Literature Review: Jan 2026

NTSP Literature Review Podcast: June 2025 (S7, Ep1)

This months papers cover:
 - Open surgical tracheostomy and asprin
 - Out-of-pocket costs and potential surprise bills for tracheostomy
 - Impact of tracheostomy follow-up care
 - Effectiveness of VR training

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

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Transcript

SPEAKER_00 0:07

Hello and welcome to January 2026's Tracheytalk. This is our monthly roundup of the literature that's caught my eye in the medical press. So this month we've got four papers. The first looks at continuing low-dose aspirin during open surgical tracheostomy. Then we'll have a look at the hidden financial burdens for tracheostomy for patients and families in insurance-based healthcare systems. Third up, we've got a paper examining structured follow-up after discharge with a focus on self-care and timely decannulation. And finally, we'll look at virtual reality simulation and emergency knowledge retention in a small study from the United Kingdom. So let's dive in. So our first paper is Should We Stop Aspiring Before Open Surgical Tracheostomy. This is a small study, but it's relevant because it's something that crops up in day-to-day practice for those of us involved in putting tracheostomies in. This is a retrospective single stenter study from Chula Long Korn University in Thailand. It only had 47 adult patients undergoing open tracheostomy between 2019 and 2023, so hardly a high volume centre, but I picked this because it's a recurrent problem that keeps cropping up in the literature. So 15 of their patients continued low dose aspirin at 81 milligrams per day, which is pretty low dose really, and 32 of the group had the aspirin withheld. The reason why it's a problem potentially being on aspirin is it increases bleeding, reduces the way that platelets and your blood stick together, and that's its mechanism of action when it's trying to reduce the risk of thrombotic events like strokes and heart attacks. The problem with aspirin is it has a relatively long duration of action. So even a couple of doses, you've got to stop it for usually a week, 10 days, something like that. And so if you decide you're going to stop aspirin to do a procedure like tracheostomy, you've got to wait. And that has implications for the patients, often for a tracheostomy sitting around an ICU with a ventilator tubing in your mouth, sedated, exposed to risk-intensive care. So it is a big deal whether you can have to stop it or not. So the headline findings were relatively straightforward from this group. There were no bleeding complications at all in the group that carried on with the aspirin. Now, in contrast, in the group that did stop taking aspirin, there was a couple of major bleeding events, there were two, and then also two minor bleeding events. But these small numbers, you know, the difference, not surprisingly, wasn't statistically significant, and it isn't really biologically plausible that you stop the aspirin and you have more bleeding events. So I think this is just showing us that you know the bleeding event rates were down to chance. So in other words, there was no difference between those groups. Now that's a good thing because what you're basically saying is stopping aspirin doesn't seem to make any difference. So what can we take away from this small study? Well, I think the practical message is that carrying on low dose aspirin doesn't appear to increase perioptive bleeding risk in open surgical tracheostomy. And we've seen that before and we've discussed that on this podcast. And I think that matters because you know if you have a clinical concern that a patient's on aspirin and you're thinking about doing a tracheostomy, stopping the aspirin and waiting for it to wash out pharmacologically can really prolong their intensive care stay and can potentially worsen some of those downstream outcomes. So for me, this paper adds to that sort of growing body of literature that you don't need to stop things like aspirin before cracking on with a tracheostomy. So we've looked at dual antiplatelet therapies before and additional anticoagulants like heparins and warfarins, and I think the take-home message is that you can stop anticoagulants if you need to. So if it's something that you can stop without increasing the thrombotic risk, by all means do so, but don't cause delays in getting the tracheostomy done. You can find more detailed summaries in other episodes that we've got on this podcast series. This is a shift from the bedside to something that we discuss far less often, really, in tracheostomy care. And this is the the burdens that patients and their families are exposed to, particularly in those healthcare systems that are insurance-based. And this study was a large retrospective analysis using something called the Merative Market Scan Database. This looked at just under 9,000 commercially insured adults age 18 to 64 and the underwent tracheostomy between 2014 and 2022. For anyone not that familiar with the way the US healthcare systems and their costs are covered, including me, I'll try my best to explain. So, firstly, something called a deductible. That's the amount the patient must pay each year before the insurer starts sharing costs. After that, many insurance plans switch to something called co-insurance, and that's where the patient still pays a percentage of every covered bill, usually between 10 and 30%, but sometimes more. So for a tracheostomy mission, the cost of a journey looks something like this. You get admitted, you end up maybe on the ICU or going straight to surgery, and the patient essentially pays first any remaining deductibles. After the deductible limit is reached, the