26th ESICM ANNUAL CONGRESS — PARIS, FRANCE — 5–9 OCTOBER 2013GroupUltrasoundexamination
time (min)Ultrasoundguidedtracheostomy
time (min)Totaltime(min)Incidence ofcomplicationsn (%)

1: patient 1–10

13 ± 617 ± 830 ± 112 (2 %)2: patient 11–20

14 ± 617 ± 732 ± 117 (9 %)3: patient 21–30

12 ± 713 ± 625 ± 19

9 (11 %)

4: patient 31–40

11 ± 89±320 ± 8

4 (5 %)
2 (3 %)

5: patient 41–50

10 ± 510 ± 920 ± 12

6: patient 51–60

8±310 ± 3

17 ± 5

1 (1 %)7: patient 61–70

9±68±317 ± 80 (0 %)8: patient 71–80

9±69±618 ± 52 (3 %)CONCLUSIONS. Our study suggested that a minimum of 30 ultrasound-guided percutaneous tracheostomy was necessary to realize this technique with a low complication rate anda short realization time.
REFERENCE(S). 1. Guinot P, Zogheib E, Petiot S. Ultrasound-guided percutaneous tracheostomy in critically ill obese patients. Crit Care. 2012;16:R40.

0151
A COMPARISON OF THREE ENDOSCOPES IN ASSESSMENT
OF TRACHEOSTOMY POSITION IN SIMULATION MANIKINS
R. Templeton1, B. McGrath1, K. Webster1, W. Simpson1
1

South Manchester University Hospital Trust, Intensive Care Unit, Manchester, UK
INTRODUCTION. Displacement of tracheostomy tubes causes significant patient
harm. Fibreoptic endoscopy can assess the position of a tracheostomy tube within the trachea both in elective and emergency situations and can reduce the incidence of patient harm.
Simulation manikins are a useful tool in developing the relevant skills.
OBJECTIVES. To compare the time taken to achieve adequate views for assessment oftracheostomy position and the operator’s ease of endoscopy score with 3 different endoscopes in manikins.
METHODS. Twenty five anaesthetic trainees assessed tracheostomy tube placement using
the Ambu aScope2, Olympus LF-GP, and Olympus MAF. Observations were made using
three training manikin variants: METIman (using both ‘standard’ and ‘difficult’ airwaysettings) and SimMan.
Tube position was assessed via the tube lumen and within the trachea by both the oral andnasal routes. For each assessment of tracheostomy placement, the time taken to achievesatisfactory visualisation (determined by observer) was recorded. In addition, the trainee
allocated an ‘ease of endoscopy score’- with a score of ‘1’ indicating great difficulty and ascore of ‘10’ indicating great ease.
Data were analysed using Friedman test to compare the three endoscopes (observations werematched for trainee, route of visualisation, and manikin variant).
RESULTS. 225 observations were made with each endoscope. Satisfactory visualisation
was achieved in 120 s or less in over 99 % of observations and in 60 s or less in 92 %.There
was a small, but statistically significant, difference between the endoscopes in the mean timeto achieve satisfactory visualisation, with the Olympus MAF taking slightly longer.
(Friedman test with Dunn’s post-test, p = 0.01).

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arbitrary scoring system indicated that trainees generally rated the procedures as ‘easy’.
Assessment of position is achievable in a clinically relevant timeframe.
REFERENCE(S). 1. McGrath BA, Thomas AN. Patient safety incidents associated withtracheostomies occurring in hospital wards: a review of reports to the UK National PatientSafety Agency. Postgrad Med J. 2010;86(1019):522–5. 2. Rai MR, Popat MT. Evaluation ofairway equipment: man or manikin? Anaesthesia. 2011;66:1–3.

