Desafios de familiares no cuidado domiciliar da criança em uso de cânula de traqueostomia / Home care challenges facing families of children using a tracheostomy cannula / Desafíos de familiares en el cuidado domiciliario al niño en uso de cánula de traqueotomía

Objetivo: descrever os desafios enfrentados por familiares para cuidar da criança com traqueostomia no domicílio. Método: pesquisa descritiva, qualitativa, desenvolvida através da análise de conteúdo, pela perspectiva do referencial teórico de Collière. Foram entrevistados oito familiares de crianças com traqueostomia, na faixa etária entre 3 e 9 anos acompanhadas em um ambulatório pediátrico no município do Rio de Janeiro, no período de janeiro a maio de 2016. Resultados: os desafios envolveram principalmente o enfrentamento da nova realidade, as novas demandas de cuidado, a dificuldade com a aquisição de materiais e a limitação no convívio social da criança. Para superar as dificuldades os familiares cuidadores reinventam as estratégias de cuidado a fim de preservar a vida. Conclusão: foram identificadas condutas que oferecem risco à saúde dessas crianças, apontando a necessidade de instrumentalizar as práticas dos familiares para a manutenção adequada e segura das vias aéreas no ambiente domiciliar

Objective: to describe the challenges faced by family members in providing home care for children with tracheostomy. Method: this qualitative, descriptive study, applied content analysis from the perspective of Collière's theoretical framework. Eight family members of children with tracheostomies, aged between 3 and 9 years, treated at a pediatric outpatient clinic in Rio de Janeiro city, were interviewed between January and May 2016. Results: the main challenges found were coping with the new situation, new care demands, difficulty acquiring material, and limitations on social life. To overcome the difficulties, family caregivers reinvent care strategies in order to preserve lives. Conclusion: behaviors that pose risks to these children's health were identified, pointing to the need to equip families' care practices so that they can maintain airways properly and safely at home.

Objetivo: describir los desafíos enfrentados por familiares para cuidar al niño con traqueotomía, en el domicilio. Método: investigación descriptiva, cualitativa, desarrollada a través del análisis de contenido, desde la perspectiva del marco teórico de Collière. Se entrevistaron ocho familiares de niños con traqueotomía, con edad entre 3 y 9 años, cuyo seguimiento tuvo lugar en un ambulatorio pediátrico situado en el municipio de Río de Janeiro, de enero a mayo de 2016. Resultados: los desafíos involucraron principalmente el enfrentamiento de la nueva realidad, las nuevas demandas de cuidado, la dificultad en la adquisición de materiales y la limitación en la convivencia social del niño. Para superar las dificultades, los familiares cuidadores reinventan las estrategias de cuidado con fines de preservar la vida. Conclusión: se identificaron conductas que representan riesgos a la salud de estos niños, lo que señala la necesidad de instrumentalizar las prácticas de los familiares para el mantenimiento adecuado y seguro de las vías respiratorias en el entorno del hogar.

Predictores de éxito después de la decanulación en pacientes adultos críticamente enfermos: un estudio de cohorte retrospectivo / Success predictors after decannulation in critically ill adult patients: a retrospective cohort study

