Israel Medical Association Journal

Background: Management of acquired laryngotracheal stenosis (LTS) is challenging and often requires recurrent procedures.

Objectives: To compare the efficacy and safety of balloon dilatation (BD) versus rigid dilatation (RD) in the treatment of LTS.

Methods: A retrospective study of patients undergoing endoscopic intervention for LTS was performed.

Results: The study included 69 balloon (BD) and 48 rigid dilations (RD). Most cases were grade 3 Cotton-Meyer stenosis. Mean time interval to recurrence after BD and RD were 27.9 and 19.6 weeks, respectively. Remission of over 8 weeks was achieved in 71% of BD compared to 31.2% of RD (P < 0.05). In the BD group, dilatation of subglottic stenosis showed higher rates of remission of over 8 weeks compared to upper and mid-tracheal stenosis (92% vs. 62% and 20%, respectively, P < 0.05). Complications were encountered in 4.2% of RD and 2.9% of BD.

Conclusions: BD and RD are effective and safe procedures. Overall, BD achieved slightly better long-term results compared to RD

Background: In Israel, critically ill patients are ventilated and managed in intensive care units or general wards.

Objectives: To compare the mortality rates and long-term cognitive and functional outcomes of ventilated patients who underwent tracheostomy insertion in the Medical ICU (MICU) versus those cared for in the in-patient wards.

Methods: The study comprised 170 patients who underwent percutaneous dilatational tracheostomy (PDT) over an 18-month period in the MICU (n=102) and in in-patient wards (internal medicine and neurology) (n=68). Telephone interviews were conducted with living patients and/or their relatives at least 6 months after discharge from the hospital.

Results: Ward patients were 10 years older than ICU patients undergoing PDT (P = 0.003). The length of stay (LOS) in the wards was longer than in the ICU (P < 0.001), whereas the total LOS in the hospital was similar (P = 0.43). ICU mortality was lower than in the wards (P = 0.001) but hospital mortality was comparable between the two groups (P = 0.17). At 6 months follow-up more ICU patients were fully conscious, weaned from ventilation, and decannulated. More patients in the ICU group were at home and were independent or had mildly impaired activities of daily living. More patients in the ward group were residing in long-term care facilities with functional limitations.

Conclusions: MICU patients who undergo tracheostomy may have a good long-term functional and cognitive outcome. More studies are needed to further assess long-term outcomes in these patients.

Background: Percutaneous dilatational tracheostomy (PDT) has become a standard technique for critically ill patients who require long-term ventilation. The most common early post-operative complication is bleeding related to anatomical variation in vasculature. The procedure is performed at the patient's bedside unless this is deemed unsafe and then the accepted alternative is open tracheostomy in the operating room. 

Objectives: To evaluate the use of pre-procedural ultrasound to aid in the decision of whether PDT in critical care patients should be performed at the patient's bedside or by open surgical tracheostomy.

Methods: Patients were jointly evaluated by a critical care physician and a head and neck surgeon. Based on this evaluation, the method of tracheostomy was determined. Subsequently, pre-procedural ultrasound examination of the anterior neck was performed. The final decision whether to perform PDT or open surgical tracheostomy was based on the ultrasound findings. Changes in management decisions following ultrasound were recorded. 

Results: We included 36 patients in this prospective study. Following ultrasound examination, the management decision was changed in nine patients (25%).

Conclusions: Pre-procedural ultrasound for critically ill patients undergoing tracheostomy can influence management decisions regarding the performance of tracheostomy.