Literature Review: Feb 2026

NTSP Literature Review Podcast: Feb 2026 (S7, Ep1)

This months papers cover:

First— a huge global survey from the Global Tracheostomy Collaborative showed the biggest problems in trach care aren’t always technical. They’re education, staffing, access, and caregiver support.

Second — fasting before percutaneous tracheostomy. A Turkish ICU study found longer fasting did not reduce aspiration risk, but did delay nutrition recovery and increase oxygen requirements, supporting our approach at the NTSP for tracheostomy in recovering critically ill patients.

Third — a German team showed minimally invasive tracheostomy could be safely performed even in patients with previous neck surgery using ultrasound, bronchoscopy, and blunt dissection techniques.

Fourth — a Korean study looked at landmark-guided PDT without bronchoscopy or ultrasound in resource-limited settings. It appeared feasible and safe after an initial learning curve — but adjuncts still matter in high-risk patients.

And finally… tracheostomy in cats. Yes, really. 

Link to supporting PDF: https://tracheostomy.org.uk/Podcast-Resources

The UK National Tracheostomy Safety Project (NTSP) is committed to providing education, information and resources to improve patient safety and the patient experience for those with tracheostomies and laryngectomies. All of our resources are housed on our website www.tracheostomy.org.uk, accessed by over 30,000 visitors each month from around the world.

This is the only podcast to bring you literature reviews, hot topic discussions and interviews with healthcare staff, patients and families.

Our goal is to improve the safety and quality of care for patients with tracheostomies and laryngectomies through education. We work closely with patients, families and healthcare professionals to develop new resources to improve care. We’ve collaborated with key stakeholders in tracheostomy care since 2009, and developed freely accessible resources, supported by online learning developed with the UK Department of Health. We’ve worked with the Global Tracheostomy Collaborative since 2012 to improve care for patients and their families everywhere.

We are funded by grants, donations and in partnership with medical device companies through unrestricted awards. This podcast series is supported by unrestricted education funding from the Atos Learning Institute. The funding supports the professional production of the podcasts and videos, and the medical device companies that support us do not have any creative influence over the content that we record. All of our work is undertaken by volunteer healthcare staff, patients and their families. 