Introducción: la traqueostomía es una práctica frecuente dentro de las unidades de cuidados intensivos (UCI). El proceso de decanulación y el tiempo utilizado en ella resultan de interés clínico, mientras que los factores asociados al proceso y la dificultad en dicho proceso han sido poco estudiados. Objetivos: describir características clínicas y epidemiológicas de la población en estudio y su evolución desde el momento del ingreso en la UCI hasta el alta hospitalaria. Informar la incidencia de fallo de decanulación y analizar los factores de riesgo independientes asociados a la imposibilidad de esta. Materiales y métodos: estudio observacional de cohorte retrospectivo de pacientes internados en la UCI del Hospital Italiano de San Justo Agustín Rocca que requirieron traqueostomía durante su estadía. Utilizando la historia clínica informatizada se registraron variables epidemiológicas previas al ingreso en la UCI y datos evolutivos durante la internación. El período analizado fue desde el 5 de enero de 2016 hasta el 17 de diciembre de 2017. Se utilizaron modelos de regresión logística para la evaluación de potenciales predictores. Resultados: se reclutaron 50 pacientes, y todos fueron incluidos en el presente análisis. La edad promedio fue de 66 años (desvío estándar [DE] ± 15,5) y el 66% fueron hombres. El 42% fue decanulado durante el seguimiento. La incidencia en el fallo de decanulación fue del 4,77% (intervalo de confianza [IC] 95% 0,85-22,67). La mediana de tiempo hasta la decanulación desde la desvinculación de la asistencia ventilatoria fue de 17 días. En el análisis univariado hubo diferencias estadísticamente significativas en tipo de diagnóstico de ingreso en UCI y en el alta vivo hospitalaria al comparar pacientes decanulados versus no decanulados. En el análisis multivariado de regresión logística se halló el tipo de diagnóstico de ingreso en UCI como predictor independiente de imposibilidad de decanulación. Conclusiones: el motivo de ingreso clínico en UCI fue un factor predictor independiente asociado al fracaso de la decanulación y esto, posiblemente, está relacionado con la condición clínica y el estado general al ingreso, en comparación con los pacientes que ingresaron por causas quirúrgicas. No se hallaron comorbilidades ni antecedentes que se relacionen con el fracaso de la decanulación. (AU)

Introduction: the tracheostomy remains a very common surgical procedure done in the intensive care unit (ICU). The process of decannulation is of scientific interest with its associated factors not being sufficiently studied. Objectives: to describe the clinical and epidemiological characteristics of the population and their relationship to effective decanulation. To report the cumulative incidence of decannulation failure and success. To analyze independent risk factors associated with decannulation failure. Materials and methods: the present was a retrospective cohort of adult patients in the ICU at Hospital Italiano de San Justo who required tracheostomy during their in-hospital stay. Epidemiological variables were recorded before ICU admission and during their hospital stay using data from the electronic medical record. The inclusion period was 2 years long. We used descriptive statistics and logistic regression models to compare the proportion of patients who could be decannulated versus those who could not. Results: 50 patients were enrolled in the present study. Their mean age was 66 (±15.5) years and 66% of patients were male. 21 patients (42%) achieved to be decannulated. The cumulative incidence of decannulation failure was 4.77% (95% CI: 0.85-22.87). Median time from weaning to decannulation was 17 days. In univariate analysis, statistically significant differences were found in ICU admission diagnosis (p<0.001) and hospital discharge alive (p<0.001) when comparing decannulated versus not decannulated patients. In multivariate logistic regression analysis, ICU admission diagnosis was found to be an independent predictor of decannulation failure (p<0.01). Conclusions: clinical ICU admission diagnosis was an independent predictor associated with decannulation failure. This could be related to differences in baseline morbidity and clinical condition of these patients compared with surgical patients. However, no individual morbidities or clinical conditions were found to be associated in decannulation failure. (AU)

First Clinical Consensus and National Recommendations on Tracheostomized Children of the Brazilian Academy of Pediatric Otorhinolaryngology (ABOPe) and Brazilian Society of Pediatrics (SBP) / Primeiro Consenso Clínico e Recomendações Nacionais em Crianças Traqueostomizadas da Academia Brasileira de Otorrinolaringologia Pediátrica (ABOPe) e Sociedade Brasileira de Pediatria (SBP)

Abstract Introduction: Tracheostomy is a procedure that can be performed in any age group, including children under 1 year of age. Unfortunately health professionals in Brazil have great difficulty dealing with this condition due to the lack of standard care orientation. Objective: This clinical consensus by Academia Brasileira de Otorrinolaringologia Pediátrica (ABOPe) and Sociedade Brasileira de Pediatria (SBP) aims to generate national recommendations on the care concerning tracheostomized children. Methods: A group of experts experienced in pediatric tracheostomy (otorhinolaryngologists, intensive care pediatricians, endoscopists, and pediatric pulmonologists) were selected, taking into account the different regions of Brazil and following inclusion and exclusion criteria. Results: The results generated from this document were based on the agreement of the majority of participants regarding the indications, type of cannula, surgical techniques, care, and general guidelines and decannulation. Conclusion: These guidelines can be used as directives for a wide range of health professionals across the country that deal with tracheostomized children.

