Swallowing disorders in tracheostomised patients: a multidisciplinary/multiprofessional approach in decannulation protocols

Safe removal of tracheal cannula is a major goal in the rehabilitation of tracheostomised patients to achieve progressive independence from mechanical support and reduce the risk of respiratory complications. A tracheal cannula may also cause significant discomfort to the patient, making verbal communication difficult. Particularly when cuffed, tracheal cannula reduces the normal movement of the larynx which can further compromise the basic swallowing defect. A close connection between respiratory, phonating, swallowing and feeding abilities to be recovered, implies a strict integration among different professionals of the rehabilitation team. An appropriate management of tracheostomy cannula is closely connected with assessment and treatment of swallowing disorders in order to limit the development of severe pulmonary and nutritional complications, but at present there are no uniform protocols in the scientific literature. Furthermore, several studies report as an essential criterion for decannulation the presence of good patient consciousness, which is often altered in patients with tracheostomy, but a general agreement is lacking

The role of non-invasive ventilation in weaning and decannulating critically ill patients with tracheostomy: A narrative review of the literature

Abstract Introduction Invasive mechanical ventilation (IMV) is associated with several complications. Placement of a long-term airway (tracheostomy) is also associated with short and long-term risks for patients. Nevertheless, tracheostomies are placed to help reduce the duration of IMV, facilitate weaning and eventually undergo successful decannulation. Methods We performed a narrative review by searching PubMed, Embase and Medline databases to identify relevant citations using the search terms (with synonyms and closely related words) "non-invasive ventilation", "tracheostomy" and "weaning". We identified 13 publications comprising retrospective or prospective studies in which non-invasive ventilation (NIV) was one of the strategies used during weaning from IMV and/or tracheostomy decannulation. Results In some studies, patients with tracheostomies represented a subgroup of patients on IMV. Most of the studies involved patients with underlying cardiopulmonary comorbidities and conditions, and primarily involved specialized weaning centres. Not all studies provided data on decannulation, although those which did, report high success rates for weaning and decannulation when using NIV as an adjunct to weaning patient off ventilatory support. However, a significant percentage of patients still needed home NIV after discharge. Conclusions The review supports a potential role for NIV in weaning patients with a tracheostomy either off the ventilator and/or with its decannulation. Additional research is needed to develop weaning protocols and better characterize the role of NIV during weaning

Management of patients with neuromuscular disorders and acute respiratory failure

Acute respiratory failure (ARF) is a common cause of morbidity and mortality in most advanced neuromuscular disorders (NMD). Deterioration of lung function during NMD may have different severity and time course. During slowly progressive neuromuscular disease an acute event can precipitate the respiratory failure, while rapidly progressive NMD may present as ARF at the onset of the disease. During ARF a patient with NMD may be affected by inspiratory muscles weakness responsible for decreased ventilation, expiratory muscles weakness responsible for altered coughing effectiveness, and bulbar involvement responsible for altered swallowing and airway protection. Neuromuscular disorders may also affect central control of breathing, sleep disorder, bones and joints deformities with consequent ventilatory dysfunction. Usually ARF in NMD is prompted by precipitating factors such as upper airways infections, pneumonia, atelectasis etc. It is important to distinguish respiratory failure due to an acute event or to a rapidly progression of underlying conditions to properly allocate the patient in the more appropriate setting of care. Generally, excessive invasiveness of care must be avoided, and a pro-active early rehabilitation program may help early recovery and minimize complications. Mechanical non invasive positive pressure ventilation(NIPPV) combined with mechanically assisted coughing (MAC) has been established as the standard treatment of severe ARF in NMD. Superiority of NIPPV vs invasive mechanical ventilation (MV) was showed in term of lower mortality, treatment failure, duration of ICU in several studies. Home mechanical noninvasive ventilation and MAC may result dramatic reduction in the need for hospitalization and a prolongation of life expectancy of these patients. To avoid the progression of respiratory failure an early identification of respiratory deterioration is needed, as such as prevention of acute episodes. So, especially in the progressive diseases, is very important to monitor respiratory status with periodic lung function tests. Any respiratory tract infection in neuromuscular disease could trigger acute respiratory failure so it is mandatory take any aggressive measures to prevent and treat this complication. Some of principal preventive measures include vaccination against Pneumococcus Pn. and influenza virus, early antibiotic treatment when bacterial infection is suspected, chest physiotherapy for removal airway secretions or mechanical assisted maneuvers to increase cough efficiency. In conclusion, a proactive, preventive approach is the key for optimal management acute respiratory problems in neuromuscular disorders

Prolonged Disease-Free Survival in a Relapsed Adult Granulosa Cell Tumor of the Ovary Treated by Combined Leuprolide and Letrozole: Case Report

