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      Management of tracheostomies in the intensive care unit: a scoping review

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          Abstract

          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 Additional sources were searched for published and unpublished literature.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.

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          Most cited references99

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          Guidance for conducting systematic scoping reviews.

          Reviews of primary research are becoming more common as evidence-based practice gains recognition as the benchmark for care, and the number of, and access to, primary research sources has grown. One of the newer review types is the 'scoping review'. In general, scoping reviews are commonly used for 'reconnaissance' - to clarify working definitions and conceptual boundaries of a topic or field. Scoping reviews are therefore particularly useful when a body of literature has not yet been comprehensively reviewed, or exhibits a complex or heterogeneous nature not amenable to a more precise systematic review of the evidence. While scoping reviews may be conducted to determine the value and probable scope of a full systematic review, they may also be undertaken as exercises in and of themselves to summarize and disseminate research findings, to identify research gaps, and to make recommendations for the future research. This article briefly introduces the reader to scoping reviews, how they are different to systematic reviews, and why they might be conducted. The methodology and guidance for the conduct of systematic scoping reviews outlined below was developed by members of the Joanna Briggs Institute and members of five Joanna Briggs Collaborating Centres.
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            Effect of early versus late or no tracheostomy on mortality and pneumonia of critically ill patients receiving mechanical ventilation: a systematic review and meta-analysis.

            Delay of tracheostomy for roughly 2 weeks after translaryngeal intubation of critically ill patients is the presently recommended practice and is supported by findings from large trials. However, these trials were suboptimally powered to detect small but clinically important effects on mortality. We aimed to assess the benefit of early versus late or no tracheostomy on mortality and pneumonia in critically ill patients who need mechanical ventilation.
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              Criteria for extubation and tracheostomy tube removal for patients with ventilatory failure. A different approach to weaning.

              The purpose of this study was to prospectively compare parameters that might predict successful translaryngeal extubation and tracheostomy tube decannulation. Irrespective of ventilatory function, 62 extubation/decannulation attempts were made on 49 consecutive patients with primarily neuromuscular ventilatory insufficiency who satisfied criteria. Thirty-four patients required 24-h ventilatory support. Noninvasive intermittent positive pressure ventilation (IPPV) was substituted as needed for IPPV via translaryngeal or tracheostomy tubes. Successful decannulation was defined as extubation or decannulation and site closure with no consequent respiratory symptoms or blood gas deterioration for at least 2 weeks. Failure was defined by the appearance of respiratory distress and decreases in vital capacity and oxyhemoglobin saturation despite use of noninvasive IPPV and assisted coughing. The independent variables of age, extent of predecannulation ventilator use, vital capacity, and peak cough flows (PCF) were studied to determine their utility in predicting successful extubation and decannulation. Only the ability to generate PCF greater than 160 L/min predicted success, whereas inability to generate 160 L/min predicted the need to replace the tube. All 43 attempts on patients with PCF greater than 160 L/min succeeded; all 15 attempts on patients with PCF below 160 L/min failed; and of 4 patients with PCF of 160 L/min, 2 succeeded and 2 failed. We conclude that the ability to generate PCF of at least 160 L/min is necessary for the successful extubation or tracheostomy tube decannulation of patients with neuromuscular disease irrespective of ability to breathe.
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                Author and article information

                Journal
                BMJ Open Respir Res
                BMJ Open Respir Res
                bmjresp
                bmjopenrespres
                BMJ Open Respiratory Research
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2052-4439
                2020
                28 July 2020
                : 7
                : 1
                : e000651
                Affiliations
                [1 ]departmentDepartment of Intensive Care Services , Royal Brisbane and Women’s Hospital , Herston, Queensland, Australia
                [2 ]departmentFaculty of Medicine , The University of Queensland , Saint Lucia, Queensland, Australia
                [3 ]departmentFaculty of Health , Queensland University of Technology , Brisbane, Queensland, Australia
                Author notes
                [Correspondence to ] Professor Kevin B Laupland; Kevin.Laupland@ 123456qut.edu.au
                Author information
                http://orcid.org/0000-0003-2787-0789
                http://orcid.org/0000-0002-1205-5354
                Article
                bmjresp-2020-000651
                10.1136/bmjresp-2020-000651
                7390235
                32723731
                d208c4ad-0203-453d-b00b-59e8de20b004
                © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

                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/.

                History
                : 26 May 2020
                : 20 June 2020
                : 25 June 2020
                Categories
                Critical Care
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