Resumo Introdução: A traqueostomia é um procedimento que pode ser feito em qualquer faixa etária, inclusive em crianças abaixo de um ano. Infelizmente no Brasil existe uma enorme dificuldade dos profissionais de saúde em lidar com esta condição e uma falta de padronização dos cuidados. Objetivo: Este consenso clínico realizado pela Academia Brasileira de Otorrinolaringologia Pediátrica (ABOPe) e Sociedade Brasileira de Pediatria (SBP) tem como objetivo gerar recomendações nacionais sobre os cuidados e condutas diante das crianças traqueostomizadas. Método: Foram selecionados um grupo de especialistas com experiência em traqueostomia na infância (otorrinolaringologistas, pediatras intensivistas, endoscopistas, pneumopediatras) que tivessem comprovada atuação prática no assunto, e que também contemplassem as diversas regiões do Brasil, de acordo com os critérios de inclusão e exclusão. Resultados: Os resultados gerados neste documento foram obtidos a partir da concordância da maioria dos participantes em relação as indicações, tipo de cânula, técnicas cirúrgicas, cuidados e orientações gerais e decanulação. Conclusão: Estas diretrizes poderão servir como norteadoras para os mais diversos profissionais de saúde em todo país que lidam com as dificuldades das crianças traqueostomizadas.

Traqueostomia percutânea: técnica ideal? / Percutaneous Tracheosthomy: ideal technique?

A traqueostomia percutânea tem substituído a traqueostomia convencional em muitas Unidades de Terapia Intensiva, devido à facilidade e segurança do método realizado à beira do leito, dispensando o transporte do paciente da Unidade de Terapia Intensiva para o Centro Cirúrgico. Alguns autores sugerem que a dissecção limitada resulta em menor dano tecidual, diminui o risco de sangramento e infecção de ferida operatória. Esta revisão visa analisar e sintetizar estudos prospectivos e randomizados, revisões sistemáticas e meta-análises, comparando a traqueostomia percutânea e traqueostomia convencional em pacientes adultos em Unidades de Terapia Intensiva.

OBJECTIVES: The percutaneous dilatational tracheostomy has become the technique of choice in the Intensive Care Unit, due safety and facilities to be performed at bedside, wich may overcome the risks associated with transport of critically ill patients to the Operating Room. Proponents of percutaneous dilatational tracheostomy suggest that the limited dissection results in less tissue damage, lowers the risk of bleeding and wound infection. The aim of this study is to review the techniques of percutaneous dilatational tracheostomy through a critical analysis of it's indications, contra-indications and complications, as well to compare percutaneous dilatational tracheostomy to surgical tracheostomy. This manuscript analysis and synthesizes randomized prospective studies, meta-analysis and systematic reviews, comparing both techniques in adult critically ill patients in the Intensive Care Unit.

Fractured tracheostomy tube migrating into the tracheobronchial tree: A rare complication.

Tracheostomy is a life saving procedure and many patients are discharged with permanent tracheostomy tubes. We report the rare occurrence of a fractured tracheostomy tube migrating into the tracheobronchial tree and highlight the clinical manifestations of this uncommon complication that carries the potential risk of fatal respiratory obstruction.