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Transcript

SPEAKER_00 0:07

Hi, it's Brendan McGraw from the NTSP. This is our February 2026 look at the literature that's caught my eye to do with tracheostomy and laryngectomy care. First up, we've got a huge survey from the Global Tracheostomy Collaborative which is looking at the biggest problems in tracheostomy care and they're not always technical. Next, we've got a series of papers looking at percutaneous tracheostomy insertion. We're looking at fasting, blood dissection, and the use of bronchoscopy and ultrasound in resource-limited settings. And finally, tracheostomy in cats. Yep, really, you'll have to stick to the end for that one. So let's dive in. So our first paper is published in the journal Tracheostomy by Michael Brenner, Vincia Pandion and colleagues from the Global Trache Collaborative in the USA. It's titled Addressing Education and Care Gaps in Tracheostomy Management Insights from a Multi-Stakeholder Global Survey. Now it wasn't a very technical paper about a new device or new surgical technique or anything like that, but it asked a very broad question: what are the biggest real-world problems facing people involved in tracheostomy care around the world? Importantly, the authors didn't just ask medical staff. They surveyed a wide range of stakeholders across 14 countries, including nurses, speech and language therapists, respiratory physiotherapists, physicians, patients, and caregivers. And I think that's important because one of the biggest challenges in tracheostomy care often happened to patients outside of the operating theatre or the ICU or even our hospitals. The survey itself was relatively straightforward. It was a 19-item questionnaire asking participants to score the severity of different challenges on a scale of 0 to 10, alongside free text comments about their experiences. But the findings were pretty striking. The highest rate is challenge was the limited availability of healthcare professionals with tracheostomy expertise. This scored a median of 8 out of 10, and that probably won't surprise many of you. Even in well-resourced systems, tracheostomy care expertise can be patchy. Staff turnover is high and training opportunities are variable. Many clinicians may only see tracheosyemergencies very occasionally, which has real implications for our patients. In low resource settings, these problems become even more pronounced. The next major themes were inequities in access to care and affordability. Participants describe problems with transport, insurance coverage, delayed follow-up, supply costs and geographical isolation, especially for rural patients and those that you could classify as in underserved populations. Again, this reflects something that resonates with me clinically. A patient may leave hospital with excellent care plans and training, but the duality of managing tracheostomy at home can be incredibly difficult, especially if expensive equipment or community services are required and specialist advice can be really hard to access. One of the most interesting aspects of the paper was the detail around specific areas of care that most people struggle with. This was highlighted by suctioning, a major issue, and respondents described a wide variation in technique, uncertainty about best practice, and then concerns about causing pain or trauma. Tube change were another area associated with fear, a lack of confidence, especially amongst less experienced staff or family caregivers. And stomach care problems included pressure injuries, skin breakdown infections, all areas that lots of us know can have a huge impact on the quality of life, despite sometimes receiving relatively little or no formal training or attention. The authors repeatedly come back to this one central issue that keeps coming up again and again: workforce competency. I think the team argue very reasonably that many of these complications associated with tracheostomy are not actually caused by the tube itself, but gaps in education, communication, our systems, and the support available. And that's a really important distinction because it suggests that improving outcomes might depend less on inventing entirely new technologies, but more on getting the basics consistently right. Standardised education, multidisciplinary teamwork, accessible expertise, and caregiver empowerment. The paper advocates very strongly for simulation-based training and standardised curriculums. Again, that aligns closely with what many groups internationally, including the NTSP and the Global Tracking Collaborative, have been pushing for years. Simulation obviously allows staff to rehearse emergencies and routine care, improve communication, and build on confidence before encountering real patients. And importantly, it helps standardise approaches across professions, across specialties and across organisations. Another theme that came out of this survey was the importance of empowering caregivers. Many respondents felt that families were underprepared for discharge, they lacked confidence in emergency management and didn't receive sufficiently tailored education. That's particularly relevant as more complex patients are being managed at home, often with long-term tracheostomies and even ventilatory support. The authors did discuss the potential role of newer technologies, including telehealth, virtual reality, augmented reality, and even artificial intelligence, which is obviously something that we've been looking at here. But whilst these technologies can help scale education globally, they might have a difficult or a challenging role in low resource settings. However, if access to specialist trainers is limited, then this is actually an opportunity and there is a chance to deliver standardized basic education at a global level with a bit of thought and probably a bit of investment. So technology alone is not the answer. I mean if digital systems are expensive or inaccessible or poorly integrated, they actually risk widening inequalities rather than reducing them. The authors are very clear that innovation has got to be paired with equitable access and thoughtful implementation. Now, the survey was distributed through the GTC, so respondents already probably represent relatively engaged or resource-rich institutions. Caregivers were also relatively underrepresented compared with healthcare staff, and with any survey, responses are subjective and self-reported. But despite that, I think the paper does provide a valuable snapshot of the current state of global tracheostomy care. Perhaps the biggest takeaway is that