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  • Volume 7, Issue 1
  • Management of tracheostomies in the intensive care unit: a scoping review
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  • http://orcid.org/0000-0003-2787-0789 Kirsty A Whitmore 1 , 2 ,
  • Shane C Townsend 1 and
  • http://orcid.org/0000-0002-1205-5354 Kevin B Laupland 1 , 3
  • 1 Department of Intensive Care Services , Royal Brisbane and Women’s Hospital , Herston , Queensland , Australia
  • 2 Faculty of Medicine , The University of Queensland , Saint Lucia , Queensland , Australia
  • 3 Faculty of Health , Queensland University of Technology , Brisbane , Queensland , Australia
  • Correspondence to Professor Kevin B Laupland; Kevin.Laupland{at}qut.edu.au

Objectives While there is an extensive body of literature surrounding the decision to insert, and methods for inserting, a tracheostomy, the optimal management of tracheostomies within the intensive care unit (ICU) from after insertion until ICU discharge is not well understood. The objective was to identify and map the key concepts relating to, and identify research priorities for, postinsertion management of adult patients with tracheostomies in the ICU.

Design Scoping review of the literature.

Data sources PubMed, Embase and Cumulative Index to Nursing and Allied Health Literature were searched from inception to 3 October 2019. Additional sources were searched for published and unpublished literature.

Eligibility criteria We included studies of any methodology that addressed the a priori key questions relating to tracheostomy management in the ICU. No restrictions were placed on language or year of publication.

Data extraction and synthesis Titles and abstracts were screened by two reviewers. Studies that met inclusion criteria were reviewed in full by two reviewers, with discrepancies resolved by a third. Data were extracted for included studies, and results mapped along the prespecified research questions.

Results 6132 articles were screened, and 102 articles were included for detailed analysis. Protocolised weaning was found to be successful in liberating patients from the ventilator in several cohort studies. Observational studies showed that strategies that use T-pieces and high-flow oxygen delivery improve weaning success. Several lines of evidence, including one clinical trial, support early cuff deflation as a safe and effective strategy as it results in a reduced time to wean, shorter ICU stays and fewer complications. Early tracheostomy downsizing and/or switching to cuffless tubes was found to be of benefit in one study. A substantial body of evidence supports the use of speaking valves to facilitate communication. While this does not influence time to wean or incidence of complications, it is associated with a major benefit in patient satisfaction and experience. Use of care bundles and multidisciplinary team approaches have been associated with reduced complications and improved outcomes in several observational studies.

Conclusions The limited body of evidence supports use of weaning protocols, early cuff deflation, use of speaking valves and multidisciplinary approaches. Clinical trials examining post-tracheostomy management strategies in ICUs are a priority.

  • not applicable

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjresp-2020-000651

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Key messages

What is the key question.

What evidence exists regarding postinsertion tracheostomy management in the ICU, and where are the gaps in the evidence?

What is the bottom line?

There is a lack of quality research on this topic, with significant variations in practice primarily driven by clinician experience and local preferences.

Why read on?

This review scopes and summarises all available literature on this topic and identifies priority areas for future studies regarding tracheostomy management.

Tracheostomy is performed in approximately 10%–15% of patients who are admitted to intensive care units (ICU). 1 This procedure, which involves either percutaneous or surgical placement of a tube across the anterior neck into the airway, may be indicated for relief of airway obstruction, facilitation of pulmonary toilet and for facilitation of wean from mechanical ventilation. 2 In addition, tracheostomy may allow a reduction of sedation, improve patient safety and comfort, and reduce overall costs of care. 3 4 There is a vast body of literature published on the indications, timing and technique of tracheostomy insertion, including several meta-analyses. 5–9 Likewise, there are a number of systematic reviews, surveys and expert guidelines on the timing and act of decannulation, or removal of the tracheostomy. 10 11

While there is extensive research on tracheostomy insertion and decannulation, their optimal management in ICUs between the time of insertion and ICU discharge has received little attention. Management aspects such as optimal cuff management, tracheostomy changes or downsizing, and weaning approaches are typically directed by individual expertise, anecdotal experience and local preferences.

The objective of this study was to conduct a scoping review to systematically explore and map the key concepts and gaps in the literature, in order to identify research priorities relating to the management of intensive care patients with tracheostomies from after insertion of the tracheostomy to the time of ICU discharge. Scoping reviews are used to determine the scope or coverage of a body of literature on an emerging topic and aims to identify and map the available evidence to provide an overview that may guide further research. 12 13 While a systematic review can answer a single precise question to inform clinical practice, a scoping review addresses the extent, range and nature of the evidence, and identifies common concepts or gaps. Given the limited volume and heterogeneous nature of the literature published on this topic, the scoping review methodology was most suited to the objectives of this review. It is our hope that this review may subsequently guide future high-level research, such as clinical trials and systematic reviews to answer more precise questions and address research priorities that have been identified.

The study protocol was established a priori and was developed as outlined by the members of the Joanna Briggs Institute and members of the Joanna Briggs Collaborating Centres. 12 The specific research questions were, ‘What evidence exists regarding the ideal strategies to:

liberate patients from the ventilator?

manage cuff inflation and deflation?

manage tracheostomy change and revision?

optimise speech and communication?

optimise swallowing and oral intake?’

Eligibility criteria

Studies of any methodology that addressed one or more of the research questions were considered. Clinical studies were selected for inclusion if:

the study subjects were adults (age ≥18 years) admitted to medical, general surgical or specialty surgical ICUs;

a tracheostomy was inserted during the current hospital admission;

the study related to a period after insertion of the tracheostomy and prior to ICU discharge; and

the subjects had respiratory failure requiring mechanical ventilation.

Studies that met all inclusion criteria but did not address one of the prespecified research questions were included. This approach was taken to enable this review to address concepts that emerged during the review and had not previously been considered.

Studies that focused on patients who had chronic tracheostomies or who had a tracheostomy placed prior to ICU admission for reasons other than for acute respiratory failure (eg, elective upper airway surgery) were excluded. Studies that focused on the indications for, timing of, and performance of the tracheostomy insertion procedure were excluded. Studies that did not involve patients as subjects (eg, studies relating to medical devices not tested in a live patient population) were only included if they addressed research questions relevant to the patient population in the inclusion criteria. Review articles and editorials that did not contain novel information were excluded.

Search methodology

An initial electronic search was conducted of three key databases (PubMed, Embase and Cumulative Index to Nursing and Allied Health Literature) from inception through to 3 October 2019. The keywords used were “ICU” or “intensive care unit” and “tracheostomy”. The study strategy is available in as an electronic supplement ( e-supplementary file 1 ) The search was not limited by design, language or year of study. The reference lists of included articles, review articles and editorials were searched for additional potential studies.

Supplemental material

Titles and abstracts were screened independently by two authors (KAW and KBL) for potential inclusion. Articles that met inclusion criteria based on title and abstract review were included for full text review. Full-text articles were retrieved and reviewed independently by two authors (KAW and SCT) to assess whether they met the inclusion criteria. Discrepancies between the two reviewers were resolved by a third. Following the compilation of a list of articles for inclusion, data were extracted by one of the authors (KAW), discussed and reviewed by all authors, and results mapped along the prespecified research questions. Data extracted included first author’s surname, year of publication, setting, country of origin, aims or objectives, study population and size (if applicable), study design, duration of intervention (if applicable) and key findings. Analysis was descriptive.

Patient and public involvement

This review includes studies that consider the patient experience of tracheostomy management in the intensive care, including qualitative or phenomenological studies. Patients and the public were not involved in the completion of this review.

Electronic searches conducted retrieved 8801 citations across the PubMed (2198), Embase (5805) and Cumulative Index to Nursing and Allied Health Literature (798) databases. An additional 47 citations were identified from other sources, including from hand-searched reference lists, guidelines and resources published by professional bodies, online searches and conference abstracts. Following the removal of duplicates and the application of study inclusion and exclusion criteria, 102 articles were included in the final review, as detailed in figure 1 .

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Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram for study identification and inclusion.

Of the 102 articles included, 25 were only available as abstracts published in conference proceedings. Given that the objective of this review was to map all available evidence, these abstracts were included. Care should be taken in the interpretation of such results; therefore, abstract-only publications have been noted as such throughout this review. Articles included in this review were published between 1987 and 2019, with the majority published since 2013, as shown in figure 2 . Studies were conducted in 21 different countries, with the most common being the USA (n=22), the UK (n=16) and Australia (n=15). The remaining 48 studies originated from Europe (n=31), Asia (n=7), South America (n=5), Africa (n=2) and North America (n=1). The country of origin was not specified in three cases. Most (n=69) of the identified articles addressed one or more of the five research questions, as mapped in figure 3 . Studies that addressed more than one key question were categorised based on the question that was most extensively addressed. Thirty-three articles addressed other topics and have been included in a separate ‘Other’ category. The results of the studies are summarised in the electronic supplement e-supplementary file 2 . The key findings, categorised by theme, have been summarised in table 1 .

Annual publications investigating postinsertion tracheostomy management strategies for patients admitted to intensive care units.

Mapping of included articles based on key research question addressed.

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Key findings

Liberation from ventilator

Twenty studies investigated topics related to weaning from mechanical ventilation. Five studies compared protocolised weaning models and reported successful weaning in 77%–89% of patients. Those studies reported that the use of protocols resulted in no difference in the time to weaning, length of stay, rates of emergent reintubation or readmission to the ICU. 14–18 Two studies addressed nurse-led and protocolised weaning. One randomised trial compared nurse-led protocolised weaning and physician-led weaning, and found that patients were more likely to be weaned prior to ICU discharge in the nurse-led group (77% protocolised vs 45% physician led, p=0.031). 14 16 A prospective study involving 192 patients found that there was no difference in weaning outcomes when medical management was provided by an attending physician and either a unit-based nurse practitioner, or a critical care rotational fellow. 16

Three studies evaluated predictors of successful weaning outcomes or decannulation. Two studies found that weaning or decannulation success was more likely in patients that were able to increase the force-generating capacity of the diaphragm. 19 20 An observational study of 49 patients found that the ability to generate peak cough flows of greater than 160 L/min was predictive of successful decannulation. 19 In a retrospective audit of 129 patients in a Dutch medical-surgical ICU, patients whose primary pathology was neurosurgical or cardiopulmonary were statistically more likely to have shorter weaning times (3–7 days) when compared with medical (9 days) or surgical (8 days) patients. 17

An observational study of 25 patients compared T-piece ventilation and continuous positive pressure ventilation during weaning and found that T-piece ventilation resulted in improved arterial and central venous oxygenation. 21 One letter reported that configuring the mixing tube between the T-piece and Venturi mask connector improved oxygenation. 22 Three articles, including a case report and an abstract, discussed the use of high-flow oxygen during weaning. 23–25 One of these studies, a randomised cross-over trial, found that during cuff deflation, the use of high-flow oxygen improved oxygenation when compared with T-piece ventilation alone (p<0.02). 23 Two studies evaluated different types of humidification systems and concluded that heat-moisture-exchange systems and heated humidifiers provided adequate humidification, and that cold humidifiers provided inadequate humidification in 50% of patients. 26 27

Two studies addressed aspects of respiratory physiology during weaning. A clinical trial of 10 patients found that tracheostomy tube-related additional work of breathing was highest in continuous positive airway pressure and was reduced most effectively in automatic tube compensation mode. 28 An observational study of 24 patients found that the dead-space and airway resistance of tracheostomy tubes were comparable to endotracheal tubes, contrary to common perception. 29

Management of the cuff

Eight studies addressed issues related to cuff inflation management. One was an anecdotal case series 30 and another was an abstract aimed at optimising adherence to cuff inflation pressures between 20 mm Hg and 30 mm Hg. 31 Three studies investigated the impact of cuff deflation on respiratory parameters during positive pressure ventilation or weaning. 32–34 One measured airway pressure in 16 patients and found clinically insignificant decreases in end-expiratory pressure with cuff deflation; however, all patients could vocalise and three quarters (n=12) could swallow effectively. 32 In a report of a series of long-term wean patients, most (99/104; 95%) were found to be managed safely with either deflated cuffs or cuffless tubes. 33 Another investigation with T-piece trials among 13 patients found that diaphragmatic effort was significantly lower with cuff deflation as compared with inflation. 34

One retrospective review of 113 patients found that 95% (n=107) of patients tolerated cuff deflation on first attempt and that clinical stability and aspirated above-cuff secretions≤1 mL/h were highly predictive of success. 35 Another retrospective audit found that among 30 patients, use of an early cuff deflation strategy resulted in a decreased ICU length of stay (28 vs 45 days) and mean number of tracheostomy days (16 vs 38) compared with historical controls. 36 Hernandez et al conducted a clinical trial comparing cuff deflation and inflation during spontaneous breathing trials. 37 They found that cuff deflation resulted in a significantly shorter wean time (3 vs 8 days, p<0.01) with an associated significantly lower incidence of respiratory infection (20 vs 36%, p=0.02).