Traqueostomia percutânea / Percutaneous tracheostomy

Este estudo é uma revisão atualizada a respeito das duas técnicas de traqueostomia percutânea disponíveis em nosso meio, expondo suas limitações e sua implicação na prática clínica.A técnica mostrou ser uma opção segura, com baixas taxas de morbidade e mortalidade, e aparentemente com menor incidência de complicações tardias quando comparada à técnica convencional cirúrgica, além da possibilidade de ser realizada à beira do leito, sem a necessidade de submeter um paciente de terapia intensiva a um transporte de risco até o centro cirúrgico. Esses fatos tem feito com que a traqueostomia percutânea seja um procedimento que vem sendo cada vez mais utilizado. Entretanto ainda há necessidade de mais estudos controlados comparando a traqueostomia convencional com a percutânea para definir qual dos métodos é mais benéfico para os pacientes.

This study is an updated review about the two percutaneous tracheostomy techniques available in Brazil, addressing their limitations and clinical implications.The method proved to be a safe option, with low rates of morbidity and mortality, and apparently with a lower incidence of late complications comparedto conventional surgical technique, plus the ability to be performed at the bedside, without theneed to transport a critically ill patient to the surgical ward. Consequently. percutaneous tracheostomy is a procedure that has been more widely used. However there is still need formore controlled studies comparing conventional with percutaneous tracheostomy to define which method is most beneficial for patients.

Percutaneous tracheotomy: forceps vs. cone dilatation techniques

Percutanoeous tracheotomy [PT] is a minimal invasive procedure alternative to surgical tracheotomy. PT offers an added advantage of enormous decrease of time interval between decision of doing tracheotomy and actually doing it. Moreover hazards of patient transport can be avoided as it can be safely performed at the bedside. We started doing PT in 2003 and performed 100 cases using forceps dilatation. Later we switched over to cone dilatation where we performed 215 cases. This study aims to compare two techniques of forceps vs. cone dilatation methods for PT. A total of 100 cases of PT were performed starting from December 2003 to August 2005 using the forceps dilatation method [group A]. Further 215 cases were conducted [group B] from September 2003 to July 2008 using the cone dilatation method. Time of performing both procedures was recorded. Also incidence of complications was also recorded in both groups. The incidence of minor bleeding in group A was 9%, whereas in group B was 5.58%. Major bleeding occurred in two patients in group B. Both cases suffered of pneumothorax and emphysema. One patient developed life-threatening tension pneumothorax and required cardio pulmonary resuscitation. This was one case in this series, in which the procedure has contributed to patient's morbidity. Guide wire-related technical difficulties were seen in 2% of the cases in group A, and 3.7% of cases in group B. forceps dilatation PT is superior to the cone dilatation technique in terms of safety. Further studies are needed to confirm our results

Pediatric tracheostomy: [revision] / Traqueostomia na criança: [revisão]

OBJETIVO: Apresentar revisão atualizada sobre a traqueostomia na idade pediátrica, com ênfase nas indicações, técnica cirúrgica, complicações e manejo da traqueostomia a nível hospitalar e domiciliar. FONTES DOS DADOS: Foram selecionados pelo site de busca médica (MEDLINE e PubMed) artigos originais e de revisão sobre traqueostomia na criança, utilizando as seguintes palavras-chave: tracheostomy, tracheotomy, children, newborn. SíNTESE DOS DADOS: A indicação de traqueostomia vem mudando progressivamente. No momento, ela é mais indicada na criança em ventilação mecânica prolongada. A faixa etária mais comum do procedimento também mudou, sendo atualmente mais comumente realizada em crianças menores de 1 ano de idade. Exceto em situações de emergência, a traqueostomia deve ser realizada em unidade cirúrgica, com a criança entubada. É preconizada a incisão transversa da pele e abertura longitudinal da traqueia, sem ressecção da mesma. Embora as complicações da traqueostomia na criança não sejam incomuns, elas, na maioria das vezes, não necessitam de tratamentos sofisticados ou mesmo de intervenção cirúrgica. Embora a mortalidade possa ocorrer em até 40% das crianças traqueostomizadas, ela é diretamente relacionada à traqueostomia em apenas 0 a 6% das crianças. CONCLUSÕES: A decisão de realizar traqueostomia na criança continua complexa e dependente de vários fatores. O procedimento é seguro e com menores complicações quando realizado em hospital terciário de referência e por equipe treinada e experiente.