many of the most important challenges in tracheostomy care are not just technical, they're educational, organisational, social and systemic. So anything to improve care requires collaboration between healthcare staff, patients, families, educators, policymakers and healthcare systems. Does that sound familiar? I think that's a message many of us working in this field would strongly agree with. Next up, we've got a series of papers that cover some controversies, I'll call them, in PDT insertion. So the second paper is called Effect of Duration of Pre-Predural Fasting on Clinical Outcomes in Intensive Care Patients Undergoing Percutaneous Tracheostomy. This comes from Ekin and colleagues from the University of Health Science in Turkey. Fasting before operations is something that's sort of enshrined in anesthesia and sort of surgical care. And the reason for that is because if you're rendered unconscious, then you lose the protective mechanisms at the back of your throat that stop you effectively regurgitating anything that's in your stomach and then potentially inhaling it or aspirating it into your lungs. And so traditionally we fast patients before operations because of concerns about aspiration. In reality, fasting practice varies hugely between hospitals and clinicians, and there's not actually very good evidence telling us how long patients can really need to be fasted for. And this question has been thrown into the spotlight again recently with the advent of some of the drugs to reduce appetite because they slow down the way that your food moves through your gut, and so the traditional six hours of fasting is probably not applicable in every situation. So this study tried to address that question, specifically applied to tracheostomies in the intensive care unit. So you need to balance these traditional sort of fasting rules against some practicalities, especially if you're in an ICU. So in order to become a tracheostomy candidate for someone recovering from critical illness, they've usually been critically ill for a number of weeks. They're usually receiving a whole load of drugs that can affect gut motility, but specifically drugs like morphine or alfentinyl or fentanyl, which actively slow down gut transit. And that means if you have probably fasted for days, there's no guarantee of actually an empty stomach. Stopping feed in somebody who's critically ill is not actually a benign thing because patients are often on insulin to keep their blood sugars under control. And there's been plenty of incidents of problems where you stop feed and forget the insulin or the other way around. There's also problems with calorie and fluid intake that if you're stopping and starting feed all the time, it really messes up calculations for what is an acceptable and adequate intake for some of our critically ill patients. And we know from experience and things we discussed previously on this podcast that frequent cancellations and rescheduling of surgery, particularly as our patients needing tracheostomy, are often in a place of safety, so you know, arguably they can wait until the following day, but that gives real problems for stopping and starting feeds and timing when drugs can be administered. Some drugs need to be administered in feeding gaps, some need to be administered with food. So stopping and starting feed is problematic. We also have nasogastric tubes in nearly everyone on an ICU, and you can probably just aspirate the nasogastric tube, although a lot of feeding tubes nowadays don't aspirate very well. So there's a number of complexities that go into whether we should be fasting our patients or not. Anyway, back to the study. The authors looked retrospectively, so backwards, at 222 ICU patients undergoing PDT who were all receiving enteral feedings. Now patients were grouped according to how long they'd been fasted before the procedure, and that went from less than one hour all the way up to more than 12 hours. The primary question they were trying to address was whether longer fasting reduced aspiration pneumonia. The study looked at oxygen requirements, nutritional recovery, complications, ICU state, and mortality. The keys finding here was pretty striking but probably fairly obvious. Longer fasting did not reduce aspiration pneumonia. And I think that's because of all those things that I've highlighted in the sort of introduction to this paper. There were no significant differences in aspiration rates between the groups, regardless of how long the patients had been fasted. What did differ though was recovery afterwards. Patients fasted for more than 12 hours had significantly higher oxygen requirements after tracheostomy. I don't know why, that's biologically a little bit implausible, but they took longer to return to target calorie intake, which is definitely plausible. So, in other words, prolonged fasting appeared to worsen respiratory and nutritional recovery without providing any clear safety benefit. I definitely think it worsens nutritional recovery, and I'd like to see a bit more data about the respiratory bit. There were no significant differences in IC length of stay, hospital stay, complications, or mortality. And the authors argue that this challenges the traditional assumption that prolonged fasting is necessary before PDT in critically ill patients, and I think it reflects a broader shift in what we're seeing in critical care, moving away from blanket protocols towards a more individualized physiology-based approach. We've already discussed the importance of maintaining nutrition in the critically ill, and interruptions are problematic, but I think the message is fairly clear. You don't need to fast your patients before you're going to do a PDT. And I'll explain a little bit about what we do in our practice in Manchester. I mean, we we don't fast our patients, we stop the feed and we aspirate it prior to a PDT. I think when we're managing the airway, we're doing it under direct vision, although that's with a video laryngoscope, but we can we can see the airway, the airway is never completely empty, there's always a tube in it, yeah, usually with a with a cuff inflated, uh, although it's more of a ball cock valve rather than the tube actually in the airway. But you know, the airway isn't is never unprotected even though we're manipulating the upper airway. Uh personally, we don't see problems. Uh, aspiration is not something I particularly worry about when we're doing uh perk trackies. But I think my sort of take-home sort of practical tip is you need to just be careful about doing PDTs if you're not going to fast the patient. And that