0152
TEACHING FOUNDATION DOCTORS ABOUT TRACHEOSTOMYCOMPLICATIONS: A 6 MONTH FOLLOW UP STUDY
A. Cumpstey1, E. Horwell2, S. Benham2, J. Chantler2, S. McKechnie2
1Musgrove Park Hospital, Taunton, UK, 2John Radcliffe Hospital, Oxford, UKINTRODUCTION. Over 50 % of patients who have a tracheostomy in ICU are discharged
before decannulation [1] NAP4 showed that 70 % of all airway-incidents and 60 % of alldeaths in ICU involved tracheostomy complications. Similar complications occur after
discharge from ICU and lack of training is a common factor [2]. How much training juniordoctors receive in this area remains unknown.
OBJECTIVES. • Quantify the training medical students receive about tracheostomy
management.
• Increase the training on preventing and managing tracheostomy complications (e.g.
obstruction, displacement) for junior doctors working in Oxford.
• Assess the effectiveness of this training at 6 months.

METHODS. 81 Foundation Year 1 (F1) doctors (from 22 medical schools) completed
a new session on preventing and managing tracheostomy complications. Online surveys were distributed before and 6 months after the course (completion rates 83 and24 % respectively). A paper survey was distributed immediately after the course(100 % completion rate). Each survey assessed knowledge of current best practice as
defined by the Intensive Care Society [4] as well as confidence in managing
tracheostomies.
RESULTS. Knowledge and confidence were poor before the course: over 70 % were ‘not at
all confident’ in managing complications; in the event of an obstruction just 20 % would
correctly deflate the air cuff and only 72 % would call the emergency airway team. 66 %saw patient(s) with a tracheostomy during their medical degree but only 19 % received
formal teaching about managing such patients. Immediately after the course, confidence andknowledge increased significantly. 79 % were 0 fairly confident0 to 0 very confident0 inmanaging an obstruction and 74 % would leave the air cuff deflated. 100 % found thecourse relevant and useful to their work. In their first 6 months as an F1, 47 % had managed
at least 1 patient with a tracheostomy. Knowledge faded after the course, e.g. at 6 months
only 65 % would deflate the air cuff. 94 % would call for the emergency airway team to atracheostomy complication.
CONCLUSIONS. Teaching in this area is rare and variable despite most students seeing
tracheostomies. Most junior doctors will manage a patient with a tracheostomy during F1/
F2. Teaching about tracheostomy complications is seen as both relevant and useful withlong term benefit for patients. To maximise effectiveness, teaching should be given justbefore it is needed to minimise knowledge fade.
REFERENCE(S). 1. Martinez GH, Fernandez R, et al. Tracheostomy tube in place at
intensive care unit discharge is associated with increased ward mortality. Respir Care.
2009;54(12):1644–52. 2. McGrath BA, Thomas AN. Patient safety incidents associated withtracheostomies occurring in hospital wards: a review of reports to the UK National Patient
Safety Agency. Postgrad Med J. 2010;86(1019):522–5. 3. MacKenzie S, Murphy P, et al.
Standards for the care of adult patients with a temporary tracheostomy, Guidelines from theIntensive Care Society; 2008.

0153
Time taken to assess tracheostomy placement
Generally, trainees perceived the overall procedure as ‘easy’, allocating a median ‘endoscopy score’ of 8 for all three endoscopes. No statistically significant differences in‘endoscopy scores’ between the endoscopes were demonstrable (Friedman test with Dunn’s
post-test, p [ 0.05).

Endoscopy scores by endoscope
CONCLUSIONS. Trainees were able to gain satisfactory views to assess tracheostomy
placement in under 60 s in the vast majority of observations regardless of the endoscopeused, however procedures using the Olympus MAF took slightly longer. Application of an

EVALUATING THE AMBU ASCOPETM 3 SYSTEM FOR PERFORMINGPERCUTANEOUS DILATATIONAL TRACHEOSTOMY IN CRITICAL CARE
PATIENTS
B.A. McGrath1, A.M. Bentley1
1