OBJECTIVE: To provide an up-to-date review of pediatric tracheostomy, primarily focusing on indications, surgical technique, complications and hospital and home care. SOURCES: MEDLINE and PubMed databases were searched using the following keywords: tracheostomy, tracheotomy, children, newborn. SUMMARY OF THE FINDINGS: Indications for tracheostomy in children are changing. Today the most common indication is prolonged ventilation. The age at the time of the procedure has also changed, with a peak incidence of tracheostomy in patients less than 1 year old. Except under emergency conditions, pediatric tracheostomy should be performed in the operating room with the child intubated. A horizontal skin incision with vertical tracheal incision and no tracheal resection is recommended. Although post-tracheostomy complications are not uncommon, they usually do not need special treatment or surgical procedures. Tracheostomy mortality can occur in up to 40% of pediatric cases, however the tracheostomy-related mortality rate is only 0 to 6%. CONCLUSIONS: The decision to perform a tracheostomy remains complex, and depends on several factors. The procedure is safe and with a low number of complications if carried out at a tertiary hospital by a trained and experienced team.

Válvula fonatória brasileira para traqueotomia: padronização de pressão de diafragma / Brazilian tracheotomy speech valve: diaphragm pressure standardization

A traqueotomia está indicada em condições com obstrução respiratória alta ou doença pulmonar obstrutiva crônica. As Válvulas Fonatórias (VF) melhoram a comunicação, higienização e umidificação das vias aéreas dos pacientes traqueotomizados. OBJETIVO: Demonstrar a VF nacional, de menor custo, e sua utilização na reabilitação fonatória desses pacientes, avaliar resistência de abertura pelo diafragma, o que confere melhor conforto ao paciente. Forma de Estudo: Experimental, coorte contemporâneo. MATERIAL E MÉTODO: A VF foi utilizada em 32 pacientes. A válvula tem diafragma dentro de um corpo em aço inox com encaixes de plástico. Estudou-se grau de conforto respiratório de acordo com a resistência do diafragma da válvula, 40, 50 e 60 shores. RESULTADOS: Obteve-se uso regular da VF acoplada à cânula por todos os pacientes, 26 o fizeram por mais de 12h diárias e destes 14 por 24h diárias. A pressão do diafragma obtida foi de 40 shores para 13 pacientes e 50 shores para 19 pacientes, sem utilização de 60 shores. CONCLUSÃO: A VF metálica permite fonação, sem a oclusão digital da cânula, e respiração sob conforto. Obteve-se resistência padronizada do diafragma. Atualmente todos os pacientes do estudo utilizam estas VF com fonação e 43,75% período integral.

Tracheotomy is performed in cases of upper airway obstruction or chronic pulmonary disorders. The Tracheotomy Speech Valves (TSV) improve communication and airway hygiene and humidification of tracheotomized patients. AIM: To show the low cost Brazilian TSV and its use in speech rehabilitation of tracheotomized patients, to evaluate diaphragm opening resistance and comfort to the patient. Study Design: Experimental, contemporary cohort. MATERIALS AND METHODS: The TSV was used in 32 patients. The valve has a diaphragm within a stainless steel body with plastic fittings. We studied the level of respiratory comfort according to the degree of valve diaphragm resistance, 40, 50 and 60 shores. RESULTS: All the patients used the TSV coupled to the cannula in a regular basis, 26 of them did it for more than 12 hours daily and from these, 14 used it for 24h daily. The diaphragm pressure obtained was that of 40 shores for 13 patients and 50 shores for 19 patients. 60 shores was never used. CONCLUSION: the metal TSV helps with speech without the need for closing the cannula with one's finger, and breathing was comfortable. We achieved standard diaphragm resistance. Currently all the patients from this study use this TSV with speech and 43.75% use it full time.