doesn't mean that's because there's a risk. I think the problems you get is if you pass that patient on to somebody else. So if they're going to theatre or if you personally aren't doing the procedure and someone else does it, uh they may suddenly say that oh, this person's not fasted, therefore we can't do it. And I think you know, politely, that probably just reflects a lack of understanding about the physiology that's going on and and of reading papers like this, which sort of reinforce that practice. But we've certainly had incidents where we've got an anesthesia team and a surgical team are quite happy to do the patient just say, right, when we send for them, we'll just stop the feed, we'll aspirate, not a problem. And then in the afternoon, it's a different uh anaesthetist, it's a different surgical team, and uh they have a different view about the fasting state of the patient. So I think if you're going to uh not fast the patients, just talk to everybody involved. As I say, for us, we don't have any problems when we do the trachees on the ICU with our teams just stopping the feed, aspirating it, we don't seem to have a problem. And so I like this paper because it reinforces what I do. The next paper is also related to PERC trachees. It's in a journal called JT CVS Techniques from the American Association for Thoracic Surgery. And this is entitled Safe Retracheostomy Critical Ill Patients with Previous Neck Surgery using the minimally invasive tracheostomy approach. This is from Harra and colleagues from the University Hospital of Regensburg in Germany. So they refer to the minimally invasive tracheostomy or MIT as a sort of novel approach, although as we get through the paper, you I'll argue it's not that novel, but uh it it it's they're describing it nonetheless, and this is particularly relevant for patients who've got challenging neck anatomy, and specifically in this paper, people who've had previous neck surgery. Now, a lot of people would consider prior neck surgery as a contraindication for ICU bedside tracheostomy. That's because the anatomy may be distorted, there's scar tissue, there's fibrosis, the blood vessels might be in the way, and there's perceived higher procedural risk. These patients are often referred for a formal surgical tracheostomy, and that as we discussed before, often incurs delays for the patient. Median delay in a couple of papers we looked at is around four to five days, which has implications for cost, resource use, and for the patient. They're sedative for longer and we can't move their care forwards. So, over a two-year period, this group looked at the minimally invasive approach in 11 IC patients in whom they considered to have difficult neck anatomy. They combined a few tools together: ultrasound, colour flow mapping, looking for vessels, blunt dissection, bronchoscopy, and something they called diaphonoscopy, which helps to visualize the sort of puncture path. And I would call this transillumination. It basically means trying to shine the light of the bronchoscope at the anterior wall of the trachea so you can see where you're going. Now it's good and bad, I think. It sort of lights it up, a bit like ET's finger, but it it's it's lights up a general area. You've usually got to switch the lights off, which arguably, if you're about to stick a sharp point of needle in someone's neck, is is not ideal. Um, but nonetheless, uh the group uh described the technique and uh they said it was helpful. So, what they're doing through these sort of sequence of steps is creating a much more controlled and anatomy-specific approach than the conventional per trache, where that you know the purist would just stick a needle straight through the skin, aiming for the trachea, and you know, you don't know what's in the way. So these patients were not straightforward, as I said, they'd had neck dissections, uh, pharyngectomy, obesity, a couple of neck cancers, liver disease, large goiters, and a couple of patients without normal blood vessels. All 11 procedures were completed successfully at the bedside without any significant complications, and that included bleeding events, pneumothoraces, tracheal injuries, and misplaced tubes. They reported no wound infections, no long-term tracheal stenosis, and long no long-term airway problems after follow-up. A few patients did have temporary voice changes, but these resolved within a couple of months, uh I think they said three months, and uh you know they were all felt to be transient. I think this is a relatively useful option for patients who would otherwise be considered not suitable for a bedside PDT. And the authors here argue that this MIT, minimally invasive trachea, sits somewhere between conventional perk trachee and a formal surgical trachee. You get the advantage of doing it at the bedside and it's a minimally invasive procedure, but you you save that sort of delay and transfer risks. Um, I think again it's another paper that I like because it reinforces uh what we do and what we teach in our course in Manchester. So we've started putting together all the things that we've learned over the years from our own practice, our reflections, and from working with other people around the world who are putting perk trackeys in. And personally, I open the neck with an incision, I then do blunt dissection because that's what I was taught, and the rationale for that is because I want to see where I'm going. We've already done our pre-procedural ultrasound and vascular mapping, so I've got a good idea what's between the skin and the trachea, but the blunt dissection I think allows you to visualize it, check there's no surprises, check there's nothing in the way, and get down to trachea fairly easily. All we use is the tracheal dilators that tend to come in our perk trachee uh packets, and then that allows you to put your finger in the hole and it allows you to put the needle essentially straight onto the pre-tracheal fascia, which I think significantly reduces the uh the chance of missing. So I like this paper, I like the description of what they do, and I think it's relevant because I I would advocate doing that in uh every perk trackey uh that you do because I think it is sensible, I think it's safe, I think it's logical, but it also means if you've got a more challenging case, then you are skilled, experienced, and more comfortable in tackling these cases that would otherwise perhaps be sent off to the operating theatre. Of course, we're working on some technology to help us place the needle in the first place, and if you want to find out more information about that, check out the gift