To the Editor: Expulsion of tracheal rings is a rarely encountered airway catastrophe. The etiologies of tracheal ring expulsion can be traumatic, infectious (bacterial tracheitis, endobronchial tuberculosis),1,2 rheumatologic (relapsing polychondritis), malignant (squamous cell carcinoma), and toxic (external beam radiation). Herein we report a case of acute respiratory failure due to expulsion of tracheal rings in a young male. The case posed a challenge in terms of initial airway stabilization, bronchoscopic evaluation, and further management. A 38-year-old obese male (body mass index of 41.1 kg/m2) with a past medical history of end-stage renal disease on hemodialysis and obstructive sleep apnea initially presented for hemodialysis fistulogram revision 21 days before case report event. Following sedation for this procedure, the patient experienced acute hypoxic respiratory failure requiring emergent intubation that was technically difficult secondary to body habitus. Chest radiograph obtained at this time did not show any evidence of pneumomediastinum. Following extubation, the patient experienced dysphagia and dysphonia, for which he was treated with steroids and conservative management for presumed vocal cord edema. Although the symptoms did not completely resolve, he was stable enough for discharge. One day following discharge, patient had an episode of expectoration of “hard light brown semicircular material” for which he was readmitted to perform a bronchoscopic evaluation of the airways. Before being able to perform the bronchoscopy, he developed acute hypoxic respiratory failure with stridor and required an emergent fiberoptic intubation. Extracorporeal membrane oxygenation set up was placed on standby in case endotracheal intubation could not be performed. At the time of intubation, multiple fragments of fractured/displaced tracheal rings were found in the proximal to mid trachea and were removed (Fig. 1). Complete collapse of the surrounding tissues in the proximal trachea was noticed with significant tracheomalacia (Fig. 2A). Follow-up CT neck imaging showed loss of typical cartilaginous structure and air within the soft tissue surrounding the tracheal lumen (Fig. 2B). Evaluation for infectious and rheumatological causes of tracheal ring expulsion were unremarkable. At this point, the patient was transferred to a major quaternary care center with more specialized experience. The patient’s airway damage was considered too extensive for a primary tracheal repair (∼6 cm span with indistinguishable subglottic structures) and therefore a conservative approach was pursued. Following multidisciplinary discussions, a Shiley XLT trachesotomy tube was placed with eventual plans to transition to a T-tube. Patient was stable and transferred to a long-term acute care facility where he currently remains ventilator dependent.FIGURE 1: A, Cartilaginous tracheal ring fragments in specimen container. B, Intact cartilaginous tracheal ring with pen placed for scale.FIGURE 2: A, Bronchoscopic image demonstrating complete collapse of the surrounding tissues in the proximal trachea. B, Axial computed tomographic imaging of the soft tissues of the neck showing loss of tracheal cartilage and possible air within the soft tissue, about 5 cm above the level of the carina. ET tube is in place.Fracture of tracheal rings is an uncommon airway emergency and has been reported previously secondary to etiologies such as trauma, infection (bacterial tracheitis, endobronchial tuberculosis), rheumatologic conditions (relapsing polychondritis), malignancy (squamous cell carcinoma), and toxic insult (external beam radiation).1–3 With the history of an emergent difficult endotracheal intubation preceding the events, a traumatic tracheal insult causing expulsion of rings was the major consideration in our patient. We hypothesize that the injury to the tracheal wall resulted from direct trauma from the stylet or aggressive downward cricoid pressure during an anteriorly directed endotracheal intubation. In a systematic review of tracheal damage following endotracheal intubation, emergency intubation was associated with a 3-fold increased risk of mortality in these patients when compared with nonemergent intubation.4 Regardless of etiology, treatment for tracheal ring expulsion focuses on airway stabilization. First line involves intubation of the patient to temporarily stent the airway. Further measures include either evaluation for surgical repair or conservative management.4 Methods for repairing tracheal rupture secondary to traumatic intubation include end-to-end anastomosis, simple sutures, anterior transverse tracheotomy, and longitudinal tracheotomy.4 Another technique for repair is autologous tracheal substitution, which uses free fasciocutaneous flaps in cases of tracheal resection secondary to trachea neoplasms.5 In the systematic review by Miñambres et al,4 surgical repair is associated with a 2-fold increase in mortality compared with conservative management and therefore patients should be carefully selected. Tracheal ring expulsion is rarely encountered and is a life-threatening airway emergency. Urgent airway stabilization is the key to resuscitation. Immediate bronchoscopic evaluation is mandatory in making the diagnosis. Long-term management options include conservative treatment, as in our patient, or surgical repair in selected patients. Katherine Ravid, MD* Heather Heiser, MD* Annum Faisal, MD† Gustavo Cumbo-Nacheli, MD‡ Benjamin Young, MD§ Sonali Sethi, MD∥ Anupam Kumar, MD‡*Michigan State University College of Human Medicine†Grand Rapids Medical Education Partners/MSU College of Human Medicine‡Division of Pulmonary & Critical Care Spectrum Health-Michigan State University Grand Rapids, MI§Cleveland Clinic Foundation∥Respiratory Institute, Cleveland Clinic Foundation, Cleveland, OH
Abstract Introduction The Choosing Wisely guidelines advise against ordering routine blood tests for hospitalised patients unless they change management. Unnecessary testing can lead to adverse effects (eg, iatrogenic anaemia, poor sleep quality, risk for infections and increased cost of care). Methods An 8-week quality initiative aimed at reducing unnecessary blood tests was implemented in three internal medicine resident inpatient services. The initiative included a 30 min educational session, reminders prior to rotation and midrotation and posters in work areas that displayed lab pricing and urged judicious testing. Residents were encouraged to justify the purpose of ordering tests in their daily progress notes. Attending physicians were made aware of the initiative. Preintervention and postintervention time points were used to compare key metrics. A >10% decrease between time periods was used as an evaluation criterion. Results There were 293 patient records reviewed in the preintervention period and 419 in the postintervention period. The two groups were similar in terms of age and gender. Median blood test count (complete blood count/basic metabolic profile/comprehensive metabolic profile) decreased from 4 to 2 tests per patient per day (50 % decrease) after the intervention. The median length of hospital stay decreased from 4.9 to 3.9 days (21% decrease). A decreased percentage of people requiring transfusions was also noted (2016: 6.1%, 2017: 2.9%). Conclusion The frequency of unnecessary routine blood tests ordered in the hospital can be decreased by educating resident physicians, making them cost conscious and aware of the indications for ordering routine labs. Frequent reminders are needed to sustain the educational benefit.
This review intends to explain the Center for Medicare and Medicaid Services (CMS) 30-days unplanned readmission rule under its Hospital Reduction Readmission Program (HRRP).In this article, we will briefly define this rule with its intent, origin, impact on patients, hospitals, and staff/managers.In other words, we will describe who, what, when, where, why, and how this rule applies.We would also make some recommendations in this regard.