Tracheostomy change and revision

Two studies investigated tracheostomy changes or revision. In an observational study of 130 stable respiratory care unit patients, tracheostomy changes before 7 days were associated with earlier liberation from the ventilator (2.2 vs 3.9 days), use of speaking valves (7 vs 12 days), oral intake (10 vs 20 days) and discharge from the ICU (11 vs 17 days). 38 It may be argued that this population is more likely to have a better prognosis and that outcomes may not be directly related to early tracheostomy change. A survey of Dutch ICUs found that 59% of units (n=26) did not routinely change the tracheostomy. 39 One phenomenological study explored the patient experience of tracheostomy changes, and identified four key themes including physical sensation, psychological preparation, essentialness of communication and trust and competence. 40

Optimisation of speech and communication

Twenty-eight articles investigated the optimisation of speech and communication. One-way speaking valves are widely used and were found to safely achieve successful phonation in most patients who were fit for cuff deflation, with adverse effects rare. 41 A 1993 prospective study found that one-way speaking valves can be used to facilitate communication during positive pressure ventilation; however, this method has largely been superseded by newer adjuncts. 42

Studies suggest that in-line speaking valves can significantly hasten time to phonation in patients who are unable to tolerate cuff deflation. 43–45 A randomised clinical trial of 30 ventilated patients found that, compared with cuff deflation with one-way speaking valves, early speech interventions with in-line speaking valves reduced time to phonation (7 vs 18 days, p=0.001), with no increase in time to decannulation, time of ventilation, length of stay or adverse events. 44 Further, Sutt et al used electrical impedance tomography to demonstrate that in-line speaking valves can improve gas distribution and alveolar recruitment. 46

There were mixed findings on the role of fenestrated tubes; however, both studies that considered this topic were low-quality evidence studies including one abstract. 47 48

Several studies evaluated tracheostomy ‘talk tubes’. 49–53 In those studies, 90%–100% of patients were able to achieve phonation, with 78%–100% adequately intelligible for effective communication. 49–53 Excessive secretions and cough were the most common adverse effects. 49–51 There was no demonstrated significant air leak when using the devices, even at higher pressures, and no mucosal injuries on bronchoscopy. 50 An interventional study of 20 patients found that patients using Portex ‘Talk’ tubes had shorter time to phonation compared with Communi-Trach I tubes (2.1 vs 5.6 days, p<0.001). 52

A feasibility study of above-cuff vocalisation involving 10 patients found that this technique resulted in phonation in eight patients, with 72% (66/91) of attempts resulting in audible speech. 45

Three articles addressed the use of augmentative and alternative communication devices, with all finding statistically significant improvements in a patient’s ability to communicate. One prospective pilot study involving 12 patients found 50% (n=6) reported frustration with the use of these devices. 54 Two studies also included communication skills training of doctors and nurses caring for patients uses the devices, and found this resulted in significant improvements in their ability to communicate with patients. 55 56

Eight studies evaluated patient experience or quality of life relating to speech or communication. The participants highlighted that feelings of powerlessness, being misunderstood and physical discomfort impacted on their quality of life. Patients also acknowledged the importance of non-verbal communication. 57–59 One study interviewed both patients and nurses and identified mutual experiences of frustration and powerlessness attributable to communication difficulties. 59 One randomised controlled trial used talk tubes and found significant improvements in voice-related quality of life. 53 Another used in-line speaking valves and favoured the use of in-line valves over one-way speaking valve but found that the improvement in quality of life was not statistically significant. 44

Optimisation of swallow

Nine studies considered the optimisation of swallowing and oral intake. The incidence of swallowing dysfunction in tracheostomised patients has been reported as between 30% and 70%; however, several factors can increase this risk, including pre-existing swallowing impairment, neurological disorders, age, sedation and hypercarbia. 60–63 In a study excluding patients with neurological disorders, 38% (15/40) had swallowing dysfunction, suggesting that previous studies may have overestimated incidence based on this patient group. 62

Two Australian studies found almost 80% of tracheostomised patients were seen by speech-language pathologists. 60 64 While the majority (86%; 108/126) of patients will commence oral intake with a tracheostomy in situ, only 43% (54/126) of patients had commenced oral intake in the ICU. 60 A prospective study of 14 patients evaluated a swallowing rehabilitation programme administered by speech-language pathologists and an otorhinolaryngologist. 65 Ten of the 14 patients (71%) were able to receive oral intake, with 6 (42%) having complete resolution of dysphagia, and 2 (14%) experiencing partial improvement.

There are multiple methods for assessing swallow in the tracheostomised patient. 64 One abstract found the Evans Blue Dye Test had a sensitivity of 84% and specificity of 100% when compared with fibreoptic endoscopic evaluation of swallow. 66 A prospective study involving 35 patients found 12 patients (34%) had a swallowing abnormality on bedside assessment. Of those 12 patients, and a further 7 patients with a high index of suspicion, 83% had abnormal swallow on videofluoroscopy. 63

Three studies considered specific elements of swallow physiology, including the impact of cuff pressure and subglottic insufflation, finding that increased cuff pressure influences both the sensory and motor components of the swallow reflex. 67 68 A prospective cross-over randomised and physiological study of 16 patients investigated the impact of meals on respiratory mechanics. 69 While there was a significant increase in respiratory rate, tidal volume and subjective dyspnoea, this was not associated with desaturation or cardiovascular instability. 69

Several articles were included that did not directly fit within the a priori themes according to the research questions posed.

Three articles addressed stomal care and complications, including the dressing choice, wound granulation and pressure injuries. 70–72 The most common complications relating to stoma care in the acute phase are bleeding, infection and granulation; however, their incidence varies between sources from 4% to 40%. 70 73 74 In an academic poster that assessed 23 possible risk factors for pressure injuries, percutaneous tracheostomy was the only factor that reached statistical significance in univariate analysis. 71 A randomised trial found no difference in the incidence of stomal infection when using gauze dressings compared with absorbent foam (17.5% v 10%, p=0.051). 70

Nine articles addressed the topic of tracheostomy bacterial colonisation, and tracheostomy-associated and ventilator-associated pneumonia. Oral care bundles with surveillance and auditing protocols were found to significantly reduce the incidence of tracheostomy-associated or ventilator-associated pneumonia. 75 76 Studies also found that suction-above-the-cuff in tracheostomised patients reduced infection and microbial quantity. 77–79 A randomised controlled trial (abstract) of 19 patients found the use of speaking valves during weaning reduced the incidence of nosocomial respiratory infection and may reduce time to decannulation. 80

One cohort study (abstract) found that 89% (67/75) of tracheostomised patients in ICU reported trouble falling asleep. 81 Studies found that sleep time and efficiency were poor, and that sleep time was not improved by melatonin (240 vs 243 min, p=0.68 for melatonin vs placebo). 82 83 Patients ventilated with mechanical ventilation compared with spontaneously ventilating had a significantly longer total sleep time (183 vs 132 min, p=0.04); however, there was no improvement in rapid eye movement sleep or sleep fragmentation. 83 An observational study found that after insertion of a tracheostomy, there was a significant reduction in sedative drug requirements and time spent ‘heavily sedated’ which was reduced from 7 hours per day to one. 84

Four studies (including three abstracts) evaluated the impact of multidisciplinary tracheostomy teams, finding they resulted in reduced time to first oral intake, first tube change and decannulation, and reduced length of stay and complication rates. 85–88 Reduced time to weaning and decannulation were noted in three of the four studies. 85 87 88

Three studies including one abstract addressed quality of life or stressful experiences, with patients reporting that psychosocial discomfort, sleeplessness, physical symptoms of thirst and pain, fear and relationships had a significant impact on their experience. 81 89 90

Four studies (including three abstracts) were observational audits, 91–94 three (including two abstracts) surveyed participants’ knowledge on an aspect of tracheostomy care 95–97 and two were surveys regarding standards of practice. 39 98 There was one clinical consensus statement published by the American Academy of Otolaryngology-Head and Neck Surgery Foundation, using a Delphi process. 99

In this scoping review, we identified and explored five main themes related to the management of patients with a tracheostomy from time post insertion to ICU discharge. Despite slow-growing interest in this area, research remains limited. There were a significant number of low-quality studies and abstracts published only in conference proceedings without progression to peer-reviewed publication, and a lack of clinical trials.

Weaning from the ventilator is an integral part of practice in critical care medicine. In our review, we found that there is support for the use of protocols, including nurse-led protocols; that T-piece and high-flow oxygen delivery may be used during weaning to improve oxygenation; and that diaphragmatic strengthening may improve weaning success. 21 23–25

Personal experience and anecdotal surveys of intensivists have revealed vast practice variation in cuff management both within and between countries. 39 60 64 Some clinicians view cuff deflation as a late step in the weaning process, while others view cuff deflation, tube downsizing and exchange to cuffless tubes, as the standard practice. The former view may, in part, be related to an erroneous belief that cuff inflation during weaning reduces aspiration and associated pneumonia. 60 61 100 The available evidence indicates that early cuff deflation is widely tolerated by patients during weaning, can be reliably predicted based on clinical assessment, facilitates speech and oral intake, reduces time to weaning and decannulation, and can reduce rates of respiratory infections. 32–37 While data are limited, there is potential benefit from early tracheostomy downsizing or switching to cuffless tubes. 38 60 88

There is a significant body of literature that supports the optimisation of speech and communication as it is important from a rehabilitative and psychoemotional point of view. 44 53 57 101 Many of the strategies for enhancing communication that were considered in the included articles have been demonstrated as safe, simple to use and improving both communication and quality of life. 43–46 58 102 Speech adjuncts, used alongside strategies for early cuff deflation, may lead to earlier weaning, fewer complications and improved patient experience, and may also lead to earlier oral intake, with its associated benefits. 43 44 53

In the course of this review, we have identified several areas of clinical importance that have not been adequately explored in the literature. While not an exhaustive list, we believe the 10 topics listed in table 2 should be considered as priorities for further research.

Research priorities related to tracheostomy care in intensive care

There are some methodological aspects of our study that merit discussion. Our report benefits from the use of a structured, predefined scoping review methodology, as outlined by The Joanna Briggs Institute. 12 As the objective was to map the evidence rather than conduct a critical appraisal, and as is recommended for the scoping review methodology, we made no further attempts to grade the quality of the included reports. 12 13 We recognised in advance of our study that there may be a small body of literature and therefore used broad search terms with the resulting need to screen more than 6000 citations. However, we limited our search to the three most widely used citations databases and therefore may have missed articles not included within these. Finally, it should be recognised that we limited our scope of review to the stay in ICU. As such, there may be other management issues that could arise post-ICU discharge that are not included in our investigative themes.

In summary, this scoping review addresses an area of the critical care literature that, while of major clinical importance, has garnered relatively little attention. While major efforts have been expended to investigate the optimal decision-making for, and timing and insertion of, tracheostomies in critically ill patients, the body of knowledge surrounding management of tracheostomies in intensive care is limited by low-quality and non-peer reviewed research. While there has been an increase in research in this area ( figure 2 ), it is evident that there needs to be a shift in our research focus from the conduct of the procedure itself to optimising the management of the tracheostomised patients within our ICUs.

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Contributors KBL takes responsibility for the content of the manuscript including data and analysis, as the guarantor. KBL and KAW made substantial contribution to the conception and design of the work. All authors were involved in the acquisition, analysis and interpretation of data. All authors were involved in drafting and revising the manuscript and approved the version to be published. All authors agreed to be accountable for all aspects of the work in ensuring that questions relating to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Patient consent for publication Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.

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Onuoha, Joy. "Developing an Educational Program for Tracheostomy Care." ScholarWorks, 2019. https://scholarworks.waldenu.edu/dissertations/6934.

Björling, Gunilla. "Long-term tracheostomy : outcome, cannula care and material wear /." Stockholm : Karolinska institutet, 2007. http://diss.kib.ki.se/2007/978-91-7357-261-3/.

Crosby, William. "An evaluation of tracheostomy care anxiety relief through education and support (t-cares) a pilot study." Honors in the Major Thesis, University of Central Florida, 2012. http://digital.library.ucf.edu/cdm/ref/collection/ETH/id/1530.

Kostyliovienė, Silva. "Slaugytojų žinios ir įgūdžiai atliekant tracheostomos priežiūrą." Master's thesis, Lithuanian Academic Libraries Network (LABT), 2014. http://vddb.library.lt/obj/LT-eLABa-0001:E.02~2014~D_20140711_084834-26889.

Ramakrishnan, Vijaya. "Use of Simulation for Tracheostomy Care, a Low Volume, High Risk Nursing Procedure." ScholarWorks, 2018. https://scholarworks.waldenu.edu/dissertations/4981.

McGrath, Brendan Anthony. "Advances in multidisciplinary tracheostomy care and their impact on the safety and quality of care in the critically ill." Thesis, Manchester Metropolitan University, 2018. http://e-space.mmu.ac.uk/620231/.

Wang, Tongyao. "Pictographic Education Handout: Significant Impact on Patients and Family Caregivers' Self-Efficacy on Tracheostomy Care." Case Western Reserve University School of Graduate Studies / OhioLINK, 2021. http://rave.ohiolink.edu/etdc/view?acc_num=case161945406039485.

McHenry, Kristen L., Randy L. Byington, Ester L. Verhovsek, and S. Keene. "A Study of the Relationship between APACHE II Scores and the Need for a Tracheostomy." Digital Commons @ East Tennessee State University, 2014. http://ispub.com/IJWH/9/1/14799.

