Chapters Transcript Management of Patients After Bronchoscopic Lung Volume Reduction Procedures Course: Bronchoscopic and Pleural Procedures for the Intensivist I'm gonna review some things that they've talked about and focus a little bit more on complications of trick. I have no disclosures relevant to this talk. Um, so I just want to quickly in the next 15 minutes talk about complications of prick trach in the immediate post-procedural, uh, early post-op, and uh and late post-op periods, um, a little bit about the differences between open and, and, uh, and percutaneous approaches, though a lot of that has already been addressed, and then I'd like to review some data on early interventions to reduce complications after tracheostomy. So you know, tracheostomy and percutaneous tracheostomy is approached very differently at different institutions. I think it's really helpful to take a step backwards and look kind of at a national level about what outcomes are actually like with people who undergo tracheostomy insertion. So there was this really great study that looked at um national mortality data on patients who had undergone tracheostomy from 1985 to 2013. 8000 patients were included. So taking a, a, um, you know, high altitude of view, the overall procedure specific mortality for trache was around 2%. 1/3 of those happen during the procedure and about 50 within the first week. So the early period during and after tracheostomy insertion is clearly a really important time to be on the lookout for possible uh possible uh issues. In this cohort of patients, about half had bronchoscopic guidance, though a lot changed in our overall approach to percutaneous tracheostomy between the beginning and the end of their of their study period, and what they identified was that the highest risk factors included low tracheal access, which is a major risk factor for bleeding during and after the procedure, uh, and the tracheal perforation was uh noted in about um. A 50% of people who had a kinked guide wire, so the guide wire and how that's managed seems to play a really important role in uh airway perforation issues post trach. So focusing a little bit more specifically on outcomes from um uh tracheostomy looking at mortality, um, there was a retrospective review of national mortality data done from 2007 to 2016 that found a 10-fold higher rate of trachea related deaths in children versus adults and an o ratio of 2 for black children, and also that there's an odratio of 1.2 for mortality on the weekend with a third of all trach related deaths occurring on a Saturday or Sunday. My takeaway from this is that there are um opportunities for intervention and early recognition of problems that are leading to mortality that seem to be related to how we approach this at a systems level. Thinking about percutaneous versus open approaches, um, there's a systematic review encompassing 24 studies. This has been alluded to by both of my fellow speakers, um, but I like this meta-analysis because what it really shows is that there's really not a whole lot of difference actually between the two approaches in terms of overall outcomes. This doesn't take into account the patient selection that goes into the choice for one versus the other approach. Um, the overall mortality for both in this study in this meta-analysis was around 0.5%. With a slightly higher rate of technical difficulty for PDT, occasionally requiring conversion to open tracheostomy with a total of almost 2% converted midp procedures, so not common, but it does happen, uh, and as Elaine mentioned, a slightly higher rate of infection with open trach versus percutaneous, that's both stomal infection and pneumonias. So the COVID-19 pandemic changed everything, you could say, uh, changed a lot of things and what it also did is sort of uh highlight um things that we may be able to do better, and I think tracheostomy was one thing that changed a lot. I think many institutions moved to early tracheostomy for patients with COVID-19 for a lot of very good reasons. I think there's some lessons to learn from that experience. Uh, as Si mom will tell you, having done about 300 trachs a year for the 1st 2 years of the pandemic. Um, so there was a study that was conducted in Europe, the wean Trach study. They enrolled 153 patients who had COVID-19 infection who had either gone open or percutaneous trach. So in this cohort of patients, the median time to trach was about 2 weeks, with no difference in survival for those who had it early versus late. As you might expect, there was a significantly shorter ICU length of stay for patients who had an early tracheostomy and more lower respiratory tract infections for those who had an open versus a percutaneous trach. I had a slide on ECMO that I moved later. I just realized, but it's really important. I'll get back to it. So put a pin in ECMO. I have for patients who are having a trach. So when it comes to post during after pre uh tracheostomy complications, timing is everything and when I think of a differential when I'm when I'm called about a complication with the trach, the first thing I ask is when was the trach placed. Actually, the first thing I ask is who placed it. I'm kidding, is when is it placed because that really dictates, I think, how we think about the risks that we're thinking about, right? So you can see all sorts of bleeding after a trach, but the timing is, is, is relevant there. So periprocedural, so during or immediately after, um, we worry about the risks of bleeding, tracheal ring fracture, uh, loss of the