University Hospital of South Manchester, Acute Intensive Care Unit, Manchester, UK
INTRODUCTION. The Ambu aScopeTM 3 system is a novel disposable bronchoscope(5.5 mm maximum external diameter with 2.2 mm suction/working channel) which connects to a separate portable aViewTM monitor. We report the first observations in clinicalpractice of this system for performing percutaneous dilatational tracheostomy (PDT) incritical care patients.
OBJECTIVES. To evaluate the functionality and ease of use of the aScopeTM 3 system
performing PDT in our ICU.
METHODS. Five CE-marked aScopeTM 3 bronchoscopes and an aViewTM monitor weresupplied by Ambu for the evaluation. Standard practice for our unit is to use non-disposable bronchoscopy (Olympus BF-260) to guide PDT insertion, with images displayedon the EVIS LUCERA SPECTRUM ‘stack’ system. Clinical decision to perform PDT wasmade by attending clinicians who also performed the procedures. Bronchoscopy to guide thePDT using the aScopeTM 3 system was performed by the authors. A 5-point Likert scale wasused (1 fully disagree, 3 neutral, 5 fully agree) to evaluate functionality and ease of use ofthe system, applied to 10 statements (see Table 1). Overall impressions of performance(satisfactory: yes/no) and whether the operator felt that the aScopeTM 3 system could replace
our existing non-disposable system (yes/no) were also recorded.
RESULTS. All 5 procedures were completed uneventfully between 11/3/13 and 8/4/13(BAM 4 procedures, AB 1). Data were explored using the Shapiro–Wilk test and theresults (median Likert scores for functionality and ease of use) shown in Table 1. Clear
images of the needle and guide-wire entering the trachea were recorded in all 5 procedures. The authors agreed in all 5 PDTs that the aScopeTM 3 system was satisfactory andthat the system could have replaced our existing non-disposable system for guiding thePDT.

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26th ESICM ANNUAL CONGRESS — PARIS, FRANCE — 5–9 OCTOBER 2013

Table 1 Median Likert scores for functionality
Median Range of scores
score(min–max)
Easy to connect and set up the aScope 3 system

5Blood and secretions were easily cleared from the lens 55
4–5

most prevalent was desaturation due to mucus plugging (51 %, 26/51). ICU readmission dueto tracheostomy complication was 5.9 %. The ICU LOS was 21 ± 20.5 days and thehospital LOS was 67.5 ± 48.9 days.
CONCLUSIONS. Decannulation time is long and complications are common. The
implementation of specific strategies and a multidisciplinary tracheostomy team for regularreview and consensus decisions regarding tracheostomy weaning might improve patient careand decannulation time.
REFERENCE(S). 1. Tobin A, Santamaria J. An intensivist-led tracheostomy review teamis associated with shorter decannulation time and length of stay: a prospective cohort study.
Crit Care. 2008;12R48. 2. Garrubba M, Turner T, Grieveson C. Multidisciplinary care fortracheostomy patients: a systematic review. Crit Care. 2009;13:R177.

Easy and intuitive to use suction system55Suction capability was adequate for clearing bloodand secretions

54–5

Functionality of working channel was satisfactory

44–5

Easy navigation and recording of images
on aView monitor

31–4Ergonomics of the device satisfactory

43–5Lightweight design was a clear benefit

330155

Image quality was clear and adequate toverify accurate placement of the tracheostomy

55CICATRICIAL STENOSIS OF TRACHEA AFTER PROLONGED ARTIFICIALLUNG VENTILATION. STRATEGY OF COMBINED TREATMENTCONCLUSIONS. Our evaluation demonstrated that the Ambu aScopeTM 3 system wasassessed as easy to use and performs satisfactorily for guiding PDT in critically ill patients.
The system is portable and easy to position for the bronchoscopist and clinician performing
PDT to view. The monitor display is smaller and of lower resolution (800 9 480 pixel, 8.5
inch colour TFT LCD screen) than our non-disposable system, but image quality was goodenough to guide the procedures and the smaller monitor could be positioned flexibly at thebedside. Suction capabilities were adequate. The lowest scores were in relation to thefunctionality of the aViewTM monitor, which had pre-release software installed. The
lightweight handle was not perceived as a particular advantage. The disposable nature of thesystem may have cost advantages, especially when considering potential damage to bronchoscopes during PDT. One patient had cavitating lung lesions which illustrates an example
of potential infection control advantages over non-disposable equipment.