Lemoignan, Josée. "Decision-making for assisted ventilation in amyotrophic lateral sclerosis." Thesis, McGill University, 2007. http://digitool.Library.McGill.CA:80/R/?func=dbin-jump-full&object_id=101862.

Ramos, Michele de Cassia Santos. "Estudo comparativo de pacientes neurocirúrgicos submetidos à traqueostomia precoce e tardia durante o período na unidade de terapia intensiva em um hospital terciário." Universidade de São Paulo, 2015. http://www.teses.usp.br/teses/disponiveis/5/5170/tde-12052015-091053/.

Rwakonda, Munyaradzi Ephie. "Lived Experiences of Individuals Quality of Life on Prolonged Home Mechanical Ventilation." ScholarWorks, 2017. https://scholarworks.waldenu.edu/dissertations/4558.

Svanström, Maria, and Ulrica Karlsson. "Sjuksköterskan som höll min hand... Intensivvårdspatienters upplevelser av att vara intuberad eller tracheostomerad - en litteraturstudie." Thesis, Karlstads universitet, Avdelningen för omvårdnad, 2012. http://urn.kb.se/resolve?urn=urn:nbn:se:kau:diva-14461.

Hedlund, Niclas. "Tyst kunskap och produktdatasystem vid medicinteknisk tillverkning : Pilotstudie av system för produktdatahantering och kartläggning av den tysta kunskapen vid Nationellt respirationscetrum, NRC." Thesis, Uppsala University, Department of Information Technology, 2009. http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-126753.

This thesis looks at two sides of the same coin: how to support the production and future development at a specialist medical technology department at Danderyd Hospital. The two sides are; a pilot study of a product management system (PDM) and an interview based study on the characteristics of the silent knowledge of the technicians. The department (National respiratory centre, NRC) is facing retirement of several key employees.

The technical study shows that the success of an implementation is largely dependent on the users’ prior knowledge and use of a 3D Computer aided design system (CAD).The system itself is shown to fulfill the Lifecycle requirement of tracking the products (mostly tracheostomy tubes) but without a CAD centered workflow, some substantial education and preferably some new recruits, an implementation of the PDM system will fail. The author recommends development of the current “low-tech” system of MS Excel and Access rather than redistribute the dependency from technician towards a complex, commercial software and its vendor.

The analysis of the technicians’ silent knowledge with the newly developed method, epithet for silent knowledge (ETK), shows that the longer employment time:

  • the more differentiated technicians become in describing their work,
  • practical knowledge are regarded higher and
  • the social and collective problem solving factors of the work becomes more important.

Typically, it is shown that a new employee should preferably enjoy problem solving, being pragmatic and social as well as having some prior education or work experience in a CAD and/or a PDM system.

Chvějová, Bronislava. "Role sestry při tracheostomii u dospělých v intenzivní péči - punkční versus chirurgická tracheostomie." Master's thesis, 2019. http://www.nusl.cz/ntk/nusl-404084.

Kritznerová, Tereza. "Ošetřování pacienta s tracheotomickou kanylou z pohledu sestry." Master's thesis, 2015. http://www.nusl.cz/ntk/nusl-335191.

Polášková, Veronika. "Problematika edukace rodinných příslušníků pečujících o pacienty na domácí umělé plicní ventilaci." Master's thesis, 2021. http://www.nusl.cz/ntk/nusl-438341.

POLÍVKOVÁ, Eva. "Problematika komunikačních bariér u pacientů s tracheotomií na jednotkách intenzivní péče." Master's thesis, 2011. http://www.nusl.cz/ntk/nusl-54219.

Lee, Yu-chan, and 李玉嬋. "The importance of tracheostomy to the weaning success in patients with conscious disturbance in the respiratory care center." Thesis, 2015. http://ndltd.ncl.edu.tw/handle/50480909688113201890.

Králová, Eva. "Intenzivní domácí péče - Domácí péče s prvky intenzivního ošetřovatelství." Master's thesis, 2013. http://www.nusl.cz/ntk/nusl-330027.

Stattin, Karl. "Observational study of percutaneous vs. surgical tracheostomy in the critically ill: A comparison of outcome in Swedish intensive care unit patients." Thesis, 2013. http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-224544.

Tai, Hsueh-Ping, and 戴雪萍. "The Association between Early Tracheostomy and Weaning from Mechanical Ventilation in Patients in a Sub-acute Respiratory Care Ward in a Medical Center." Thesis, 2016. http://ndltd.ncl.edu.tw/handle/a32s37.

Hoosen, Azra. "Bridging the gap : establishing the need for a dysphagia training programme for nurses and speech-language therapists working with tracheostomised patients in critical care in government hospitals in Gauteng." Thesis, 2012. http://hdl.handle.net/10539/11840.

Klozová, Ivana. "Péče o dýchací cesty u hospitalizovaných na JIP očima samotných pacientů." Master's thesis, 2016. http://www.nusl.cz/ntk/nusl-342092.

WU, HI LUN, and 吳慧倫. "A Case Study: Collaborative Assistance among Parent, Foreign Care Giver and Special Education Teacher to Include A Young Child with Tracheostomy in Early Childhood Special Education from the Mesosystem Perspective." Thesis, 2017. http://ndltd.ncl.edu.tw/handle/exu7p3.

KUBEKOVÁ, Martina. "Zajištění průchodnosti dýchacích cest u dětských pacientů na ARO." Master's thesis, 2016. http://www.nusl.cz/ntk/nusl-252155.

Duff, Miriam Anne. "The child and family living with complex health needs in the community: lived experiences and patterns of coping and relationship." 2012. http://hdl.handle.net/1993/8605.

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  • Published: 15 March 2018

Tracheotomy in the intensive care unit: guidelines from a French expert panel

  • Jean Louis Trouillet 1 ,
  • Olivier Collange 2 , 3 ,
  • Fouad Belafia 4 ,
  • François Blot 5 ,
  • Gilles Capellier 6 , 7 ,
  • Eric Cesareo 8 , 9 ,
  • Jean-Michel Constantin 10 , 11 ,
  • Alexandre Demoule 12 ,
  • Jean-Luc Diehl 13 , 14 ,
  • Pierre-Grégoire Guinot 15 , 16 ,
  • Franck Jegoux 17 ,
  • Erwan L’Her 18 , 19 ,
  • Charles-Edouard Luyt 1 , 20 ,
  • Yazine Mahjoub 21 ,
  • Julien Mayaux 12 ,
  • Hervé Quintard 22 , 23 ,
  • François Ravat 24 ,
  • Sebastien Vergez 25 ,
  • Julien Amour 26 &
  • Max Guillot 3 , 27  

Annals of Intensive Care volume  8 , Article number:  37 ( 2018 ) Cite this article

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Tracheotomy is widely used in intensive care units, albeit with great disparities between medical teams in terms of frequency and modality. Indications and techniques are, however, associated with variable levels of evidence based on inhomogeneous or even contradictory literature. Our aim was to conduct a systematic analysis of the published data in order to provide guidelines. We present herein recommendations for the use of tracheotomy in adult critically ill patients developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. These guidelines were conducted by a group of experts from the French Intensive Care Society (Société de Réanimation de Langue Française) and the French Society of Anesthesia and Intensive Care Medicine (Société Francaise d’Anesthésie Réanimation) with the participation of the French Emergency Medicine Association (Société Française de Médecine d’Urgence), the French Society of Otorhinolaryngology. Sixteen experts and two coordinators agreed to consider questions concerning tracheotomy and its practical implementation. Five topics were defined: indications and contraindications for tracheotomy in intensive care, tracheotomy techniques in intensive care, modalities of tracheotomy in intensive care, management of patients undergoing tracheotomy in intensive care, and decannulation in intensive care. The summary made by the experts and the application of GRADE methodology led to the drawing up of 8 formal guidelines, 10 recommendations, and 3 treatment protocols. Among the 8 formal guidelines, 2 have a high level of proof (Grade 1+/−) and 6 a low level of proof (Grade 2+/−). For the 10 recommendations, GRADE methodology was not applicable and instead 10 expert opinions were produced.

Tracheotomy is a procedure commonly used in intensive care, albeit with great disparities between medical teams in terms of frequency (5–54%) and modality (surgical or percutaneous) [ 1 , 2 ]. Although tracheotomy has a long history, its utility, indications, duration, and techniques are the subject of debate [ 3 , 4 ]. Also, the real or potential advantages of tracheotomy need to be weighed against its risks, which are rare but sometimes serious. The advantages are a reduction in pharyngolaryngeal lesions, lower risk of sinusitis, reduced sedation requirements, easier buccopharyngeal hygiene, improved patient comfort with easier communication, facilitated care by nursing personnel, maintenance of swallowing, possible glottic closure, simpler reinsertion in cases of accidental decannulation, and easier weaning from mechanical ventilation [ 5 ]. In some studies, early use of tracheotomy was associated with decreased incidence of ventilator-acquired pneumonia, reduced duration of mechanical ventilation and of intensive care, and so of costs, and decreased hospital mortality [ 6 , 7 ]. However, several recent randomized trials found no evidence of these benefits [ 8 , 9 , 10 , 11 ]. The most frequent complications can be qualified as minor (for example, minor stomal bleeding). Rare and life-threatening complications, such as lesions of the brachiocephalic artery trunk, have been reported.

Among the controversies surrounding tracheotomy in intensive care, the greatest is probably that of its indication. Tracheotomy is most often considered in cases of failed extubation and of prolonged mechanical ventilation. Three remarks are relevant here. First, there is currently no consensus regarding the contribution of failed extubation (one, two, three attempts? in what conditions?) and of prolonged mechanical ventilation. Second, it may be worthwhile preventing failure of extubation and not adding the deleterious effects of prolonged intubation to those of tracheotomy. The intensivist should predict the failure of extubation and the duration of ventilation so as to perform tracheotomy without delay [ 5 ], but prediction of the duration of ventilation is an inexact “science” [ 12 , 13 ]. Third, the duration of mechanical ventilation and the success of extubation depend on intensive care management as a whole (notably the appropriate treatment of an infection, the water–sodium balance and acid–base balance, nutrition, and sedation). In particular, a sedation protocol is essential.

The most recent SRLF guidelines concerning the surgical approach to the trachea of ventilated patients in intensive care date back to 1998 [ 14 ]. There are no recent international guidelines and national guidelines are rare [ 15 , 16 ]. In the absence of clearly defined and unquestionable criteria, tracheotomy is most often decided solely by the medical team in charge of the patient. In the last ten or so years, the medical literature has been enriched by new clinical data, often compiled in the form of meta-analyses [ 17 , 18 , 19 ]. It was against this backdrop that the Société de Réanimation de Langue Française (SRLF) and the Société Française d’Anesthésie et de Réanimation (SFAR) decided to draw up the present guidelines entitled “Tracheotomy in the Intensive Care Unit.” The aim of these guidelines is to define the indications, contraindications, modalities, and monitoring of tracheotomy in light of the current literature data.

These guidelines were prepared by a working group of experts from the SRLF and the SFAR. The organizing committee, together with the coordinators, first defined the questions to be addressed and then designated the experts in charge of each question. The questions were formulated according to the Patient Intervention Comparison Outcome (PICO) format. Grade of Recommendation Assessment, Development and Evaluation (GRADE) methodology was used to analyze the literature and formulate guidelines. A level of proof was defined for each bibliographical reference cited, as a function of the type of study. This level of proof could be reviewed in light of the methodological quality of the study. An overall level of proof was determined for each endpoint, taking into account the level of proof of each reference, the between-study consistency of the results, the direct or indirect nature of the proof, and cost analysis. A “strong” overall level of proof enabled formulation of a “strong” guideline (must be done, must not be done… GRADE 1 + or 1 −). A “moderate,” “weak,” or “very weak” overall level of proof led to the writing of an “optional” guideline (should probably be done or should probably not be done… GRADE 2 + or 2 −). When the literature was inexistent, the question could be the subject of a guideline in the form of an expert opinion (the experts suggest…). The proposed guidelines were presented and discussed one by one. The aim was not necessarily to reach a single, unanimous opinion of all the experts for each proposal, but to derive points of agreement or disagreement and of indecision. Each expert then reviewed every guideline and rated it using a scale from 1 (complete disagreement) to 9 (complete agreement). The collective rating was done using a GRADE grid. To validate a guideline on a criterion, at least 50% of the experts had to be in broad agreement, while < 20% of them expressed the opposite opinion. For a guideline to be strong, at least 70% of the experts had to be in broad agreement. In the absence of strong agreement, the guidelines were reformulated and again rated, with a view to reaching a consensus.

Topics of the guidelines: summary of the results

Because of the specificity of emergency airway management (in emergency medicine or intensive care, and in particular in patients with cervicofacial trauma or burns), we did not include it in our literature analysis or in the guidelines. We shall, therefore, address tracheotomy only in the setting of planned tracheotomy in adults in intensive care.