section, uh guidance for tracheostomy, uh, on our website, which is tracheostomy.org.uk. The next paper in this little mini-series was looking at landmark guided perk tracking without visualization, and the key bit in the end of the title is in resource limited settings. This comes from Lee and colleagues at the Catholic University of Korea in Seoul, and this I think is an important practical problem in global tracky care. But I'll stress again the words and titles as resource limited settings because I think there's good evidence to show that using a bronch makes it safer and doesn't add any risk. Having said that, the reality is that many hospitals around the world simply do not have consistent access to technologies like bronchoscopy and ultrasound scanning. And so this study from Seoul looked at 71 ICU patients who underwent completely landmark guided PDT without any real-time visualisation from either ultrasound or bronchoscopy. Now, the operator here was already experienced in surgical tracheostomy, but relatively new to percutaneous techniques, so the authors were able to examine not only the safety but also the procedural learning curve of these operators. The results were fairly reassuring, but again in this setting. The median procedure time was seven minutes, but most procedures were performed at the bedside again in the ICU, a couple of them were occurring in the theatre but still with the PDT technique. Complications in about 14, 1-4% of patients, but again mostly minor, like bleeding, a bit of subcutaneous emphysema. Major bleeding and pneumothorax were present but were uncommon. The interesting thing I found was the learning curve. So early procedures took considerably longer, up to 35 minutes, but rapidly improved to around 5 minutes as experience developed. Complications also became less common over time. Now I think the message here is that clearly landmark guided PDT is feasible, it's relatively safe, but there are safe options. So if you have access to things like ultrasound or bronchoscopy, it will make that safer, it will probably reduce those early complications, it might have an influence on the learning curve because there's not many papers out there that describe the learning curve. But here there was definitely in an early adoption phase where structured supervision and careful case selection were really important. The authors found two predictors of more difficult procedures a history of stroke, I don't know why, and an increased cricoid to manubrium distance. So essentially, patients with longer and more anatomically challenged. Managing necks. So these bedside factors may help clinicians identify cases more likely to be technically difficult. They're not the classic indications of difficulty, which are usually shorter necks and necks that are obese, but that's what they found, and so I'm telling you what's in the paper. So importantly to bring things together, the paper is not arguing that bronchoscopy and ultrasound are unnecessary, but they're clear that it is possible to do this with a landmark technique, but just be careful about disordered anatomy and all the other potential contraindications or things that will complicate a tracheostomy. In a resource-limited setting, landmark guided PDT is a practical alternative if you put some thought into it and the operator is experienced. And so I don't want you to get the wrong message about this paper, but hopefully I've been able to explain it in such a way that I'm saying, look, it's possible, but safe options are available. The last thing we'll talk about is complications and outcomes of temporary tracheostomy in 24 cats. So this is a very slightly different paper, one from the world of veterinary care. This comes from the Journal of Small Animal Practice. It's published by a group in Solihull in the United Kingdom, the Willows Veterinary Centre and Referral Service. And so if anyone wants to switch off and that this has got nothing to do with human care, well, I think veterinary airway management sometimes gives us some insights and some parallels into the way we manage airways in adults. And this study looked at 24 cats that had temporary tracheostomy across three specialist centres in the UK. The most common reasons for tracheostomy were inflammation of the airways, infection, laryngeal cancers causing upper airway obstruction. There were also a couple of cases related to trauma, post-surgery, and laryngeal paralysis. Unsurprisingly, complications were common. Just over half the cats developed some kind of tracheostomy-related complication. Their biggest problems were complete tube obstruction, partial obstruction, and accidental tube displacement. Now that'll sound very familiar to anyone involved in human tracheostomy care. Airway blockage remains one of the most immediate and dangerous complications across all tracheostomy populations, regardless of the species. But what I found particularly interesting was despite the relatively high complication rate, most complications were actually managed successfully. Importantly, no cats were euthanized because of the tracheostomy tube itself, and survival to discharge was 58%. This was usually related to the severity of the underlying disease rather than the tracheostomy itself, just like what we see in human case series. So I think this is a bit of fun, isn't it, with tracheostomies in cats, and you probably picked up I'm not a cat lover, but some people are, and if you want to put a tracheostomy in a cat, then by all means. But I think it again reflects it's the severity of the underlying neurological, respiratory, or oncological or systematic disease, which is the problem that drives mortality in tracheostomy care, not necessarily the tracheostomy itself. But you know, the the authors conclude that yes, we have complications, but the procedure can still be successful in cats, and you know, you need to pay attention to all the things that that we do to try and keep tracheostomy tubes patent and in the right place. But I think the take-home message resonates just as strongly in human tracheostomy care as it does in veterinary medicine. So that's it for this episode. We've covered global surveys, multiple aspects of PDT insertion, and then finally tracheostomy in cats. I hope you found some of that interesting. Please follow us on our various platforms and social media and feel free to comment on the discussions that we've just had. As ever, the views are our own and don't represent any of the organizations for which I work. Thanks for listening and see you next time. Bye for now, you can't get a little bit more than a B.