O.D. Eshonkhodjaev1, R.A. Ibadov1, S.N. Khudaybergenov1, A.S. Arifjanov1
Republican Specialized Center of Surgery named after acad. V. Vakhidov, Tashkent,Uzbekistan
INTRODUCTION. Thanks to the achievements of the modern resuscitation, saving of thepatients that are on long-term artificial lung ventilation (ALV) who were previously considered to be hopeless has been possible.
OBJECTIVES. Thus, the CST being a life-threatening and disabling illness remains to thisday to be the most urgent problem of intensive care, thoracic surgery, endoscopy andotorhinolaryngology.
METHODS. 46 patients with the CST have been treated in RSCS Vakhidov:stenoses
located in the upper third of trachea in 25 (54.34 %) patients, 6 (13.1 %) had narrowing of
the thoracic part of trachea, tracheolaryngeal localization with the affliction of the subglottic
part of larynx and the upper third of trachea has been seen in 8 (17.4 %), the combined
affliction of the larynx and thoracic part of trachea was present in 3 (6.5 %), and in 4 cases
there were cicatricial narrowing of the cervical and thoracic parts of trachea (8.69 %).
RESULTS. Radical method that allows removing the scar-narrowed segment of trachea
completely is a circular resection of trachea which was performed by us in 11 patients. So, thepatients after severe combined head injuries and polytraumas or after neurosurgical interventions for acute emergency conditions in pathologies of the central nervous system requirea long rehabilitation because of the neurological status which does not allow a radical
intervention in the form of circular resection of trachea for such patients. In the first stage wehave conducted a bronchoscopic laser photodestruction or diathermocoagulation of the stenosis with a subsequent bougienage of the narrowing of trachea. In patients with a total scarryobliteration of the lumen of trachea an endoscopic recanalization has been performed.
Afterwards, in order to prevent the growth of granulation and restenosis of the lumen oftrachea, as well as for the formation of a stable lumen, stents in a variety of modifications,
including linear silicone ones with the spines on the surface- the types of Dumont have been
installed, and also the T-shaped endoprosthesis have been used. After removing the T-shaped
endoprosthesis the plastics of the defect in the anterior wall of trachea was performed.
CONCLUSIONS. Dissection of stenosis with the excision of scarry tissues and the formation of a lumen on the T-shaped endoprosthesis in patients with cicatricial stenosis of thelaryngo-tracheal localization allows to rehabilitate patients from their comorbidities, toeliminate the signs of purulent endobronchitis, to retain the ability of breathing through thenatural airways and phonation, eliminating the risk of migration and obstruction of the stentand allows to generate a sufficient lumen of trachea with a subsequent performing of theplastic surgery to close the defect of the anterior wall of trachea and the soft tissues of theneck.
10156
ET TUBE IN EMERGENCY: DOES SIZE MATTER?
V. Joshi1, J. Nikhilesh2, P. Bajpai3
1aScope 3 aView monitor view of PDT
GRANT ACKNOWLEDGMENT. Ambu provided a donation to our ICU research fundfor conducting this evaluation.