Five topics were defined: indications and contraindications for tracheotomy in intensive care, tracheotomy techniques in intensive care, modalities of tracheotomy in intensive care, management of patients undergoing tracheotomy in intensive care, and decannulation in intensive care. An extensive search of the bibliography from recent years was performed using PubMed and the Cochrane database. To be selected for the analysis, articles had to be written in English or in French.

The summary made by the experts and the application of GRADE methodology led to the drawing up of 8 formal guidelines, 10 recommendations, and 3 treatment protocols. Among the 8 formal guidelines, 2 have a high level of proof (Grade 1+/−) and 6 a low level of proof (Grade 2+/−). For the 10 recommendations, GRADE methodology was not applicable and instead 10 expert opinions were produced. After 2 rounds of rating and various amendments, strong agreement was obtained for all the guidelines and protocols.

Indications and contraindications for tracheotomy in intensive care

The experts suggest that tracheotomy be proposed in cases of prolonged weaning from mechanical ventilation and of acquired and potentially reversible neuromuscular disorder.

(Expert opinion)

The term neuromuscular refers to acquired and potentially reversible cerebrospinal, motor, and muscle disorders (e.g., Guillain–Barré syndrome, intensive care unit acquired muscle weakness, myasthenia, lupus myelitis). No study has provided formal evidence that tracheotomy improves the prognosis for survival of patients with these types of disorders. In this indication, no randomized study has evaluated the specific usefulness of early compared with late tracheotomy. Nevertheless, studies, often retrospective, suggest that late tracheotomy raises the risk of ventilator-associated pneumonia [ 20 ]. Tracheotomy can be proposed when weaning from mechanical ventilation is prolonged: weaning lasting more than 7 days after the first spontaneous breathing trial [ 21 ].

In the case of Guillain–Barré syndrome, tracheotomy should only be considered if weaning from invasive mechanical ventilation is not achieved after completion of immunotherapy (intravenous immunoglobulins or plasma exchange). At the end of immunotherapy, deficit in plantar flexion associated with sciatic nerve block was found to be an early predictor of prolonged (> 15 days) invasive mechanical ventilation in 100% of cases [ 22 ]. Alone, deficit in plantar flexion at the end of immunotherapy had a positive predictive value of 82% for prolonged mechanical ventilation.

The experts suggest that the indication for tracheotomy in patients with chronic respiratory failure should be the subject of multidisciplinary discussion.

The usefulness of intermittent mechanical ventilation in the management of patients with chronic respiratory failure is beyond the scope of these recommendations. When intermittent mechanical ventilation is indicated, a randomized study does not seem necessary before recommending first-line noninvasive ventilation rather than tracheotomy.

Life-threatening decompensation of chronic respiratory failure is generally managed in intensive care. In this setting, certain forms of chronic respiratory failure, notably those resulting from neurological disorders, can be managed using tracheotomy to enable mechanical ventilation and to simplify upper airway management. A 2016 meta-analysis including data from a randomized trial and 25 observational studies suggests that intermittent mechanical ventilation can improve the quality of life of patients with chronic respiratory failure [ 23 ]. The meta-analysis considered together patients receiving intermittent noninvasive mechanical ventilation and tracheotomized patients. More specifically, several studies have looked into the usefulness of tracheotomy in amyotrophic lateral sclerosis (ALS). In a 2011 study, an Italian team found that of 60 ALS patients who underwent tracheotomy, 44 (70%) left hospital completely dependent on mechanical ventilation, 17 (28%) were partially dependent, and a single patient was completely weaned from mechanical ventilation. At 1-year follow-up, 13 (22%) patients were still alive and had a quality of life deemed similar to that of ALS patients who did not have a tracheotomy [ 24 ].

In this type of situation, the patient and his or her family must be informed that tracheotomy does not alter the prognosis of the causal disease. The usefulness of tracheotomy in improving patient comfort and management following a stay in intensive care must be accurately evaluated, in particular with the patient and the medical team. Facilitation of upper airway management does not necessarily lead to improved comfort; tracheotomy can unduly prolong suffering associated with the underlying illness. In a context of chronic respiratory failure, these ethical considerations must be carefully thought through and discussed with the patient and his or her family before performing a tracheotomy.

Tracheotomy in intensive care should not be performed before the fourth day of mechanical ventilation.

(GRADE 1+/STRONG agreement)

The question of the timing of tracheotomy in intensive care is hard to analyze, because: 1) it is necessary beforehand to demonstrate the usefulness of tracheotomy (independently of its timing) and 2) most studies comparing early and late tracheotomy include nontracheotomized patients in the “late” group.

Several good-quality prospective studies relate to “objective” criteria (mortality, incidence of ventilator-associated lung injury, duration of mechanical ventilation and of stay in intensive care). Early tracheotomy (in general before the fourth day of mechanical ventilation) is not associated with decreases in mortality, the incidence of ventilator-associated lung injury, or the duration of mechanical ventilation [ 8 , 9 , 10 , 11 , 25 , 26 ]. It does seem to reduce the consumption of hypnotic drugs. Improvement in comfort is not proven, and is insufficiently studied, but seems likely when tracheotomy is done early.

Lastly, early tracheotomy in burn patients with cervicofacial involvement and in patients with cervicofacial trauma more properly comes under the heading of emergency tracheotomy and is not within the scope of these guidelines.

The experts suggest that tracheotomy (percutaneous or surgical) should not be performed in intensive care in situations at high risk of complications.

The potentially serious complications are hemorrhage, hypoxemia, and neurological deterioration. Most studies have excluded patients at risk of these complications [ 6 , 9 , 10 , 25 ]. Tracheotomy should not, therefore, be performed in intensive care in the following situations:

Hemodynamic instability.

Intracranial hypertension (intracranial pressure > 15 mmHg).

Severe hypoxemia: PaO 2 /FiO 2  < 100 mmHg, with positive expiratory pressure > 10 cmH 2 O.

Uncorrected bleeding disorders (platelets < 50 000/mm 3 and/or international normalized ratio > 1.5 and/or partial thromboplastin time > 2 normal).

Refusal by the patient and/or family.

Patient is dying or active treatment is being withdrawn.

Tracheotomy techniques in intensive care

Percutaneous tracheotomy is the standard method in intensive care patients.

Several randomized studies have compared the impact of the technique of tracheotomy (percutaneous or surgical) on the incidence of complications (short-, medium-, and long-term), mortality, and cost [ 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 ]. The great heterogeneity of endpoints (immediate or delayed, minor or major complications) complicates comparison of studies. To date, neither of the two techniques (percutaneous or surgical) has proven superior in terms of mortality or incidence of major complications (respiratory distress, hemorrhagic shock, tracheal stenosis) [ 37 ]. A 2014 meta-analysis including 14 randomized studies suggests that the percutaneous technique is associated with a shorter operative time and a decreased incidence of stoma infection and inflammation [ 37 ]. The incidence of other complications does not seem to differ between the two tracheotomy techniques [ 37 ]. These results, plus the spread and availability of this technique in intensive care units, mean that percutaneous tracheotomy should whenever possible be preferred to surgical technique.

Whatever the technique used, prior training is needed to perform tracheotomy, which must be done by physicians able to manage any complications or accidents quickly.

The experts suggest that medical and surgical teams should discuss and decide upon the tracheotomy technique to be used when there is a risk of complications.

Percutaneous tracheotomy can be made difficult, even impossible, by the patient’s condition. For instance, an unstable cervical spine, an anterior cervical infection, a neck that has been treated (surgery or radiotherapy), difficulty in identifying anatomical landmarks (e.g., obesity, short neck, thyroid hypertrophy), or stiffness of the cervical spine are relative contraindications to percutaneous tracheotomy and prompt instead use of surgical tracheotomy [ 27 ]. It is nevertheless difficult to draw up formal guidelines. Indeed, at-risk situations are conventionally exclusion criteria for prospective studies. Observational studies have yielded contradictory results on which technique to prefer in cases of morbid obesity, spinal fracture, or a history of tracheotomy [ 35 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 ]. A single randomized prospective study has compared surgical tracheotomy with modified percutaneous tracheotomy or so-called mini-surgical percutaneous dilatational tracheotomy (surgical tracheal access followed by a percutaneous procedure) in at-risk situations (anatomical difficulties, coagulation disorders, hypoxemia, hemodynamic instability). This study found no difference between the two techniques in terms of complications [ 52 ].

Such situations should therefore prompt discussions between the medical and surgical teams to decide on what benefit tracheotomy provides and which technique is the most suitable. Percutaneous tracheotomy in these situations can be envisioned by an experienced team with access to the technical means to improve the usual procedure: fiberoptic bronchoscopy, cervical Doppler ultrasound, surgical approach to the tracheal rings, tracheotomy equipment adapted to the anatomical problem (e.g., special tracheotomy kits for obese patients).

Percutaneous dilatational tracheotomy should probably be preferred as the standard method in intensive care patients.

(GRADE 2+/STRONG agreement)

Several randomized studies have compared the six techniques of percutaneous tracheotomy: multiple dilator, guide wire dilating forceps, single dilator, rotating dilation, balloon dilation, and translaryngeal tracheotomy. These comparisons have in general been made two-by-two with as principal endpoints the duration of the procedure, failure rate defined by a switch to an alternative technique, the rate of major complications, and the rate of minor complications. These techniques are relatively equivalent, with the exception of translaryngeal tracheotomy, which seems to be associated with a higher rate of failure and of complications, notably major [ 54 , 55 ]. The single dilator technique is associated with a lower failure rate than rotating dilation [ 56 ] and a lower rate of minor complications than balloon dilation or dilation with guide wire dilating forceps [ 57 , 58 , 59 ]. When the single dilator technique is compared with all the others, it seems to be associated with a higher success rate (corollary of its more widespread use) [ 60 ], but also with a higher rate of minor complications (notably minor bleeding and tracheal ring fractures) [ 60 ].

Conditions necessary for tracheotomy in intensive care

Fiberoptic bronchoscopy should probably be performed before and during percutaneous tracheotomy.

Fiberoptic bronchoscopy before tracheotomy is advantageous because it helps locate the point of incision, by transillumination and palpation, and helps position the endotracheal tube correctly, below the vocal cords. Fibroscopy directly visualizes all stages of the procedure (incision, placement of the guide wire and of the dilator, dilation) and the position of the tracheotomy tube [ 61 ]. Fibroscopy must be available during the tracheotomy and the clinician must be trained.

Three nonrandomized studies seem to suggest that fiberoptic bronchoscopy could be nonsignificantly associated with more complications [ 62 , 63 , 64 ], but they are subject to substantial methodological bias and their results seem difficult to interpret.

A single randomized trial in 60 patients has shown that fiberoptic bronchoscopy is associated with a 47% (95% CI 23–64%) decrease in early complications of percutaneous tracheotomy in intensive care [ 65 ]. The main complications observed were accidental extubation, perforation of the cuff of the endotracheal tube, and hemorrhage. In addition, the number of incisions needed for tracheotomy was statistically smaller in the fiberoptic bronchoscopy group.

In summary, the only randomized study performed found that there are fewer complications of percutaneous tracheotomy when fiberoptic bronchoscopy is used.

A laryngeal mask airway should probably not be used during percutaneous tracheotomy in intensive care.

(GRADE 2−/STRONG agreement)

Several randomized studies have compared two procedures for extubation of the endotracheal tube from the trachea while maintaining invasive mechanical ventilation: extubation followed by placement of a laryngeal mask airway or withdrawal of the endotracheal tube until the cuff is at the level of the vocal cords. A 2014 meta-analysis of 8 randomized controlled trials of the usefulness of placement of a laryngeal mask airway [ 66 ] showed that these trials examined four main outcomes: mortality (one study), the proportion of patients with one or more serious adverse events (seven studies), duration of the procedure (six studies), and failure of the procedure requiring a switch to any other procedure (seven studies). For each of these outcomes, the quality of the proof was considered low. Use of a laryngeal mask airway is not associated with decreases in mortality, complication rate, or failure related to the procedure, but does shorten the length of the procedure by an average of 1.46 (1.01–1.92) minutes. A single randomized controlled study conducted after this meta-analysis [ 67 ] found that more patients needed conversion to another procedure and had more clinically significant complications with a laryngeal mask airway.

Cervical ultrasound should probably be performed with percutaneous tracheotomy in intensive care.

(GRADE 2+/Strong agreement)

Ultrasound visualizes the trachea and the tracheal rings, thus optimizing positioning of point of incision while avoiding injury to blood vessels and/or the thyroid [ 68 ]. Four open randomized studies in a total of 560 patients have tested the usefulness of Doppler ultrasound in preventing complications of percutaneous tracheotomy [ 69 , 70 , 71 , 72 ]. Of 275 patients who underwent ultrasound-guided localization before tracheotomy, 40 (14.5%) presented a complication during or after the procedure. In the absence of Doppler ultrasound, 74 (26%) of the 285 patients presented at least one complication during or after the procedure, i.e., a 44% (95% CI 21–60) decrease in the risk of complications. The risk of puncturing a blood vessel is reduced by localization beforehand. The success of the procedure at the first attempt is significantly greater with Doppler ultrasound: 94.9% (168/177) versus 90.4% (160/177). There is, however, great heterogeneity between these studies, as the randomization procedure is not always well described [ 70 , 71 ] and the definition of complications is not uniform.

