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• Safe, patient focussed, multidisciplinary tracheostomy care should be the goal for Critical Care research teams
  James Lynch, Sarah Wallace, Barbara Bonvento and Brendan A McGrath
  Published on: 14 October 2020

• Published on: 14 October 2020

  Safe, patient focussed, multidisciplinary tracheostomy care should be the goal for Critical Care research teams

  • James Lynch, Advanced Critical Care Practitioner Manchester University NHS Foundation Trust
  • Other Contributors:
    • Sarah Wallace, Speech and Language Therapist
    • Barbara Bonvento, Physiotherapist
    • Brendan A McGrath, Consultant Intensivist

  Dear Editors
  We read with interest the scoping review by Whitmore and colleagues into the post-insertion and pre-decannulation management of tracheostomies in the Intensive Care Unit.1 This important work highlights the need and opportunity for research in some areas of the complex management of these vulnerable patients. However, the manuscript has some significant limitations particularly; search strategy; timing; omission of patient safety recommendations; and patient focus; which we discuss below.
  The search strategy is limited to minor variations in the keywords, “ICU”, “Intensive Care Unit” and “Tracheostomy,” which excludes any article with the US “tracheotomy” in the title and international variations in care locations, such as, “Intensive Therapy Unit”, “Critical Care Unit”, “Weaning Unit”, “High Care” and associated abbreviations. The authors themselves refer to “critical care” literature but have omitted this from their strategy. A PubMed search (www.pubmed.ncbi.nlm.nih.gov, 27/8/20) finds 11,553 results for “tracheotomy,” 15,894 results for “tracheostomy” and 25,243 results for “tracheostomy or tracheotomy”.
  Furthermore, whilst the search is necessarily time-limited, there has been a recent surge in tracheostomy literature including relevant publications for managing tracheostomy in the COVID-19 pandemic.2-4 Whilst the results from Whitmore and colleagues are a useful benchmark, we fear that the...

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  Dear Editors
  We read with interest the scoping review by Whitmore and colleagues into the post-insertion and pre-decannulation management of tracheostomies in the Intensive Care Unit.1 This important work highlights the need and opportunity for research in some areas of the complex management of these vulnerable patients. However, the manuscript has some significant limitations particularly; search strategy; timing; omission of patient safety recommendations; and patient focus; which we discuss below.
  The search strategy is limited to minor variations in the keywords, “ICU”, “Intensive Care Unit” and “Tracheostomy,” which excludes any article with the US “tracheotomy” in the title and international variations in care locations, such as, “Intensive Therapy Unit”, “Critical Care Unit”, “Weaning Unit”, “High Care” and associated abbreviations. The authors themselves refer to “critical care” literature but have omitted this from their strategy. A PubMed search (www.pubmed.ncbi.nlm.nih.gov, 27/8/20) finds 11,553 results for “tracheotomy,” 15,894 results for “tracheostomy” and 25,243 results for “tracheostomy or tracheotomy”.
  Furthermore, whilst the search is necessarily time-limited, there has been a recent surge in tracheostomy literature including relevant publications for managing tracheostomy in the COVID-19 pandemic.2-4 Whilst the results from Whitmore and colleagues are a useful benchmark, we fear that the review has likely missed significant studies and is already out of date.
  The review fails to address the importance of patient safety in tracheostomy care. The landmark National Confidential Enquiry into Patient Outcome and Death report found that 23.6% patients suffered complications on critical care.5 We recently reported clinical incidents affecting 27.3% tracheostomy patients in 20 diverse centres often resulting in harm, increased length of stay and contributing to death.6 This suggests that safety remains an important aspect of tracheostomy care and should remain a key priority for research.
  The review selected published papers against specific criteria but appear to have omitted patient-focussed publications with a focus on quality improvement. In such a complex multidisciplinary field, implementing, changing or standardising practice can have arguably as much impact as studies that evaluate new strategies.6,7 The involvement of patients and their families or carers is also key and allows researchers and service leads to focus on the elements of care that are most important to patients; typically a focus on the quality of care delivered around communication, eating, drinking and time to discharge.8 Initiatives such as the Global Tracheostomy Collaborative (www.globaltrach.org) promote Patient Champions who should be involved in service planning, evaluation and research.9
  The critical role of the multidisciplinary team should also be apparent from any search of recent tracheostomy literature.10 We appreciate the emphasis the authors place on the important role of Speech and Language Therapists in tracheostomy weaning, decannulation and quality of life but feel the role of Fibreoptic Endoscopic Evaluation of Swallow (FEES) is underemphasised.11 This investigation has greater sensitivity than bedside clinical assessment and Evans Blue Dye Test, can be performed safely at the bedside and may detect upper airway abnormalities important in weaning.12 (Respiratory) Physiotherapists play a key role in sputum clearance, ventilator associated pneumonia reduction and promotion of early mobilisation in the mechanically ventilated, tracheostomy patient which leads to increased functional recovery.13
  Whilst we agree with Whitmore & Colleagues’ conclusions that the literature is limited when it comes to post-insertion tracheostomy management, there is additional evidence that is relevant and worthy of inclusion in such a scoping review. We would particularly highlight the need for involvement of patients and the multidisciplinary team in future research and to focus on quality improvement programs alongside discovery science in building the evidence base for comprehensively better tracheostomy care in the future.