0154
TRACHEOSTOMY CARE IN GENERAL WARDS IN RELATION TO
DECANNULATION TIME, ADVERSE EVENTS AND LENGTH OF STAY:
A RETROSPECTIVE QUALITY OF HEALTH REVIEW
A. Huang1, M.W. Loh1
1Changi General Hospital, Anaesthesia and Surgical Intensive Care, Singapore, Singapore
INTRODUCTION. Timely review and intervention for patients with tracheostomies in thehospital is important to facilitate decannulation and prevent morbidity. Tracheostomy for
ICU patients requiring prolonged assisted ventilation provides a safe airway, allows better
pulmonary toilet, facilitates weaning and expedites discharge from the ICU. This potentiallyallows better allocation of ICU resources. The lack of a dedicated team and standardized
protocols with regards to management of tracheostomies in the general wards may lead tosuboptimal care [1, 2].
OBJECTIVES. We aim to evaluate the prevalence of tracheostomies in the surgical intensive
care unit (SICU) and outcomes of these patients upon discharge to the general wards.
METHODS. The SICU patient database was searched for patients who had a tracheostomy
while in the ICU from 1st Jan 2007 to 31st Dec 2011. Patients who had a tracheostomy forear, nose and throat pathologies were excluded. The primary outcome was decannulation
time, while secondary outcomes included adverse events related to the tracheostomy and ICU
and hospital LOS (length of stay). This study has been approved by the hospital Ethics board.
RESULTS. During these 5 years, 204 patients underwent tracheostomies during theircourse of SICU stay. There were 54.4 % survivors, 36.8 % died and 8.8 % had incomplete
data. The mean age was 57 ± 19.8 and mean APACHE II score was 22 ± 6.2. Prior tohospital discharge, 49 % of patients were decannulated. The time to decannulation was
31.3 ± 29.3 days. Out of the 25 % (51/204) of patients who encountered adverse events, theRajshree Hospital and Research Centre, Critical Care Unit, Indore, India, 2CHL Hospitals,Critical Care Unit, Indore, India, 3Aurobindo Hospital, Medicine, Indore, India
INTRODUCTION. This prospective study is done in continuation of pilot study presented
at ESICM 2012 to improve quality of airway management in emergency situation. Thiscommunication is a follow up from the same.
OBJECTIVES. To analyze outcomes in unplanned (emergency) intubations using ET tube
no.7.5 or 8.5 or any no. for adult patients in three tertiary care hospitals.
SETTING. 70 bedded multispecialty medical and surgical intensive care units (ICUs).
METHODS. Patients requiring emergency intubation in ICU were included and data wascollected with a focus on variables such as demographics, APACHE II scores, co morbidities such as diabetes(DM), hypertension(HTN), coronary artery disease (CAD), smokingand duration of stay in ICU. Death/discharge from ICU was considered as end points. They
were compared across three groups [A] A 7.5 no ET tube group [B] A 8.5 no ET tube group[C] Random no. ET tube group [random numbers] getting admitted to hospital in the same
duration for similar variables. A multivariate logistic regression analysis was done using
SPSS version 15.
RESULTS. One hundred and forty patients were included for fixed No. 7.5 ET tube
(n = 140, M: F 80:60) and one hundred and forty for 8.5 [n = 140, M: F 86:54] which werecompared against a control group of one forty patients where random no. of ET tube wereused (n = 140, M: F 78:62) during Nov 12–April 13 in three different tertiary care centers.
The results were as follows.
Comparison of using different size ET tubes
Feature7.5 gr.

8.5 gr.

Random gr.

Age in years

54.3 ± 6.3

52.7 ± 8.3

55.9 ± 7.7

APACHE II

17.0 ± 4.1

15.4 ± 3.7

16.8 ± 2.8

No. of intubation

140

140

140

Stay in ICU (days)

4.8 ± 2.3

3.6 ± 1.8

6.3 ± 5

Within 30 days mortality

9 (6.4 %)

14 (10 %)

12 (8.5 %)Hypoxic brain injury

0 (0 %)

5 (3.5 %)

3 (2.1 %)A 7.5 size tube had a lesser likelihood of 30 day mortality and hypoxic injury than tube 8.5
and random sized tube (OR = 0.82 and 5.983 respectively).