The strength of the recommendation (2 +) is related to the as-yet infrequent use of ultrasound with tracheotomy and to the quality of the randomized trials.

In conclusion, Doppler ultrasound increases the success rate of tracheotomy and reduces its immediate complications, provided the clinician masters the technique.

The experts suggest that antibiotic prophylaxis should not be prescribed for tracheotomy.

Because it opens the trachea, percutaneous tracheotomy can be considered as clean-contaminated surgery. The rate of infection of the operative site ranges between 0 and 33% depending on the study. Most studies comparing percutaneous tracheotomy and surgical tracheotomy indicate a higher rate of infection of the operative site for the surgical procedure. The infection rate for percutaneous tracheotomy is generally between 0 and 4%. In a retrospective study in 297 patients who underwent percutaneous tracheotomy, Hagiya et al. [ 73 ] reported a significantly lower rate of infection at the tracheotomy site in patients on antibiotic therapy: 2.36 versus 7.25% ( p  = 0.002). In contrast, there is no randomized study that has assessed the usefulness of antibiotic prophylaxis for tracheotomy. The quality of evidence is therefore very poor. The 2010 SFAR update concerning antibiotic prophylaxis in surgery and interventional medicine advises against antibiotic prophylaxis for tracheotomy (whether surgical or percutaneous is not specified) [ 74 ].

The experts suggest that a standardized procedure be implemented in intensive care units that perform percutaneous tracheotomy.

Percutaneous tracheotomy in intensive care is an invasive procedure which can lead to potentially serious complications [ 75 ] and for which there are contraindications. The learning curve for percutaneous tracheotomy is on average more than 80 consecutive procedures by the same team and with the same technique [ 76 ]. In addition, rules should be observed to optimize safety [ 75 ]. Intensive care units should define a standard procedure for percutaneous tracheotomy, which could indicate the following points: medical and paramedical personnel required, necessary pre-surgery laboratory tests and radiography, equipment required for airway management, equipment needed for the procedure (notably, the role of Doppler ultrasound and fiberoptic bronchoscopy), position of the patient, method of ventilation, type of analgesia, ways of checking the position of the tracheotomy tube at the end of the procedure, and then the modalities for monitoring the intensive care patient following surgery (Figs.  1 , 2 ).

Proposal for a protocol associated with guideline 3.5 (Expert opinion)

Tracheotomy monitoring and maintenance in intensive care

The experts suggest that intensive care units should have a tracheotomy management protocol.

The numerous secondary complications of tracheotomy include skin infection, granuloma, secondary bleeding from the stoma, tracheal stenosis, tracheomalacia, and erosion of blood vessels (brachiocephalic vein, brachiocephalic artery) [ 15 , 77 , 78 ]. There is no prospective study comparing different kinds of local care, such as antisepsis, type of dressing, or way of securing. Prospective randomized studies comparing surgical and percutaneous techniques, and different types of percutaneous techniques, do not specify the protocol. Studies evaluating practices for tracheotomy follow-up in intensive care reveal large disparities, absence of formalization, and lack of guidelines for follow-up during or after intensive care [ 79 , 80 ]. Use of a standard care protocol reduced local lesions [ 81 ]. Based on limited data or expert opinions, monitoring is recommended to ensure that cuff pressure does not exceed 30 cmH 2 O [ 77 , 78 , 82 ]. Too low a pressure could lead to inhalation of oropharyngeal secretions [ 15 ]. Increased cuff pressure favors ischemia of the tracheal mucosa, which is a source of tracheal stenosis. A check every 8 h is proposed.

Local infection and gastroesophageal reflux damage the cartilage of the tracheal rings, potentially leading to chondritis, tracheal stenosis, and tracheomalacia [ 83 ]. By analogy with work done on endotracheal intubation, it is recommended to use tubes fitted with a suction catheter that opens above the cuff, for regular aspiration of retained secretions from the subglottic space.

Special attention should be paid to securing the tracheotomy tube, maintenance of a corrugated tube, and prevention of repeated local trauma caused by the moving and weight of the tubes (avoid pulling the tracheotomy tube). There are no specific data on local care (antisepsis, products, frequency). A single study found no difference in bacterial contamination or local infection between the application of compresses or soft dressings [ 84 ]. Few studies specify the performance and type of local care (4–6 applications of isotonic saline, for example, in Lagambina et al.) [ 77 , 85 ].

The experts consider it useful to check the position of the tracheotomy tube (chest X-ray, ease of tracheal suction, absence of dyspnea) and, if necessary, to use fiberoptic bronchoscopy to look for injury or stenosis, without specifying the frequency or timing.

To meet intensive care safety requirements, management of the tracheotomized patient should include and specify the following: monitoring of the tracheotomy stoma, monitoring of ventilation parameters, specific local care, care of the tracheotomy tube, nature and frequency of the care provided (Fig.  3 ).

Proposed care protocol associated with guideline 4.1 (Expert opinion)

The experts recommend airway humidification in patients with a tracheotomy in intensive care.

There are no data on airway humidification in patients with a tracheotomy in intensive care. Lack of airway humidification can lead to obstruction of the tracheotomy tube in patients who need oxygen therapy in intensive care [ 86 ]. The UK 2014 guidelines suggest that humidification be envisioned for all patients undergoing tracheotomy. Airway humidification should be adapted in particular to the ventilatory support and to the amount of bronchial secretion [ 86 ].

No study has determined which airway humidification technique should be preferred in mechanically ventilated patients undergoing tracheotomy in intensive care. Only two studies have evaluated the effect on the incidence of ventilator-associated lung injury of different humidification systems (heated humidifiers or heat and moisture exchangers) in patients undergoing tracheotomy. Their results are discordant. The first study of 185 patients in each group and only 11 tracheotomized patients [ 87 ] found no benefit of airway humidification with any particular system. The second study, in a comparison of only 15 and 16 tracheotomized patients, showed a significant decrease in the incidence of ventilator-associated lung injury in the group with a heated humidifier [ 88 ].

The experts suggest that tracheotomy tubes should not be routinely changed in intensive care.

No literature study has examined the frequency of tracheotomy tube changes and the incidence of lung disease. A single prospective study in a long-stay hospital for ventilated patients with a tracheotomy showed a reduction in the incidence of granulation tissue when tubes were changed every two weeks [ 89 ]. A nonrandomized prospective study in a center for mechanical ventilation weaning showed that a change of tracheotomy tubes before the seventh day after tracheotomy was associated with faster resumption of nutrition and speech. The authors ascribed this effect to a reduction in tracheotomy tube size [ 90 ]. They reported no complication associated with the change of tracheotomy tube.

In intensive care, in a practice survey in the USA, 80% of tracheotomy tubes were changed routinely, but with substantial variability [ 91 ]. A Dutch practice survey observed that 60% of departments never change the tracheotomy tube [ 92 ].

The guidelines of the Belgian Society of Pneumology and the Belgian Association for Cardiothoracic Surgery [ 15 ] propose tracheotomy tube changes only if there is a specific indication. The British Intensive Care Society [ 86 ] advocates changing a tracheotomy tube without an inner cannula every 7–14 days and a tracheotomy tube with an inner cannula every 30 days. Tube change should be performed no less than 4 days after surgical tracheotomy, and 7–10 days after percutaneous tracheotomy. Subsequently, the frequency of tube change must be adapted to the individual patient’s condition [ 86 ].

The European Directive [ 93 ] advocates changing medical devices every 30 days. One study shows a structural alteration of the wall of 58% of tracheotomy tubes after 30 days of use [ 94 ]. A tracheotomy tube change early in intensive care is associated with risks (tube displacement and respiratory arrest) [ 15 ].

In summary, tracheotomy tube change must be guided by clinical considerations and should be envisaged, in particular, in cases of suspected local infection, bleeding, or to reduce the caliber of the tracheotomy tube and to facilitate the patient’s speech.

Tracheotomy decannulation

The experts suggest that a multidisciplinary decannulation protocol should be available in intensive care units.

The tracheotomy tube cuff should probably be deflated when the patient is breathing spontaneously.

Numerous observational and before/after studies conclude that use of a weaning protocol shortens weaning time and reduces the decannulation failure rate and the complication rate [ 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 ]. In a controlled, randomized, single-center trial in 195 patients, cuff deflation once the patient was disconnected from the ventilator reduced failure of decannulation, shortened weaning from mechanical ventilation, and decreased tracheostomy-related complications [ 105 ].

This consensual multidisciplinary protocol, which was written and is applied routinely by all members of the intensive care team who use tracheotomy, should at least define the following (Fig.  4 ): prior neurological examination and pharyngolaryngeal examinations, medical and paramedical personnel involved in decannulation, equipment needed for decannulation, immediate and subsequent monitoring of decannulation, and type and location of equipment required in cases of respiratory distress following decannulation.

Proposed endoscopic protocol associated with guideline 5.1 (Expert opinion): (according to Warnecke et al . Crit Care Med 2013 ( 106 ) )

A pharyngolaryngeal examination should probably be performed at or following decannulation.

Few prospective controlled studies consider the pharyngolaryngeal examination required during or following decannulation of intensive care patients or whether or not routine fiberoptic bronchoscopy is needed. A prospective observational study by practitioners blinded to each other’s decisions [ 106 ] shows the benefit of routine laryngotracheal endoscopy by the intensivist at decannulation, in comparison with routine clinical assessment of swallowing, possibly completed by the Evans blue dye test. Among the 100 neurological patients in the cohort, endoscopic evaluation allowed successful decannulation in 27 patients for whom clinical assessment had predicted failure of weaning. The recannulation rate was 1.9%. Pharyngolaryngeal examination on decannulation comprises sequential assessments of salivary stasis and silent inhalation, spontaneous swallowing, and laryngeal sensitivity, before considering a swallowing test using paste and then liquid. No patient who passed these three assessments had difficulty swallowing in the tests with paste and liquid.

Other prospective, observational, but noncomparative studies confirm [ 107 , 108 ]: 1) a higher incidence of swallowing dysfunction in tracheotomized patients ventilated for a prolonged period; 2) a longer intensive care stay and increased risk of inhalation and of pharyngolaryngeal lesions when tracheotomy is prolonged or decannulation is delayed.

This article is being published jointly in Anaesthesia Critical Care & Pain Medicine and Annals of Intensive Care. The manuscript validated by the board of the SRLF (12/13/2016) and the SFAR (12/15/2016).

Abbreviations

amyotrophic lateral sclerosis

Grading of Recommendations Assessment, Development, and Evaluation

Patient Intervention Comparison Outcome

Société Francaise d’Anesthésie Réanimation

Société Française de Médecine d’Urgence

Société Française d’Otorhinolaryngologie

Société de Réanimation de Langue Française

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Choate K, Barbetti J, Currey J. Tracheostomy decannulation failure rate following critical illness: a prospective descriptive study. Aust Crit Care. 2009;22(1):8–15.

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Cohen O, Tzelnick S, Lahav Y, Stavi D, Shoffel-Havakuk H, Hain M, et al. Feasibility of a single-stage tracheostomy decannulation protocol with endoscopy in adult patients. The Laryngoscope. 2016;126(9):2057–62.

Pandian V, Miller CR, Schiavi AJ, Yarmus L, Contractor A, Haut ER, et al. Utilization of a standardized tracheostomy capping and decannulation protocol to improve patient safety. The Laryngoscope. 2014;124(8):1794–800.

Ceriana P, Carlucci A, Navalesi P, Rampulla C, Delmastro M, Piaggi G, et al. Weaning from tracheotomy in long-term mechanically ventilated patients: feasibility of a decisional flowchart and clinical outcome. Intensive Care Med. 2003;29(5):845–8.

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Santus P, Gramegna A, Radovanovic D, Raccanelli R, Valenti V, Rabbiosi D, et al. A systematic review on tracheostomy decannulation: a proposal of a quantitative semiquantitative clinical score. BMC Pulm Med. 2014;14:201.

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de Zanata I. L, Santos RS, Hirata GC. Tracheal decannulation protocol in patients affected by traumatic brain injury. Int. Arch Otorhinolaryngol. 2014;18(2):108–14.

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Authors’ contributions

JLT and OC proposed the elaboration of this recommendation and manuscript in agreement with the “Société de Réanimation de Langue Française” and “Société Française d’Anesthésie et de Réanimation”; JA and MG wrote the methodology section and gave the final version with the final presentation. FB, FB, EC, J-L D, FJ contributed to elaborate recommendations and write the rationale of “Indications and contraindications for tracheotomy in intensive care.” AD and FJ contributed to elaborate recommendations and to write the rationale of “Tracheotomy techniques in intensive care.” CEL, YM, P-GG, FR contributed to elaborate recommendations and to write the rationale of Conditions necessary for tracheotomy in intensive care. GC, HQ, JM contributed to elaborate recommendations and to write the rationale of “Tracheotomy monitoring and maintenance in intensive care.” J-MC, EL, SV contributed to elaborate recommendations and to write the rationale of “Tracheotomy decannulation.” All authors provide references. JLT, OC, JA and MG drafted the manuscript. All authors read and approved the final manuscript.

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This work was financially supported by the Société de Réanimation de Langue Française (SRLF) and the Société Française d’Anesthésie et de Réanimation (SFAR).