  References:
  1. Whitmore KA, Townsend SC, Laupland KB. Management of tracheostomies in the intensive care unit: a scoping review. BMJ Open Respir Res. 2020;7(1):e000651. doi:10.1136/bmjresp-2020-000651
  2. McGrath BA, Ashby N, Birchall M, et al. Multidisciplinary guidance for safe tracheostomy care during the COVID-19 pandemic: the NHS National Patient Safety Improvement Programme (NatPatSIP) [published online ahead of print, 2020 May 12]. Anaesthesia. 2020;10.1111/anae.15120. doi:10.1111/anae.15120
  3. Zaga CJ, Pandian V, Brodsky MB, et al. Speech-Language Pathology Guidance for Tracheostomy During the COVID-19 Pandemic: An International Multidisciplinary Perspective. Am J Speech Lang Pathol. 2020;29(3):1320-1334. doi:10.1044/2020_AJSLP-20-00089
  4. McGrath BA, Brenner MJ, Warrillow SJ, et al. Tracheostomy in the COVID-19 era: global and multidisciplinary guidance. Lancet Respir Med. 2020;8(7):717-725. doi:10.1016/S2213-2600(20)30230-7
  5. Wilkinson K, Freeth H, Kelly K. 'On the Right Trach?' A review of the care received by patients who undergo tracheostomy. Br J Hosp Med (Lond). 2015;76(3):163-165. doi:10.12968/hmed.2015.76.3.163
  6. McGrath BA, Wallace S, Lynch J, et al. Improving tracheostomy care in the United Kingdom: results of a guided quality improvement programme in 20 diverse hospitals. Br J Anaesth. 2020;125(1):e119-e129. doi:10.1016/j.bja.2020.04.064
  7. McGrath BA, Lynch J, Bonvento B, et al. Evaluating the quality improvement impact of the Global Tracheostomy Collaborative in four diverse NHS hospitals. BMJ Qual Improv Rep. 2017;6(1):bmjqir.u220636.w7996. Published 2017 May 23. doi:10.1136/bmjquality.u220636.w7996
  8. Ng FK, Liney T, Dawson R, et al. By the Patient, for the Patient. Determining key quality of care measures for improving tracheostomy care. Med Res Arch. 2019;7(11) doi:10.18103/mra.v7i11.1989
  9. Brenner MJ, Pandian V, Milliren CE, et al. Global Tracheostomy Collaborative: data-driven improvements in patient safety through multidisciplinary teamwork, standardisation, education, and patient partnership. Br J Anaesth. 2020;125(1):e104-e118. doi:10.1016/j.bja.2020.04.054
  10. Bonvento B, Wallace S, Lynch J, Coe B, McGrath BA. Role of the multidisciplinary team in the care of the tracheostomy patient. J Multidiscip Healthc. 2017;10:391-398. Published 2017 Oct 11. doi:10.2147/JMDH.S118419
  11. McGrath BA, Wallace S. The UK National Tracheostomy Safety Project and the role of speech and language therapists. Curr Opin Otolaryngol Head Neck Surg. 2014;22(3):181-187. doi:10.1097/MOO.0000000000000046
  12. Neumeier AT, Moss M. We need an additional seat at the critical care multidisciplinary team table for our speech-language pathologists. Ann Am Thorac Soc. 2014;11(10):1610-1611. doi:10.1513/AnnalsATS.201411-515ED
  13. Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009;373(9678):1874-1882. doi:10.1016/S0140-6736(09)60658-9

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  Conflict of Interest:
  None declared.

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