airway during the procedure, hypoxia, malposition of the trach tube, and then, as Elaen mentioned, posterior tracheal lung injury, which is a very serious complication. So early, this is in the 1st 1 to 2 weeks post procedure, we worry about bleeding, pneumo mediastinum, pneumothorax from the manipulation of the airway, stoma infection and inadvertent decannulation before you have a mature stoma. So that's what we worry about in the 1st 2 weeks roughly. And then late complications, um, we're talking 2 weeks to a few months post, um, these are the kind of more difficult to manage chronic airway complications like tracheal stenosis, trachealalacia. And then all kinds of fistulas, whether it's uh from the airway to the anoinate, airway to the esophagus, airway to the skin, and then dysphonia. So, uh, when I'm called about a tracheostomy that's bleeding, again, timing early versus late, we have a different differential, different approach. Um, most commonly early bleeding is due to injury of the superficial veins that are, that can run near or adjacent to midline. These are mainly the anterior jugular and inferior thyroid veins. Uh, there's a lot of variability in the course of these vascular vascular structures. They usually run paramedeian, but these are just, just one example from the literature of, uh, documented examples of how the inferior thyroid vein can go, and you can see that without the use of ultrasound, it'd be very difficult to detect this pre-procedure. Uh, ultrasound is pretty routine, uh, and screening patients for percutaneous versus open approach and as important as the anoinate artery is, you're far more likely to have an issue with, uh, these venous structures, uh, and they can bleed a lot both into the airway and externally. So we're frequently in in the critical care environment asked to evaluate patients for tracheostomy who either have thrombocytopenia, platelet dysfunction, bleeding diateesis, coagulopathy of one kind or another, uh, and it can be very challenging to decide how to approach these patients safely for any tracheostomy approach, whether whether open or bracutaneous. Um, there's a couple of small studies looking at outcomes and, and patient selection factors, um, in this context. So there's a small retrospective study of thrombocytopenic patients who were referred for tracheostomy who underwent pre-procedure transfusion. The mean baseline platelet count was 26,000 in this in this uh study with a rate of major bleeding of around 5%, with a higher risk of bleeding noted when there was two or more coagulation bleeding abnormalities. So your thrombocytopenic and had an elevated INR, you had an elevated PTT and thrombocytopenia, um, the the odds ratio was 3.7 for a major bleeding post-trach. uh, and prophylactic dose heparin Lovenox, this is not really associated with an increased risk per se. So ECMO, uh, during the pandemic in particular, our application of VV ECMO increased significantly and um there was a lot of interest in early ventilator liberation or or minimizing sedating agents in these patients, um, and so there has been a lot more experience with putting trachs early and patients were on VV ECMO. The experience from this has um has shown that there are some differences in this cohort of patients. There's a higher rate of local bleeding, uh, 4 times higher in one large retrospective study, uh, with an overall rate of major bleeding in that study that I mentioned of 1.7% for patients on emo. Even when we pause anticoagulation, these patients are anticoagulated, they have platelet dysfunction, thrombocytopenia, so there's a lot of reasons for them to have bleeding, even when we pause anticoagulation during and after the procedure. Can be seen anywhere from 1.5 to 5 days post procedure and usually is manageable with local measures whether that's packing of the stoma, uh, preemptive approaches, sometimes the use of uh surgic cell fibrilar before we even resume heparin can be very helpful, uh, but about 8% of patients in this cohort that I mentioned required repeat bronchoscopy to manage airway bleeding, clots, uh, so not trivial, particularly when you're talking about people who have an aerosollizable infection. So the most feared complication you'll see it in every lecture on on uh on tracheostomy complications is TI fistula. I've seen two and I hope to never see any ever again, but it's, it's, it's terrible when it happens. Um, they're reported in 0.1 to 1% of all tracheostomy insertions. They're less common with more modern approaches like the use of low pressure cuffs, um, and they're more common with low insertions, you know, we worry when the cuff is constantly irritating this area between the 7th and 9th tracheal rings is when this is more likely to occur. About 72% of cases occur within 3 weeks of trait consertion, and the vast majority, I don't really know a number, but it's almost all of them are gonna happen for the most part within 3 weeks to 3 months. That's the, that's the range in which you'll see the vast majority of TI fistulas. Very, very importantly is that these are usually associated with so-called sentinel bleeds. So the first bleed with the TI fistula is usually if you especially if you ask in retrospect, it's not the moment that they have a horrible bleed out of the trach, it's usually that they've been having small amounts of blood from irritation of the airway wall before they have a really bad bleed. So I take every bleed uh in a trach patient seriously, even though the majority end up not being TI fistulas. What are your management