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Trouillet, J.L., Collange, O., Belafia, F. et al. Tracheotomy in the intensive care unit: guidelines from a French expert panel. Ann. Intensive Care 8 , 37 (2018). https://doi.org/10.1186/s13613-018-0381-y

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Student Explores Misconceptions About Burnout in New Research

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Ali Ryan researched the relationship between self-care, difficult work settings, burnout and mental health for school psychology graduate students. Her dissertation confronts the limits of self-care and puts more responsibility on the systems in which students work.

March 14, 2024 | By Brenda Gillen

Ali Ryan's research into the relationship between self-care, difficult work settings, burnout and mental health for school psychology graduate students revealed surprising findings. She initially thought it would help her curate a list of science-backed self-care recommendations to alleviate trainees' struggles. Now in her fourth year of the University of Northern Colorado's School Psychology, Ph.D. program , her understanding of the topic's complexities has deepened. Ryan's dissertation confronts the limits of self-care and puts more responsibility on the systems in which students work. 

"...burnout comes from dysfunctional systems where the demands are way higher than the resources. No amount of individual self-care is going to fix that." — Ali Ryan

Her background as a yoga teacher contributed to her interests in mindfulness, self-care and positive psychology. She wanted to understand why so many school psychology students were struggling and how they could be helped. Wary of unscientific recommendations, her prior investigation examined worthwhile self-care practices.  

"Along the way in my graduate career I picked up different pieces that would build toward this dissertation wherever there was an opportunity. There's a 'pull yourself up by your bootstraps' idea that helping professionals should be able to manage their work's very real emotional challenges without outside support. Through my research, I learned about the Job Demands and Resources model of burnout, which assumes that burnout develops when job demands are high, leading to energy depletion, and job resources are limited, undermining employees' motivation. When I applied that model to my work, it indicated that burnout comes from dysfunctional systems where the demands are way higher than the resources. No amount of individual self-care is going to fix that," Ryan said. 

Her research concentrated on the experiences of students in school psychology training. School psychologists work in mental health roles and provide support for special education, including learning disability evaluations. Graduate students gain experience through practicum and externship experiences where they work with supervision. During her training, Ryan saw firsthand how the mismatch of demands and resources can lead to the burned-out states of exhaustion and disengagement described in the Job Demands and Resources model.  

"This is tough work. Learning how to become a school psychologist requires introspection, self-awareness and the ability to figure out how to have psychological and emotional boundaries," she said. 

If school psychology graduate students are burned out, Ryan said those symptoms could exacerbate symptoms of anxiety and depression. Her research could help foster a mentally healthy next generation of school psychologists. 

Ali Ryan

"I hope more research will be built upon what I'm starting, and from it we can, as a field, determine the best practices to support people and train school psychologists who are able to work within complex systems and stay well. Our faculty and trainers can do a lot to shift that dynamic," Ryan said.  

Ryan worked on her dissertation and related research projects with David Hulac , professor and chair of the School Psychology Department in the College of Education and Behavioral Sciences . 

"Dr. Hulac is incredibly supportive and has been open to learning alongside me. He asks challenging questions that have helped me grow. I think through things more deeply because of regular meetings with him. Learning the methodology I'm using for analyzing statistics has been a huge growing edge for me," she said. 

Hulac said Ryan's research is important because it recognizes that within the systems that require long hours and demand more and more, people need to be provided with more resources — training, advising, mentorship or simply someone else to help. 

"When you think about becoming a professor, you think about working with students like Ali, where you have long conversations about ideas. There have been times where we have gotten pleasantly lost in a discussion about what different research topics mean. Ali is the Platonic ideal of a student: self-driven, curious and interested in challenging perspectives with curiosity," Hulac said. 

After she graduates, Ryan would like to work both as a therapist in private practice and an elementary school psychologist. Her research goals include developing best practices for teaching the benefits and limits of self-care and working toward shifting the understanding of burnout. She said mindfulness and gratitude practices aren't burnout cure-alls, but there's good research supporting their benefits.  

"If I could send one message, it's that I hope people will continue engaging in self-care, but also acknowledge the limits of their control over their career challenges. I think there's a lot of freedom in realizing we are not the problem and there may be bigger things at play," Ryan said. 

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History, Current Advances, Problems, and Pitfalls of Nephrology in Russia

The anatomy and physiology of kidneys as well as kidney diseases have been studied in Russia since the 18th century. However, there was a surge in interest in the 1920s, with numerous researchers and clinicians making substantial advances in the understanding of the pathophysiology, pathology, and diagnostics of kidney diseases. The field of nephrology as clinical practice can be traced back to 1957–1958, when the first beds for patients with kidney diseases became available and the first hemodialysis procedure was performed. Nephrology and hemodialysis units were opened soon after, offering kidney biopsy, corticosteroid and immunosuppressive therapies, and dialysis for acute renal failure and end stage of renal disease. In 1965 kidney transplantation commenced. Between 1970 and 1990, the number of centers providing care for patients with kidney diseases increased; however, they were insufficient to meet the demands of native kidney disorders and renal replacement therapy. To address this, several educational institutions established postgraduate programs in nephrology and dialysis, and professional societies and journals were funded. While economic changes at the end of the 1990s resulted in a rapid increase of dialysis service, kidney transplantation and pathology-based diagnostics of kidney diseases remained underdeveloped. During the last 2 decades cooperation among international professional societies, continuing medical education courses, and the translation and implementation of international guidelines have resulted in substantial improvements in the quality of care provided to patients with kidney diseases.

We describe the history and development of clinical nephrology, dialysis, kidney transplantation, education in nephrology and dialysis, professional societies and journals, and registry of patients on renal replacement therapy in Russia during almost 60 years. We also present the most recent registry data analysis, address current problems and difficulties, and stress the role of incorporation into the international nephrology community.

Key Message

Nephrology in Russia, despite currently experiencing many difficulties, made great advances during the 60 years of its development. General nephrology, nephropathology, and renal replacement therapy are developing fast; implementation of international guidelines, access to modern educational tools, and cooperation with international professional societies are improving the quality of care of renal patients and ensuring further progress.

Historical Aspects

Russian scientists have been interested in the anatomy and physiology of kidneys as well as kidney diseases since the 18th century. Professor Shumlansky investigated renal anatomy and defended his thesis entitled “De structura renum: Tractatus physiologicoanatomicus” in 1776; the paper was republished in Strasburg in 1788 [ 1 ]. In 1853 Professor Polunin [ 2 ] described acute renal failure in patients with cholera, and Professor Zakharyin [ 3 ] published his paper entitled “Association between protein-containing urine and convulsions in pregnant women,” which was one of the first descriptions of eclampsia. Professor Bogolybov [ 4 ] defended his PhD thesis entitled “Renal pathology of parenchymal inflammation (Bright's disease)” in 1862, and in 1876 Professor Stolnykov [ 5 ] designed the quantitative method to detect protein levels in the urine. He also studied hemoglobinuria [ 6 ], and he published the association between renal ischemia and left ventricular hypertrophy in 1880 [ 7 ]. In 1882, Professor Ivanovsky [ 8 ] published his paper entitled “Bacterial inflammation of kidneys as a consequence of erysipelas.”

The first widely recognized historical case of kidney disease in Russia was the illness of Czar Alexander III, who suffered from severe edema, ascites, itching, dyspnea, and hemoptysis. His urinalysis showed the presence of proteins and casts, and he was diagnosed with “chronic interstitial inflammation of kidneys” and died from pulmonary edema on October 20, 1894. Among the attending doctors of Czar Alexander III during his last fatal illness were Professor Ernst Viktor von Leyden from Germany and Professor Grigory Zakharyin [ 9 ].

The most important achievement in the field of kidney diseases in 19th century Russia was the first model of nephrotoxic nephritis, developed by Professor Lindemann while working in Professor Mechnikov's laboratory. Lindemann [ 10 ] published his research entitled “Sur le mode d'action de certains poisons renaux” in the Annals of Institute Pasteur in 1900, in which he demonstrated the nephrotoxicity of heterologous anti-kidney sera in experimental animals. This model remains the most widely used animal model of crescentic glomerulonephritis.

The next phase of research commenced in the 1920s. In 1921, Professor Zymnitsky [ 11 ] implemented a simple kidney function test, based on the relative density of urine, which was known as the modified Volhard test. In 1929, Professor Tareev [ 12 ] published his book entitled “Anemia in Bright's disease.” He later published several monographs, summarizing his clinical experience, and highlighting the most important issues of pathophysiology, pathology, and clinical presentation of kidney diseases: “Kidneys and the Body” (1932), “Hypoproteinemic syndrome” (1933), “Kidney diseases” (1936), “Nephritis” (1958), “Fundamentals of Nephrology” (1972) [ 13 , 14 , 15 , 16 , 17 ], and many others, all of which became handbooks for several generations of nephrologists. In 1950, Professor Lang [ 18 ] published the monograph “Hypertensive disease,” in which he stressed the role of essential hypertension in kidney damage. In 1963, Professor Gynetsynsky [ 19 ] published “Physiological mechanisms of water-electrolyte balance,” where he described the details of water reabsorption in the distal nephron.

Development of Nephrology in Russia

General nephrology.

Nephrology as a field of medical practice started its development in Russia (which was then the Soviet Union) in 1957. An initiative of Professor Woffsy, one of the most recognized internists, introduced the first beds for patients with kidney diseases in the internal diseases unit of Moscow City Hospital No. 52 [ 20 ]. Professor Ratner, who as a resident studied internal medicine with Professor Lang in the then Leningrad (now known as Saint Petersburg), was invited to manage the patients and played a leading role during the fledging years of nephrology in Russia. Under her direction the nephrology beds transformed into the first nephrology unit in 1964, and in the same year, the first kidney biopsy in the Soviet Union was performed in the unit. Professor Ratner was also the first to successfully use corticosteroids to treat glomerulonephritis at the end of 1950s. The patient was a child with severe nephrotic syndrome. Immunosuppressants were first used by the initiative of Professor Tareev in 1959, and in 1961, Professors Woffsy and Ratner [ 21 ] published a paper entitled “Corticosteroid therapy of glomerulonephritis” in the Annals of Academy of Medical Science.

The first pediatric nephrology unit at the National Medical Research Center of Children's Health (the Research Institute of Pediatrics) was opened in 1965 by the initiative of Professor Studenikin, again headed by Professor Ratner. In 1970, Professor Veltischev started the division of inherited and acquired kidney diseases in the Research Clinical Institute of Pediatrics (which was then the Research Institute of Pediatrics and Children's Surgery), headed by Professor Ignatova till 2006 [ 22 ].

The second nephrology unit opened in Moscow City Hospital No. 52 in 1971, followed soon after with nephrology units opened in Moscow City Hospital No. 24 and the Moscow City Hospital n.a. S.P. Botkin (first headed by Dr. Alexander Lokshin). Other hospitals in Moscow, Saint Petersburg, and most big cities used the Moscow City Hospital No. 52 experience as a model when opening their respective units.

Professor Ratner was active as the leader of the rapidly growing renal service in Moscow until the end of 1980s. Her main interests were glomerulonephritis, transplanted kidney issues, and tubulointerstitial disorders, on which along with Professors Serov and Tomilina, she published a book entitled “Renal dysfunctions” in 1977 [ 23 ]. She also established a school of clinical nephrology, which is currently headed by Professor Tomilina.

In 1993 Professor Tomilina initiated the merging of two nephrology units - one for patients with native kidney diseases and the other for recipients of transplanted kidney - with the dialysis and outpatient units to create the Moscow City Nephrology Center, based in Moscow City Hospital No. 52. In 1998, the first intensive care unit for patients with kidney diseases opened in this center. The Moscow City Nephrology Center provides high-quality care for patients with any type of native and transplanted kidney diseases, not only to Moscow citizens, but also to referred patients. Professor Tomilina [ 24 ] recently summarized her clinical experience and published a monograph entitled “Selected Chapters in Nephrology.” The nephrology unit of the Moscow City Hospital n.a. S.P. Botkin also became a tertiary referral center at the beginning of 2000. The main priority of both centers is kidney biopsy with high-quality pathology diagnostics for a wide range of renal diseases. The nephropathology unit, which performs kidney biopsy readings for a vast majority of the population in Moscow, the surrounding area, and referred patients from other regions, is actually part of the Moscow City Nephrology Center.

Leading the intense development of clinical and research nephrology in Leningrad were Professor Ryabov, Professor Stavskaya, Dr. Jdanova, and Professor Bagrov - the successor of Professor Gynetsynsky, representing the Novosibirsk physiology school. For almost 50 years Professor Bagrov worked in the field of renal physiology and pathophysiology in close association with clinical practice. His monograph entitled “Water-electrolyte balance in Heart Failure” was published in 1984 [ 25 ]. A complex nephrology service, including the first outpatient unit for patients with kidney diseases, was organized in Leningrad in 1977 by Professor Ryabov. In 2003, several outpatient nephrology units in Saint Petersburg were merged under Professor Komandenko, and in 2008, the Saint Petersburg City Nephrology Center was opened. Currently, there are many nephrology units in Moscow, Saint Petersburg, and other big cities actively treating patients with glomerulonephritis, systemic diseases, diabetes, amyloidosis, chronic kidney disease (CKD) complications, and even orphan diseases such as atypical hemolytic uremic syndrome, Fabry disease, and cystinosis.

