneumoniae Strains Isolated from Tracheostomy Tubes and Their Association with Antimicrobial Resistance, Virulence and Genetic Diversity

(1) Background: Due to the commonness of tracheotomy procedures and the wide use of biomaterials in the form of tracheostomy tubes (TTs), the problem of biomaterial-associated infections (BAIs) is growing. Bacterial colonization of TTs results in the development of biofilms on the surface of biomaterials, which may contribute to the development of invasive infections in tracheostomized patients. (2) Methods: Clinical strains of K. pneumoniae, isolated from TTs, were characterized according to their ability to form biofilms, as well as their resistance to antibiotics, whether they harbored ESβL genes, the presence of selected virulence factors and genetic diversity. (3) Results: From 53 patients, K. pneumoniae were detected in 18 of the TTs examined, which constitued 34% of all analyzed biomaterials. Three of the strains (11%) were ESβL producers and all had genes encoding CTX-M-1, SHV and TEM enzymes. 44.4% of isolates were biofilm formers, SEM demonstrating that K. pneumoniae formed differential biofilms on the surface of polyethylene (PE) and polyvinyl chloride (PVC) TTs in vitro. A large range of variation in the share of fimbrial genes was observed. PFGE revealed sixteen genetically distinct profiles. (4) Conclusions: Proven susceptibility of TT biomaterials to colonization by K. pneumoniae means that the attention of research groups should be focused on achieving a better understanding of the bacterial pathogens that form biofilms on the surfaces of TTs. In addition, research efforts should be directed at the development of new biomaterials or the modification of existing materials, in order to prevent bacterial adhesion to their surfaces.

Predictors of Aspiration and Silent Aspiration in Patients With New Tracheostomy

Purpose Hospitalized, medically complex patients with new tracheostomy are at risk for aspiration. This study reports incidence of aspiration in these patients with new tracheostomy and investigates possible risk factors for aspiration and silent aspiration in this patient population. Method Retrospective review of instrumental swallowing evaluations from hospitalized inpatients with new tracheostomy tubes to determine frequency of aspiration and silent aspiration and patient factors associated with aspiration. Patient variables including sex, age, reason for hospital admission, reason for tracheostomy, duration of intubation, time since tracheostomy placement, and tracheostomy cuff and cap status were examined as possible risk factors for aspiration and silent aspiration. Results Of the 272 patients with new tracheostomies who underwent instrumental swallowing evaluation, 59% aspirated on at least one consistency. Odds of aspiration were twice as high in patients with uncapped tracheostomy compared to closed (i.e., cap or speaking valve in place). Odds of aspiration were 3.4 times greater with patients who underwent tracheostomy for an oropharyngeal etiology (oropharyngeal or laryngeal tumor, surgery, or infection). Of the patients who aspirated, 81% aspirated silently on at least one consistency. Odds of silent aspiration was 4.5 greater with an uncapped tracheostomy. Conclusions Medically complex patients with new tracheostomy are at risk for aspiration and benefit from instrumental swallowing evaluations. Future prospective research is warranted to determine contributing factors responsible for this risk. Lastly, speech pathologists play an important role in the patient’s recovery.

An Overview of Tracheostomy Tubes and Mechanical Ventilation Management for the Speech-Language Pathologist

Purpose The speech-language pathologist (SLP) plays an integral role when working with patients who have tracheostomy tubes and are on mechanical ventilation. The patients and the clinical team depend on our expertise to make critical decisions on speaking valve use, introduction of food by mouth (per os), weaning off of the ventilator, weaning from the feeding tube, and tracheostomy tube decannulation. Conclusions While not expected to be experts on the cardiopulmonary function of patients, SLPs must have a solid foundation of knowledge when it comes to patients with highly complex disease processes and care plans. This clinical focus article is meant to serve as an overview for the SLP working with tracheostomy tubes and ventilators and for those SLPs interested in entering this area of practice.