options? Well, the easiest and the first should always be to overinflate the tracheostomy cuff. This might provide some tamponade, especially if you don't have like a full blown fistula between the, the trachea and the annoinate artery. Um, if that doesn't do it, uh, get the most junior fellow in the room, ask for their finger, no, I'm kidding, uh, but no, in all seriousness, actually manual pressure on the fistula is a great way to, uh, secure the airway to get some local control while you're on your way to the OR for more definitive management. This is usually something that's happening in sequence with uh intubation from above, which is the most important thing. At the end of the day, if you can get a cuff past the point of the fistulization, you can have some measure of control of the airway. Um, so in this circumstance, um, if overinflating the cuff is not working, you really don't have a lot of time. You should be securing the airway from above, not removing the trachea until the ET tube cuff is already passed with a bronchoscope in the in the ET tube, already at the level of the trach, bypass the TI fistula and get the patient to the OR. Uh, and again, if they're, if they're having issues ventilating, if the bleeding is ongoing, manual pressure is an option, uh, are. Fellow before last had to do this last week and said he learned it from my lecture, and I'm kidding, he knew. All right, so tracheal stenosis is another worrisome late complication, probably underreported, under recognized. Uh, and it's associated with both percutaneous and open approaches to tra uh tracheostomy. Those stenosis from percutaneous approach may occur earlier. So in one retrospective study, the mean onset was 5 weeks versus 28 weeks for open trach, but it can happen with either. There's a lot of reasons why stenosis can develop, whether it's um just narrowing at the tracheal insertion site, uh, ongoing pressure from the tracheostomy cuff, or, uh, and this is one that we usually can recognize pretty early, it's a so-called a frame stenosis with actual damage to the, uh, anterior cartilage. Uh, and this is often accompanied by trachea malasia. It's usually not one or the other, but both together if you have an A frame stenosis. Um, so amongst survivors, people who are decannulated, uh, from having had a tracheostomy, up to a third, if you really look carefully, up to a third can have a greater than 10% degree of tracheal stenosis. Now, 10% tracheal stenosis may not be frankly symptomatic for most people, uh but up to 6% may have symptomatic stenosis. So this is not a trivial number for people who are eventually decannulated. There are some risk factors for the development of post-tra tracheal stenosis, which include BMI over 30, trach insertion that's sort of late, quote unquote, so over 10 days post intubation. Uh, and a cuff pressure over 30 chronically and then a larger initial trach tube size, all these are associated with a higher risk of developing tracheal stenosis post, um, and multidisciplinary management of these cases is very important. As I mentioned, you know, tracheomalacia, so that's laxity of the posterior wall of the trachea, is a late complication of tracheostomy and frequently, you know, once you have a, a change in the morphology of the cartilage, this is something that unfortunately can can follow that. Um, it can be focal, it can be relatively localized near the area of initial injury or it can propagate for the length of the trachea. Uh, it may be underrecognized, uh, and often at the time of decannulation it will only manifest as an expiratory wheeze. It can be tough to differentiate from obstructive airways disease unless someone's really looking for it, so definitely have this on your radar. So we've identified that there are a lot of complications post tracheostomy that have some potentially modifiable risk factors, early intervention opportunities, and there are a few studies that have looked prospectively at what we can do to improve outcomes. Um there are a number of studies looking at nursing and respiratory therapy driven protocols which have been shown to reduce trach related adverse events, um, specifically reduction in trach obstruction, stomal infection, and decannulation, as well as ICU readmission. You know, one internal study that was done at NYU found that there was a higher rate of pressure ulcers at the inferior margin of the of the trach plate with suturing. We stopped suturing our trachs, had a nursing driven protocol to monitor proactively that there was no trach dislodgement, and our rate of stom uh sorry of um a plate related uh skin injuries significantly lower. So, um, the. Impact of these kinds of interventions um has been demonstrated with a reduction in rapid response calls and lower ICU specific length of stay for patients at institutions where these are pursued. So in summary, uh, understanding mitigating risk factors related to trach, um, requires that you are able to recognize, uh, early, late, the timing basically post uh tracheostomy insertion. Patient selection for percutaneous approach is really key to good outcomes, and that's a multidisciplinary, uh, discussion at all times. Uh, preventing serious bleeding requires a proactive approach with the early investigation of so-called sentinel bleeds or what could be sentinel bleeds, uh, and early intervention can help reduce the risk of serious harms. Thanks very much. Published July 12, 2024 Created by Related Presenters Vivek Murthy, MD View full profile
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