Maximal inspiratory and expiratory pressure measurement in tracheotomised patients.
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The present study compared four different sites and conditions for the measurement of maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) in 38 spontaneous breathing tracheotomised patients. Of the patients, 28 had chronic obstructive pulmonary disease (COPD). The four different conditions were: 1) through a cuff inflated cannula (condition A); 2) through the mouth with a deflated cannula (condition B); 3) through the mouth with a phonetic uncuffed cannula (condition C); and 4) through the mouth after stoma closure (condition D). Five trials in each condition were performed using a standardised method. The measurement of both MIP and MEP differed significantly depending on the condition of measurement. MIP taken in condition A was significantly higher when compared with conditions B, C and D. MEP in condition A was significantly higher when compared with condition B and D. In condition A the highest frequency of the best measurement of MIP and MEP was observed at the fourth and fifth effort, respectively. The same results were obtained after the selection of only COPD patients. In conclusion, respiratory muscle assessment differs significantly depending on measurement condition. Measurement through inflated cannula tracheotomy yields higher values of both maximal inspiratory and maximal expiratory pressure. (+info)
Nasogastric tube syndrome: a life-threatening laryngeal obstruction in a 72-year-old patient.
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Nasogastric tube (NGT) syndrome is a rarely reported complication of NGT use that can cause life-threatening laryngeal obstruction. The syndrome results from post-cricoid ulceration, which affects the posterior cricoarytenoid muscles, thus causing vocal cord abduction paralysis and upper airway obstruction. We describe a case of a 72-year-old patient with this syndrome who was treated successfully and emphasise the difficulty of diagnosis in frail older adults. (+info)
Tracheotomy does not affect reducing sedation requirements of patients in intensive care--a retrospective study.
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INTRODUCTION: Translaryngeal intubated and ventilated patients often need sedation to treat anxiety, agitation and/or pain. Current opinion is that tracheotomy reduces sedation requirements. We determined sedation needs before and after tracheotomy of intubated and mechanically ventilated patients. METHODS: We performed a retrospective analysis of the use of morphine, midazolam and propofol in patients before and after tracheotomy. RESULTS: Of 1,788 patients admitted to our intensive care unit during the study period, 129 (7%) were tracheotomized. After the exclusion of patients who received a tracheotomy before or at the day of admittance, 117 patients were left for analysis. The daily dose (DD; the amount of sedatives for each day) divided by the mean daily dose (MDD; the mean amount of sedatives per day for the study period) in the week before and the week after tracheotomy was 1.07 +/- 0.93 DD/MDD versus 0.30 +/- 0.65 for morphine, 0.84 +/- 1.03 versus 0.11 +/- 0.46 for midazolam, and 0.62 +/- 1.05 versus 0.15 +/- 0.45 for propofol (p < 0.01). However, when we focused on a shorter time interval (two days before and after tracheotomy), there were no differences in prescribed doses of morphine and midazolam. Studying the course in DD/MDD from seven days before the placement of tracheotomy, we found a significant decline in dosage. From day -7 to day -1, morphine dosage (DD/MDD) declined by 3.34 (95% confidence interval -1.61 to -6.24), midazolam dosage by 2.95 (-1.49 to -5.29) and propofol dosage by 1.05 (-0.41 to -2.01). After tracheotomy, no further decrease in DD/MDD was observed and the dosage remained stable for all sedatives. Patients in the non-surgical and acute surgical groups received higher dosages of midazolam than patients in the elective surgical group. Time until tracheotomy did not influence sedation requirements. In addition, there was no significant difference in sedation between different patient groups. CONCLUSION: In our intensive care unit, sedation requirements were not further reduced after tracheotomy. Sedation requirements were already sharply declining before tracheotomy was performed. (+info)
Recurrent respiratory papillomatosis.
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Recurrent respiratory papillomatosis (RRP) is a benign, often multi-focal neoplasm. A potentially fatal manifestation of human papilloma virus infection, the condition is characterised by multiple warty excrescences on the mucosal surface of the respiratory tract. RRP is rare--incidence is estimated at 3.5 per million person-years, with a prevalence of 4 in 100,000 children. Affected children usually require multiple interventions; the impact on patients, their families, and the healthcare system is considerable. Treatment of RRP accounts for an estimated dollar 109 million annual expenditure in the USA. (+info)
Relationship between tracheotomy and ventilator-associated pneumonia: a case control study.