Traqueostomía percutánea con asistencia fibrobroncoscópica: evaluación prospectiva de 100 casos consecutivos y revisión de la literatura / Fiberoptic bronchoscopy assisted percutaneous tracheostomy: report of 100 patients

Background: Development of percutaneous techniques for tracheostomy have facilitated its implementation in the intensive care unit (ICU). Aim: To evaluate the safety of performing percutaneous tracheostomy (PT) using the Ciaglia Blue Rhino thechnique with fiberoptic bronchoscopy assistance in patients with prolonged mechanical ventilation. Patients and methods: Prospective evaluation of 100 consecutive patients aged 62±16 years (38 women) subjected to percutaneous tracheostomy. AU the procedures were performed in the ICU. Demographic variables, APACHE II, days of mechanical ventilation before PT, operative and post operative complications were recorded. Results: Mean APACHE II score was 20±3. Patients required on average 16±7 days of mechanical ventilation before PT. Eight patients (8 percent) had operative complications. One had an episode of transitory desaturation, one had a transitory hypotension related to sedation and six had mild bleeding not requiríng transfusión. No patient required conversión to surgical tracheostomy. Four patients (4 percent) presentedpost operative complications. Two had a mild and transitory bleeding ofthe ostomy and two had a displacement ofthe cannula. No other complications were observed. Conclusions: PT using the Ciaglia Blue Rhino technique with fiberoptic bronchoscopy assistance is a safe procedure that can be performed in the ICU by trained intensivists.

Ventilación mecánica prolongada con BiPAP a través de traqueostomía / Long-term noninvasive ventilation via tracheostomy

No existen reportes que describan el uso de equipos generadores de flujo con presión diferencial en 2 niveles (BiPAP) a través de traqueostomía para entregar ventilación mecánica prolongada (VMP) en niños. Este documento describe los criterios de selección, modalidad de uso y requerimientos tecnológicos como guía para implementar esta estrategia ventilatoria.

Cuidados de niños con traqueostomía / Care of the child with tracheostomy

Existe un número creciente de niños con vía aérea artificial, que han debido ser traqueostomizados por necesidad de recibir ventilación mecánica prolongada o por causas congénitas y adquiridas de obstrucción de la vía aérea superior. Aproximadamente un 40 por ciento de los pacientes tienen requerimientos tecnológicos especiales que limitan aún más su posibilidad de manejo ambulatorio. El presente documento aborda los principales cuidados necesarios de observar para facilitar los manejos domiciliarios entregados por la familia, sus cuidadores inmediatos y el equipo de salud.

experience of percutaneous tracheostomy in twenty obesity patients with short neck in a tertiary care hospital in Pakistan

To evaluate the success rate, procedure time and per-operative complications of percutaneous dilational tracheostomy in obese patients with short neck. Case series, descriptive study. Military Hospital Rawalpindi, from Jan 2006 to July 2007. Twenty obese patients with short neck were referred from intensive care unit [ICU] to operation theatre for open surgical tracheostomy [ST]. Before doing open procedure, all the patients were reassessed and an attempt was made by a team of experienced ENT surgeon and anaesthetist, to do percutaneous dilational tracheostomy [PDT] as first option. The success rate, procedure time and per-operative complications were noted. Data was collected over a period of one and half year. Twenty patients [12 F and 8 M], mean age 53 [34-80] years, mean body mass index [BMI=40] [34-45] were studied. The successful PDT was performed in 18 patients and in two patients procedure was converted to open surgical tracheostomy. Average time taken was 15 min. per-operative complications noted were, false passage, bleeding and leakage of air due to cuff puncture. In obese patients with short neck, if percutaneous dilational tracheostomy is performed by an experienced operator, in operation theatre [OT] with full preparation, good light and proper positioning, the procedure can be performed with in 15 min, the success rate is high with little complications

Incendio de un Tubo endotraqueal durante traqueostomia / Fire of a Pipe endotraqueal during traqueostomia