Relapsing ovarian granulosa-cell tumor (GCT) is a challenge for physicians due to the lack of effective therapy. Current strategies did not improve the 80% death rate of recurrent disease. GCTs synthesize estrogens and express follicle-stimulating hormone, gonadotropin-releasing hormone, and estrogen and progesterone receptors. The FOXL2-C134W mutation is shared in all GCTs, and its downregulation of hormone-related apoptosis appears causal in induction of tumor phenotype. On these assumptions, hormone anti-estrogenic therapies have been proposed for recurrent GCTs. A 32-year-old woman suffering from GCT was first treated by surgery in 2004 and staged as IA disease. Two subsequent pelvic relapses were diagnosed in 2006 and 2007, and the patient underwent surgery and chemotherapy to treat both recurrences. Overall, she underwent five subsequent surgical interventions and two chemotherapy instances. A third single pelvic relapse above the vaginal cuff was diagnosed in 2013. Based on the patient’s refusal to undergo further surgery we proposed an anti-estrogen therapy consisting of combined GnRH analogue leuprolide and the aromatase inhibitor letrozole. Complete remission was obtained after 3 months from the start of therapy. Subsequently, we found that disease-free survival was maintained over 9 years of treatment. Although recent reports indicate poor effectiveness of hormone therapy to treat recurrent GCTs, the success of this case indicates that a subset of patients with recurrent GCT maintain a tumor phenotype highly responsive to anti-estrogen drugs

Prolonged Disease-Free Survival in a Relapsed Adult Granulosa Cell Tumor of the Ovary Treated by Combined Leuprolide and Letrozole: Case Report

Relapsing ovarian granulosa-cell tumor (GCT) is a challenge for physicians due to the lack of effective therapy. Current strategies did not improve the 80% death rate of recurrent disease. GCTs synthesize estrogens and express follicle-stimulating hormone, gonadotropin-releasing hormone, and estrogen and progesterone receptors. The FOXL2-C134W mutation is shared in all GCTs, and its downregulation of hormone-related apoptosis appears causal in induction of tumor phenotype. On these assumptions, hormone anti-estrogenic therapies have been proposed for recurrent GCTs. A 32-year-old woman suffering from GCT was first treated by surgery in 2004 and staged as IA disease. Two subsequent pelvic relapses were diagnosed in 2006 and 2007, and the patient underwent surgery and chemotherapy to treat both recurrences. Overall, she underwent five subsequent surgical interventions and two chemotherapy instances. A third single pelvic relapse above the vaginal cuff was diagnosed in 2013. Based on the patient’s refusal to undergo further surgery we proposed an anti-estrogen therapy consisting of combined GnRH analogue leuprolide and the aromatase inhibitor letrozole. Complete remission was obtained after 3 months from the start of therapy. Subsequently, we found that disease-free survival was maintained over 9 years of treatment. Although recent reports indicate poor effectiveness of hormone therapy to treat recurrent GCTs, the success of this case indicates that a subset of patients with recurrent GCT maintain a tumor phenotype highly responsive to anti-estrogen drugs

A Two-Step Hysteroscopic Management for Cesarean Scar Pregnancy: A Proposal Method

Background: Cesarean Scar Pregnancy (CSP) is a cause of severe maternal morbidity. Currently, no guideline for its management is shared. We assessed safety and effectiveness of Methotrexate (MTX) administration within the sub-chorionic space under hysteroscopic guidance, followed by resectoscopic placental removal. Methods: Five patients suffering from type 2 CSP underwent a sequential treatment based on hysteroscopic techniques. Pregnancy termination was firstly obtained by injection of 80 mg of MTX within the intervillous spaces of placental site. The intervention was performed in an office setting using a 16Fr hysteroscope. MTX was administered by a 17-gauge needle suitable for the operative channel of hysteroscope. Subsequently, based on the decline of Human Chorionic Gonadotropin β-subunit (β-HCG), we timed a placental removal using a 27-Fr resectoscope, under conscious sedation. Results: In all women a diagnosis of CSP was achieved between 6 and 8 gestational age weeks. Hysteroscopic MTX administration resulted easily, quickly, painlessly and uneventfully in all patients. A substantial decrease of β-HCG was obtained in all patients within 15 days from the MTX administration. After a mean time of 27 days from MTX a resectoscopic removal of CSP was carried-out without any recorded adverse outcome. After 30 days from surgery β-HCG returned to non-pregnant level and normal physical findings were found in all patients. Conclusions: Hysteroscopy-guided MTX sub-chorionic administration resulted safe and effective for CSP termination. It was followed by successful and uneventful resectoscopic placenta removal in all patients. When hysteroscopy facilities are available, this combined therapy can be an option to treat CSP