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The aim of the present study was to determine the relationship between tracheotomy and ventilator-associated pneumonia (VAP). The study used a retrospective case-control study design based on prospective data. All nontrauma immunocompetent patients, intubated and ventilated for >7 days, were eligible for inclusion in the study. A diagnosis of VAP was based on clinical, radiographical and microbiological criteria. Four matching criteria were used, including duration of mechanical ventilation (MV). The indication and timing of tracheotomy were at the discretion of attending physicians. Univariate and multivariate analyses were performed to determine risk factors for VAP in cases (patients with tracheotomy) and controls (patients without tracheotomy). In total, 1,402 patients were eligible for inclusion. Surgical tracheotomy was performed in 226 (16%) patients and matching was successful for 177 (78%). The rate of VAP (22 versus 14 VAP episodes.1,000 MV-days(-1)) was significantly higher in controls than in cases. The rate of VAP after tracheotomy in cases, or after the corresponding day of MV in controls, was also significantly higher in control than in case patients (9.2 versus 4.8 VAP episodes.1,000 MV-days(-1)). In multivariate analysis, neurological failure (odds ratio (95% confidence interval) 2.7 (1.3-5)), antibiotic treatment (2.1 (1.1-3.2)) and tracheotomy (0.18 (0.1-0.3)) were associated with VAP. In summary, the present study demonstrates that tracheotomy is independently associated with decreased risk for ventilator-associated pneumonia. (+info)
Comparison of 2 models for managing tracheotomized patients in a subacute medical intensive care unit.
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OBJECTIVE: To compare 2 models for managing patients admitted to a subacute medical intensive care unit (MICU) who required prolonged mechanical ventilation (> or = 7 d). METHODS: The subjects were 192 consecutive patients (mean +/- SD age 61.5 +/- 16.1 y, 52% male, 86% white) managed during alternating 7-month blocks of time by an attending physician in collaboration with an acute care nurse practitioner (ACNP) (n = 98 patients) or by an attending physician in collaboration with critical care/pulmonary fellows (n = 94 patients). The total observation time was 28 months (14 mo per team). RESULTS: At unit entry, there were no significant differences in age, sex, race, comorbidity, Acute Physiology and Chronic Health Evaluation III score, or time of tracheostomy between the patients managed by the 2 teams. Patients managed by the ACNP team were more likely to have required mechanical ventilation due to an acute pulmonary problem (p = 0.005). At subacute MICU discharge, the groups were not significantly different in regard to subacute MICU length of stay, days on mechanical ventilation, or discharge weaning status (p > 0.05). The number of readmissions to the MICU was similar for the ACNP team (n = 7) and fellows team (n = 8), as were readmissions to the subacute MICU < or = 72 h after discharge (ACNP = 2, fellows = 1). Each team had 2 deaths without treatment limitation. CONCLUSION: As hypothesized, management of patients who required prolonged mechanical ventilation with tracheostomy had equivalent outcomes with the ACNP team or the fellows team. (+info)
Time to wean after tracheotomy differs among subgroups of critically ill patients: retrospective analysis in a mixed medical/surgical intensive care unit.
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OBJECTIVE: To determine the time to wean from mechanical ventilation and time spent off the ventilator per day after tracheotomy in critically ill patients in a 28-bed mixed medical and surgical intensive care unit (ICU) in Amsterdam, Netherlands. METHODS: We conducted a retrospective analysis of consecutive patients during the 14-month period from November 1, 2003, through January 1, 2005. Included were translaryngeally intubated mechanically ventilated patients who received a tracheotomy during their ICU stay. RESULTS: Of all the patients admitted to the ICU, 129 (7%) received a tracheotomy. Significantly more tracheotomies were performed in neurosurgery/neurology patients and in those admitted for acute conditions (16% and 12%, respectively). Tracheotomy was performed a median 8 days (interquartile range 4-13 d) after ICU admission. For all the patients, the median time to wean after tracheotomy was 5 days (interquartile range 2-11 d). Neurosurgery/neurology patients and patients in the cardiology subgroup needed significantly less time to wean from mechanical ventilation than did patients in other subgroups (3 d, interquartile range 2-7 d, and 3 d, interquartile range 2-5 d, respectively, p < 0.05). There was a significant association between admission group and neurological status at the time of tracheotomy. A low Glasgow coma scale score was associated with shorter time to wean. Within 1 week after tracheotomy, the probability of the patient having breathed spontaneously, without ventilator assistance, for > 4 h/d was 89%, 78% for > 8 h/d, and 72% for > 12 h/d. By day 28, the probability of the patient having breathed spontaneously for > 4 h/d was 98%, 97% for > 8 h/d, and 94% for > 12 h/d. CONCLUSION: Time to wean from after tracheotomy differed among the subgroups in our ICU. After tracheotomy, the majority of patients were quickly able to breathe spontaneously without assistance of the mechanical ventilator for several hours per day. Patients who require tracheotomy only for airway protection wean sooner than other patients. (+info)
Repeated massive tongue swelling due to the combined use of estramustine phosphate and angiotensin-converting enzyme inhibitor.
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A 70-year-old man presenting with a chief complaint of tongue swelling had been diagnosed with prostate cancer 1 year earlier. He had been on an oral angiotensin-converting enzyme inhibitor (ACE) inhibitor for hypertension for 20 years. Two months before the first of 4 episodes of tongue swelling within a period of 40 days, he had been prescribed oral estramustine phosphate (EMP) for the prostate cancer. He was admitted to our hospital for the evaluation after massive swelling of the tongue and epiglottis which necessitated tracheotomy. Food allergies, allergic reactions to environmental factors, and hereditary angioneurotic edema were excluded. Massive swelling of the tongue and epiglottis disappeared completely after EMP was discontinued. We concluded that angioedema was induced by EMP used concurrently with the ACE inhibitor. (+info)