El fuego en la sala de operaciones moderna aún es considerado como un peligro constante a pesar de la ausencia usual de los gases anestésicos explosivos como lo eran el éter y el ciclopropano. Aunque estos agentes no se utilizan, no se ha eliminado el riesgo de incendios o explosiones. Durante una traqueostomia existen tres condiciones que al estar presentes van a apoyar un evento de tipo explosivo, estas son: un agente inflamable o combustible, un gas que mantenga la combustión y una fuente de ignición. Entre los materiales de la sala de operaciones que se han comunicado como combustibles están los tubos endotraqueales. El oxígeno puede mantener una combustión vigorosa. Así los resultados de los incendios en las salas de operaciones son uniformemente trágicos.

Upper Airway Volume Segmentation Analysis Using Cine MRI Findings in Children with Tracheostomy Tubes

OBJECTIVE: The purpose of this study is to evaluate the airway dynamics of the upper airway as depicted on cine MRI in children with tracheotomy tubes during two states of airflow through the upper airway. MATERIALS AND METHODS: Sagittal fast gradient echo cine MR images of the supra-glottic airway were obtained with a 1.5T MRI scanner on seven children with tracheotomy tubes. Two sets of images were obtained with either the tubes capped or uncapped. The findings of the cine MRI were retrospectively reviewed. Volume segmentation of the cine images to compare the airway volume change over time (mean volume, standard deviation, normalized range, and coefficient of variance) was performed for the capped and uncapped tubes in both the nasopharynx and hypopharynx (Signed Rank Test). RESULTS: Graphical representation of the airway volume over time demonstrates a qualitative increased fluctuation in patients with the tracheotomy tube capped as compared to uncapped in both the nasopharyngeal and hypopharyngeal regions of interest. In the nasopharynx, the mean airway volume (capped 2.72 mL, uncapped 2.09 mL, p = 0.0313), the airway volume standard deviation (capped 0.42 mL, uncapped 0.20 mL, p = 0.0156), and the airway volume range (capped 2.10 mL, uncapped 1.09 mL, p = 0.0156) were significantly larger in the capped group of patients. In the hypopharynx, the airway volume standard deviation (capped 1.54 mL, uncapped 0.67 mL, p = 0.0156), and the airway volume range (capped 6.44 mL, uncapped 2.93 mL, p = 0.0156) were significantly larger in the capped tubes. The coefficient of variance (capped 0.37, uncapped 0.26, p = 0.0469) and the normalized range (capped 1.52, uncapped 1.09, p = 0.0313) were significantly larger in the capped tubes. CONCLUSION: There is a statistically significant change in airway dynamics in children with tracheotomy tubes when breathing via the airway as compared to breathing via the tracheotomy tube.

Ventilatory management of severe tracheal stenosis.

We present here a 4 year old child with severe tracheal stenosis and respiratory failure. The patient was not responding to conventional ventilation settings and had significant hypercarbia. The difficulty in mechanical ventilation was handled successfully with specific ventilatory strategy: use of low respiratory rate, long inspiratory time and normal inspiratory time: expiratory time ratio. Thereafter the child was managed surgically and the stenosis was corrected. The child was discharged after a Montgomery T-tube placement.

Bedside percutanous forceps dilatational tracheostomy

ICU patients, mainly those who need prolonged ventilatory support, may require tracheostomy, which once was done in the operating room, nowadays is performed in the ICU, as percutaneous dilatational tracheostomy [PDT]. Forty two patients 18-72 yrs of age [mean 44 yrs], with varying indications for tracheostomy, had undergone PDT in the ICU under the standard protocol for this procedure. The mean time for completion of the procedure was 10 min. Advantages and complications are reviewed. The difficulties encountered were mainly the anatomical landmarks [10%], difficulties in dilatation [5%] and peristomal oozimg [1%]. It is concluded that percutaneous dilatational tracheostomy is an easy, cost effective, practical when done at bedside in the ICU, and spares transferring the patient to the operating theater