Unfortunately, the exact disease spectrum for CKD is not known, because general statistics, based on the main diagnosis only, does not represent CKD epidemiology. However, the database of the nephrology unit of the Moscow City Hospital n.a. S.P. Botkin provides some information and gives an impression of the disease spectrum. Table ​ Table1 1 represents unpublished data analysis.

Spectrum of CKD causes

Nephrology unit of Moscow City Hospital n.a. S.P. Botkin, 1994–2017 ( n = 18,368 cases).

The care and management of CKD include (1) CKD diagnostics and stratification; (2) monitoring of proteinuria, eGFR, and blood pressure; (3) treatment of underlying kidney diseases and measures for prevention of CKD progression; and (4) diagnostics, evaluation, and treatment of anemia, metabolic bone disease, cardiovascular complications, etc. Nephroprotection strategies, erythropoiesis-stimulating agents, iron supplementation, and phosphate binders are widely used. Diagnostic approaches and treatment of glomerulonephritis, including use of corticosteroids, immunosuppressants (cyclophosphamide, calcineurin inhibitors, mycophenolates, rituximab), and plasmapheresis are in agreement with international and national guidelines.

Of note, the International KDIGO Clinical Practice Guidelines for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease - Mineral and Bone Disorder; for Anemia in Chronic Kidney Disease; for Lipid Management in Chronic Kidney Disease; for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease; and for Glomerulonephritis were translated to Russian and widely implemented [ 26 , 27 , 28 , 29 , 30 ]. The translation of KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease - Mineral and Bone Disorder is currently in progress.

Hemodialysis (HD) techniques, invented and developed in western countries, immediately raised great interest in the Soviet Union. The first paper presenting an international experience of “artificial kidney” use was published by Dr. Parin [ 31 ] in 1955. The first Soviet “Artificial Kidney Apparatus” (AKA-60) was invented in 1957 by Yury Kozlov and his colleagues in the Research Institute of Experimental Surgical Technologies; production of the AKA-60 commenced in the Factory of Medical Equipment in Kazan [ 32 ].

In 1958, the first HD procedure using the Moeller dialysis machine was performed by Professors Pytel, Lopatkin, and Djavadzade at the University Clinic of Russian National Research Medical University n.a. N.I. Pyrogov (then the 2nd Moscow Medical Institute), based in Moscow City Hospital No. 1. Professor Pytel, a recognized urologist, was specifically interested in nephrology and had already studied crush syndrome and hepatorenal syndrome. In 1961, he published a monograph entitled “Artificial kidney and its clinical usage”, which was the first Russian monograph in the field [ 33 ].

Between 1958 and 1960 four “Experimental renal laboratories” for the treatment of patients with acute renal failure (ARF) opened: one in the Hematology Research Center (then the Research Institute of Blood Transfusion), one in Moscow Hospital No. 1, one in the Moscow City Hospital n.a. S.P. Botkin, and one in the 1st Moscow Medical University n.a. I.M. Sechenov (then the 1st Moscow Medical Institute). In 1960, the department of HD for patients with ARF, working in cooperation with the “Laboratory of Artificial Kidney” headed by Professor Gert Kulakov, was opened in the Moscow City Hospital n.a. S.P. Botkin. It was headed by Dr. Melikyan, who was one of the pioneers of HD in Russia and worked actively for 4 decades.

The year 1962 saw the first ever procedure not using donor blood with AKA-60 [ 34 ]. In 1964, the modified AKA-140 was invented, with production starting in Leningrad in 1969. HD was primarily used for the treatment of ARF in the setting of obstetric and surgical complications, poisoning, Hanta virus hemorrhagic fever, and crush syndrome. By 1971 more than 50 HD centers, equipped with AKA machines were successfully implemented throughout the Soviet Union. This allowed the expansion of indications for HD to chronic renal failure. The first dialysis unit for patients with end-stage renal disease (ESRD) was started in Moscow City Hospital No. 24 in 1967.

In 1963, the first pediatric patient, a 3-year-old child, was treated with HD. The first pediatric HD unit for the treatment of children with ARF was established in 1976 in the St. Vladimir Children's Hospital (then the Children's Hospital n.a. I.V. Rusakov), headed by Dr. Zverev. It was the only such unit in the country for many years, and later became the first center for children with hemolytic uremic syndrome; in 1991 peritoneal dialysis (PD) was successfully performed for the first time in Russia at this center.

Between 1971 and 1973 Hemodialysis System 6 (SHD-6) was invented by Professor Kulakov and engineer Balabanov. The new model of HD machine enabled HD procedures to be performed on 6 patients simultaneously [ 32 ]. The first two machines were introduced in 1974 in the “Laboratory of Artificial Kidney” in the Moscow City Hospital n.a. S.P. Botkin. Later, the SHD-8 replaced the SHD-6 and was introduced to clinical practice in many cities. In 1976, the first arteriovenous fistula was placed by Dr. Timokhov and Dr. Melikyan at the Moscow City Hospital n.a. S.P. Botkin, with arteriovenous fistula swiftly replacing shunts as the standard dialysis access technique in most HD units for ESRD patients soon after. The nephrology service in Leningrad first included HD units, working in cooperation with clinical nephrology and outpatient units; Professor Shostka coordinated this work.

During the next 2 decades, the number of HD units increased; however, they were insufficient to meet the demands of dialysis care for the ESRD patients. The biggest challenge for the dialysis service was the Spitak (Armenia) earthquake in 1988. At least 400 earthquake victims developed crush syndrome, and many of them with ARF were treated with HD. Most victims were evacuated from Armenia to Moscow and other major cities.

The economic changes following the collapse of the Soviet Union resulted in the substantial growth of dialysis care services. Unfortunately, this growth was not accompanied by the development of dialysis machine production, and now only imported equipment is used in the Russian Federation. While many intensive care units were equipped with dialysis machines that performed HD and continuous hemodiafiltration, the PD program for adult patients was started in 1995 to improve dialysis services; the first three units were opened in the Moscow City Clinical Hospital No. 52, Moscow City Hospital n.a. S.P. Botkin, and Moscow City Clinical Hospital No. 7, followed by Mariinskaya City Hospital, Saint Petersburg, and later in the other big cities. The PD unit of Moscow City Clinical Hospital No. 52 is actually the biggest in the Russian Federation.

In 2002, the Ministry of Health issued an order regarding “Excellence of Organization of Dialysis Care,” whereby public-private partnership implementation resulted in a rapid increase in the HD outpatient units. The International KDIGO and ERBP Guidelines concerning CKD and acute kidney injury were translated to Russian and widely implemented [ 30 , 35 , 36 ].

Evaluation of the disease spectrum of ESRD is based on the data from the Registry of patients on renal replacement therapy (RRT), started by the Russian Dialysis Society in 1998. The available individual data analysis is shown in Table ​ Table2 2 [ 37 ].

Causes of ESRD in patients on hemodialysis and peritoneal dialysis

Russian Dialysis Society Registry, 2011–2013 ( n = 15,880 patients).

The evaluation and management of patients receiving RRT include monitoring of dialysis dose and key quality indicators, blood pressure, body mass index, serum albumin, hemoglobin, total cholesterol, total calcium, serum phosphates, and parathyroid hormone. Comorbidities, treatment patterns, mortality, and survival are also evaluated on a regular basis. Patients on RRT receive antihypertensive medications, iron supplementation, erythropoiesis-stimulating agents, phosphate binders, and calcimimetics.

Transplantation

The first kidney transplantation from a deceased donor was performed by Dr. Voronoy in 1933 in Kherson (now a territory of Ukraine). While the procedure was not successful, the first ever attempt, published in 1936, enabled further developments [ 38 ]. The first successful kidney transplantation from a living donor, in this case a relative, was performed by Professor Petrovsky at the Russian Research Center of Surgery in 1965. In 1967, the National Medical Research Center of Transplantology and Artificial Organs n.a. V.I. Shumakov (then the Research Institute of Organ and Tissue Transplantation, first headed by Professor Solovyov) was created by Professor Petrovsky. Professor Petrovsky, along with Professor Solovyov and his group, published a book entitled “Kidney transplantation” in 1969 [ 39 ], when the program of kidney transplantation from deceased donors was initiated and widely implemented by Professor Shumakov, who headed the Research Institute of Organ and Tissue Transplantation for more than 30 years since 1974. The number of centers performing kidney transplantation exclusively from deceased donors increased over the next 2 decades. Professor Phyliptsev played a leading role in the implementation of kidney transplantation for almost 3 decades. In 1990, the first center for pediatric kidney transplantation was opened in the Russian Children's Clinical Hospital.

In 1992, the federal legislation regarding “transplantation of organs and/or tissues” was introduced, whereby only direct relatives are allowed to donate kidneys for transplantation. Several regulatory documents have been released since the order addressing “regalement of brain death diagnostics” (2014). The program of kidney transplantation from living donors commenced in 1999 in the National Medical Research Center of Transplantology and Artificial Organs, headed by Professor Moysuk, who summarized the experience of the first 2 years in the article “Kidney transplantation from living relative donor” [ 40 ].

The first Department of Nephrology came from the Department of Internal and Occupational Diseases of the 1st Moscow Medical University n.a. I.M Sechenov (formerly known as the Faculty of Medicine of Imperator's Moscow University, created in 1755), which started in 1930 and was headed by Professor Tareev from 1950. Under his leadership, nephrology became one of the main priorities, and in 1966 the Clinic of Nephrology, Internal and Occupational Diseases opened, merging the Department of Nephrology, the Department of Internal and Occupational Diseases, and the Nephrology and HD units. Between 1986 and 2017, the head of the Clinic of Nephrology was Professor Mukhin. In 1972, Professor Tareev initiated the Laboratory of Nephrology Problems, which was headed by his daughter, Professor Tareeva, from 1975 [ 41 ].

An educational course on hemodialysis at the Russian Medical Academy of Continuous Postgraduate Education (formerly the Central Institute of Medical Qualification, created in 1930) was initiated by Professor Kulakov in 1965, based at the “Laboratory of Artificial Kidney”. In 1982, this educational course developed into the first Department of Nephrology and Hemodialysis, headed by Professor Kulakov [ 32 ]. The Department was, and still is, based in the Moscow City Hospital n.a. S.P. Botkin; the close relationships between academia and clinical practice ensured the development of the field. Currently the Department is headed by Professor Ermolenko, one of the opinion leaders in the field, whose monograph entitled “Chronic Hemodialysis” was published in 1982 [ 42 ].

In 1996, the Research Institute of Nephrology was created at the 1st Saint Petersburg Medical University n.a. I.P. Pavlov (formerly the Women's Medical Institute, and later the 1st Leningrad Medical Institute), with Professor Ryabov as the first director. The Institute of Nephrology merged the Course of Nephrology and Dialysis (later the Department of Nephrology and Dialysis, headed by Professor Eacayan), the Department of Internal Medicine (formerly the Department of Internal Diseases, created in 1914 and headed by Professor Lang from 1919 to 1921), and several laboratories with the clinical nephrology unit.

A course of “efferent therapy” was started in 1994 at the Saint Petersburg Medical Academy of Postgraduate Education (formerly the Imperator's Clinical Institute, created in 1896). The course was later changed to the Department of Nephrology and Efferent Therapy and existed until 2011, when the Saint Petersburg Medical Academy of Postgraduate Education merged with the Saint Petersburg Medical Academy n.a. I.M. Mechnikov (formerly the Institute of Psychoneurology, created in 1907) under the name North-Western State Medical University n.a. I.M. Mechnikov.

In 2004, the Department of Nephrology, headed by Professor Tomilina, opened in the Moscow State University of Medicine and Dentistry (formerly the Moscow Institute of Medicine and Dentistry, created from the Moscow State Institute of Dentistry in 1949). This is a unique institution, providing postgraduate education in the fields of clinical nephrology, nephropathology, dialysis, and transplantation.

All of the abovementioned institutions provide professional education for residents and PhD students as well as certification courses and short-term continuing medical education (CME) courses.

The Society of Nephrology and Immunopathology, as part of the Moscow Scientific Society of Therapeutics created in 1895, started its work in 1958 and is currently active, conducts monthly meetings, and is devoted to selected issues of clinical nephrology, immunonephrology, and nephropathology.

The Scientific Society of Nephrology (SSN) was founded in 1969 by Professor Tareev, who was the President of the Society for almost 15 years. The congresses of the SSN have been conducted every 6 years since 1974, and during the intervening years Nephrology Summer Schools, initiated by Professor Natochin, the successor of Professor Gynetsynsky, were the most important events.

First contacts with ISN leadership were established by Professor Tomilina in 1994, when she invited Professor Brenner and Professor Dirks to attend the SSN meeting in Moscow. In 1995, the first CME course under the aegis of the ISN, ERA-EDTA, and IPNA was conducted in Moscow. The formal organizer was the SSN, but Professor Tomilina was the driving force. Among the invited international speakers were Professor Cameron and Professor Lameire. Unfortunately, due to formal official regulations the SSN was unable to continue its work for several years. The Scientific Society of Russian Nephrologists, the successor of the SSN, was started in 2005, conducting congresses and plenary assemblies and creating national guidelines and protocols.

In 1997, the Union of Pediatric Nephrologists was funded by an initiative of Professor Papayan [ 22 ]. In 1998, the Russian Dialysis Society (RDS) was established, with Professor Tomilina as the first president. This society is currently the most active professional society of nephrologists in Russia. It is affiliated with the ISN, ERA-EDTA, and EKHA, and cooperates with KDIGO, ERBP, and WKD leadership. The RDS is specifically dedicated to the education of nephrologists throughout the Russian Federation, and conducts up to five CME conferences each year in Moscow, Saint Petersburg, and the big cities in Siberia, Volga, Far East, North West, North, and South Regions. Numerous international leaders of nephrology deliver talks at these meetings as invited speakers, as well as conducting ISN Educational Ambassadors Courses. The RDS also supports the registry and the journal Nephrology and Dialysis (see below). Translations of most KDIGO and ERBP Guidelines and World Kidney Day Editorials were undertaken and published by RDS initiatives [ 26 , 27 , 28 , 29 , 30 , 35 , 36 , 43 , 44 ].

The first journal to publish papers with nephrology articles in Russian was Urology and Nephrology , which was started in 1968 on the basis of the Urology journal, issued since 1965. The journal Nephrology was started by Professor Smirnov in Saint Petersburg in 1997 and was the first journal to publish a wide range of articles in the field.

In 1998, the journal Nephrology and Dialysis (an official journal of the RDS) was initiated by Professor Tomilina. This journal is the most influential nephrology journal in Russia with one of the highest impact factors among all medical journals in Russia. The journal Clinical Nephrology was started in 2009, and was edited by Professor Mukhin till 2017.

In 1998, Professor Tomilina initiated the registry of patients on RRT. The registry data is published every other year in the journal Nephrology and Dialysis , providing detailed information about many aspects of RRT in Russia. These include information not only about the number of centers and patients, but also on issues of anemia, hypertension, CKD-MBD management, viral hepatitis diagnostics and treatment, and many other aspects. The registry is affiliated with the ERA-EDTA Registry, providing data for international publications.

The most recent analysis, which includes published data till the end of 2015 [ 45 ] and unpublished data up to the end of 2016, shows that the total number of centers providing RRT is 506 (including 466 providing HD, 111 for PD, and 37 for kidney transplantation), with many centers providing two or three modalities. Of note, only centers providing care to both adult and pediatric patients with ESRD were included, while centers providing care specifically to patients with acute kidney injury were not registered. The number of patients with ESRD on HD + PD by the end of 2016 was 44,771 (33,876 on HD, 8,537 on PD, and 2,358 living with transplanted kidney); the mean ratio was 305 per million inhabitants. Furthermore, the number of patients on HD in 2016 was 78% greater than that in 2010, mainly due to the development of public-private partnership.

Current Problems

  • Absence of nephrology courses for students in Medical schools
  • Relatively short-term professional postgraduate education (2-year residency, absence of fellowship programs)
  • Lack of certified nephrologists
  • Under-recognition of CKD burden by health authorities and policy makers
  • Under-diagnostics of CKD in the adult population
  • Lack of cooperation among nephrologists and general practitioners, endocrinologists, cardiologists, and other specialists
  • Under-diagnostics of CKD and ESRD in the pediatric population
  • Lack of nephrology units, disproportionate to the number of dialysis units, especially outside big industrial areas
  • Lack of renal pathologists and unavailability of kidney biopsy in many regions
  • Under-development of PD
  • Uneven distribution of dialysis service throughout the territory of the country, with several remote regions still poorly covered by RRT
  • Lack of transplantation and insufficient organ har vesting
  • Insufficient funds for research

Conclusions

Nephrology in Russia, despite currently experiencing many difficulties, made great advances during the 60 years of its development. General nephrology, nephropathology, and RRT are developing fast. Implementation of international guidelines, access to modern educational tools, and cooperation with international professional societies are improving the quality of care of renal patients and ensuring further progress.

Statement of Ethics

No ethic approval is required for this type of study.

Disclosure Statement

The author declares no conflict of interest.

Acknowledgments

The author thanks Dr. Anton Andrusev, Dr. Sergey Lashutin, and Prof. Natalia Tomilina for their valuable help.

IMAGES

  1. Tracheostomy

    dissertation on tracheostomy care

  2. PPT

    dissertation on tracheostomy care

  3. Tracheostomy: Uses, Procedure, Side Effects, and Results

    dissertation on tracheostomy care

  4. Tracheostomy care

    dissertation on tracheostomy care

  5. Tracheostomy Nursing Notes

    dissertation on tracheostomy care

  6. Advanced Life Support Group: Comprehensive Tracheostomy Care: The

    dissertation on tracheostomy care

COMMENTS

  1. Management of tracheostomies in the intensive care unit: a scoping

    Tracheostomy is performed in approximately 10%-15% of patients who are admitted to intensive care units (ICU).1 This procedure, which involves either percutaneous or surgical placement of a tube across the anterior neck into the airway, may be indicated for relief of airway obstruction, facilitation of pulmonary toilet and for facilitation of wean from mechanical ventilation.2 In addition ...

  2. A Systematic Review of Tracheostomy Modifications and Swallowing in

    Introduction. Tracheostomy placement is a medical intervention often used for those with complex respiratory conditions [1-3].These artificial airways provide direct, unobstructed lower respiratory tract access to maximize ventilation [4-7], expedite oxygen entry, and facilitate secretion management [6, 7].Given the anatomical location of a tracheostomy and the shared pathway of the ...

  3. PDF A Systematic Review of Patient and Caregiver Experiences with a

    Patients and their caregivers reported a range of mostly negative experiences related to the care, support, and management of a tracheostomy, speech and communication, wellbeing and QoL, disfigurement and body image, and stigma and social withdrawal. Ivana Nakarada-Kordic [email protected]. 1 Design for Health and Wellbeing (DHW) Lab, Auckland ...

  4. The present thesis investigates the outcome Long-Term Tracheostomy ...

    well as care and wear of tracheostomy tubes. It may hopefully contribute to increased evidence based care for these patients. The research was carried out at the National Respiratory Centre (NRC), Danderyd Hospital, Stockholm, Sweden. 1.1 A BRIEF HISTORY Long-term tracheostomy can today be used for patients with for instance, upper airway

  5. Use of Simulation for Tracheostomy Care, a Low Volume, High Risk

    This Dissertation is brought to you for free and open access by the Walden Dissertations and Doctoral Studies Collection at ScholarWorks. It has been ... tracheostomy care can lead to diminished quality of care and potentially an adverse event. Therefore, there is a need for a teaching method that facilitates knowledge retention as ...

  6. Critical Care Nurses' Knowledge of Tracheostomy Care

    Introduction. Tracheostomy tube placement is a procedure that may be applied in Critical Care Units (CCUs) for different reasons, including clearing or removing secretions from the airways, bypassing upper airway obstruction, providing oxygen to the lungs, and establishing long-term mechanical ventilation.[] Safe practice in tracheostomy care increases comfort for patients, decreases the ...

  7. Developing an Educational Program for Tracheostomy Care

    This Dissertation is brought to you for free and open access by the Walden Dissertations and Doctoral Studies Collection at ScholarWorks. It has been accepted for inclusion in Walden Dissertations and Doctoral Studies by an authorized administrator of ScholarWorks. For more information, please [email protected].

  8. PDF Development of a Tracheostomy Care Education Program By A Thesis

    tracheostomy care was provided to them (Hall, 2010). Proper knowledge of tracheostomy care is important for safe and successful self-care management in the home environment once the patient is discharged from the hospital. Without solid tracheostomy care education, the patient with a tracheostomy is at high risk for developing

  9. Nurses Knowledge and Practices Regarding Tracheostomy Care at a

    Only 2.5% of nurses had excellent knowledge of tracheostomy care, which differs with the findings of Dhaliwal et al. (2018), who found that 43% of nurses had good knowledge. ...

  10. University of Central Florida STARS

    is estimated to be less than 50% (Mitchell, Parker, & Giles, 2013). Most clinicians agree that. tracheostomy care needs to include skin care and hygiene of the stoma, cleaning or replacing of. the tracheostomy ties, cleaning or changing of the inner cannula, and placement of a dressing to.

  11. Dissertations / Theses: 'Tracheostomy care'

    Actions of tracheostomy care as well as the technique of secretion suctioning from tracheostomy tube can influence the incidence of complications and determine patient's safety, possibility of recovery, the duration of treatment and the cost of treatment. ... The thesis maps nursing care for pediatric patients when securing airway, it focuses ...

  12. (PDF) A study on tracheostomy

    A retrospective review of 281 consecutive tracheostomies was undertaken to evaluate the current risks of tracheostomy in tertiary care teaching hospitals. In addition, we sought to identify ...

  13. Management of tracheostomies in the intensive care unit: a scoping

    Tracheostomy is performed in approximately 10%-15% of patients who are admitted to intensive care units (ICU). 1 This procedure, which involves either percutaneous or surgical placement of a tube across the anterior neck into the airway, may be indicated for relief of airway obstruction, facilitation of pulmonary toilet and for facilitation of wean from mechanical ventilation. 2 In addition ...

  14. Tracheotomy in the intensive care unit: guidelines from a French expert

    Tracheotomy is a procedure commonly used in intensive care, albeit with great disparities between medical teams in terms of frequency (5-54%) and modality (surgical or percutaneous) [1, 2].Although tracheotomy has a long history, its utility, indications, duration, and techniques are the subject of debate [3, 4].Also, the real or potential advantages of tracheotomy need to be weighed against ...

  15. Update on management of tracheostomy

    More than 12,000 tracheostomies are inserted annually in the UK, and up to 20% of patients in ICU are managed with a tracheostomy. 1 This includes both surgically and percutaneously placed tracheostomies, and both elective and emergency procedures. As a result, these complex and challenging patients are increasingly encountered in critical care units and medical and surgical wards.

  16. PDF TRACHEOSTOMY;

    The term tracheostomy is derived from Greek word meaning "Icut" the trachea. has been known for about 3500 years. In the past it has been considered as a method of choice in saving patients with upper air way obstruction. Nowadays ,indications of tracheostomy have been extended to patients with mechanical respiratory insufficiency and ...

  17. Critical Care Nurses' Knowledge of Tracheostomy Care : Iranian Journal

    Discussion. Currently, tracheostomy care is a major health concern worldwide as the number of patients undergoing tracheostomy increases. Several deaths have occurred as a result of nurses ' insufficient knowledge. [] Although the significance of nurses ' knowledge levels regarding particular care tools is prominent, [3, 18] in the current study, the level of knowledge was moderate, which ...

  18. Interstitial inflammation and pulmonary fibrosis in COVID-19: The

    The progression of secondary pulmonary damage in SARS-COV-2 infection, associated with interstitial damage, inflammation and alveolar consolidation and eventually resulted in the development of pulmonary fibrosis (PF), remains one of the key clinical dilemmas for the treatment of patients in intensive care units (ICU).

  19. Flow in fractured rock.

    The flow through each fracture is discretized by the boundary element method. By performing numerical simulation, the percolation threshold was found to be in the range of 0.9 to 2.4 for orthogonal joint sets. There is a rapid increase in flow rate with increasing fracture density or fracture length as the percolation factor reaches the ...

  20. Assessment of knowledge regarding tracheostomy care and management of

    Our study further revealed that the areas where doctors and nurses had the poorest knowledge regarding bedside tracheostomy care were adequate cuff pressure (38.9%), adequate suction pressure (39.4%), first response in case of tube blockade (31.1%), minimum adequate time for removal of stay sutures (34.8%) and the earliest sign of stomal ...

  21. Michael Z.

    Dr. Zastrozhin 32 y.o., MD (2014), PhD (2016), MPH (2019), DMedSci (2020), Postdoc (2023), CEO (2024). During my career, I have made significant and widely recognized contributions to the study of ...

  22. Knowledge and Practices of Endotracheal Suctioning amongst Nursing

    To assess the knowledge of nurses about tracheostomy care and find out relationship between nurses knowledge about tracheostomy care and selected variables ... SCTISMT; Trivandrum: 2011. A study to assess the knowledge and practice of endotracheal suctioning among neuro nurses. Thesis, [Google Scholar] 20. Overend JT, Anderson MC, Brooks D, et ...

  23. Student Explores Misconceptions About Burnout in New Research

    Student Explores Misconceptions About Burnout in New Research. Ali Ryan researched the relationship between self-care, difficult work settings, burnout and mental health for school psychology graduate students. Her dissertation confronts the limits of self-care and puts more responsibility on the systems in which students work.

  24. History, Current Advances, Problems, and Pitfalls of Nephrology in

    Of note, only centers providing care to both adult and pediatric patients with ESRD were included, while centers providing care specifically to patients with acute kidney injury were not registered. The number of patients with ESRD on HD + PD by the end of 2016 was 44,771 (33,876 on HD, 8,537 on PD, and 2,358 living with transplanted kidney ...