insurer starts paying, but the patient may still owe. So, for example, 20% for every hospital cost, every surgical cost, intensive care cost, respiratory therapy cost, etc. etc. That also includes follow-up charges. And that continues until the patient reaches their annual out-of-pocket maximum. And after that, the insurer finally pays 100% of the covered costs. So what did they find of this study? Well, it was quite striking really. Within 30 days of tracheostomy, the average out-of-pocket cost was $1,423 US dollars. The biggest contributor was co-insurance, and that accounted for nearly two-thirds of the patient cost burden. So it's not simply about deductibles that start the hospital admission. Much of the financial impact seems to come from the shared cost structure that continues after the procedure itself. The second major finding here was the issue of potential surprise billing. So around 9.1% of episodes that they looked at here included what was called an out-of-network charge, despite the main surgeon or the hospital being in network. And that means that if you attend a certain hospital, you expect your care to be covered under that hospital umbrella, but a lot of the times some of the services or people delivering those services were outside of that network. And so those patients who had that surprise billing faced significantly higher personal costs, and the mean out-of-pocket spending for them was just over $1,900. So strongest predictors of higher patient costs were these high deductible insurance plans and the fee-for-service insurance models. Both were also associated with a significantly greater risk of surprise bills. But what the authors did find was it encouraging that the incidence of these potential surprise bills did fall steadily across the study period, and that likely reflects the impact of some policy reform in the US and those introductions called the No Surprises Act to try and tackle problems like this. So even though this is a US-based insurance data paper, I think the broader message here is actually quite transferable. So tracheostomy care is a resource-intensive, multidisciplinary, prolonged period in your life, and it often extends well beyond the index admission. So patients and families are already managing equipment, supplies, communication needs, transport, and support in the community, as well as these potential financial burdens. What this paper suggests is in models like the US that we should think about financial counselling, early discharge planning, and early identification for those patients at risk of economic hardship. So there may well be equivalent costs outside the US, such as travel, unpaid caregiver time, consumables, home adaptations, and loss of earnings for our patients, all of which we need to think about. So I think it reminds us that tracheostomy care to be called a success is not just about decannulation or a safe discharge or getting back to eating, drinking or talking. It's also where the patients can realistically afford the pathway that we design around them. So it strengthens the case for whole pathway thinking where financial burden is recognised and it's another determinant of recovery, really, which ties in with quality of life and equitable access to care. So if you're interested in that side of things, I think this paper is well worth a look. The next paper we'll look at is whether specific follow-up after discharge improves tracheostomy recovery. This is a longitudinal cohort study from the Johns Hopkins Hospital in Baltimore in the US, and it followed 220 adult tracheostomy patients at three months and then three years after discharge. About three-quarters of the patients received some sort of tracheostomy-specific follow-up within those three months, usually with head and neck or otolaryngology or ENT teams. The patients who attended follow-up were significantly better at things like stoma cleaning, but there wasn't much difference in sort of tube change frequency. So what the authors observed is that the patients who had better, more regular stoma cleaning, they were more likely to have reduction in complications like stoma infection or delayed wound healing. They felt that overall some of those sort of follow-up interventions could influence some of those everyday care behaviours, and some of those translated into potential long-term benefits around the management of the tracheostomy itself. One of the more nuanced findings that they found was that the active follow-up group actually reported more breathing difficulties and had more recognised complications. But I don't think this should be interpreted as the follow-up caused worse outcomes, because I think patients were just getting asked more questions, they were being seen more frequently, and so there were more opportunities for issues to be raised and for problems to be recorded. And I think essentially that's exactly what good follow-up is supposed to do. I think the most clinically important longer-term finding is that follow-up was associated with more timely decannulation, faster stoma closure, and better cosmetic outcomes. So by three years, only 6.8% of patients still had a tracheostomy in place, and that was commonly due to tracheal stenosis. So should this paper change your practice? Well, I think it sort of supports formalised multidisciplinary tracheostomy survivorship pathways. And what I mean by that is that follow-up is not just an optional outpatient extra. It's part of safe tracheostomy care, it can help reinforce self-management, it can help identify late complications, and if a patient's being discharged with a tracheostomy in situ, it can support more timely decannulation. There's probably also an opportunity to highlight hybrid models with virtual reviews and telehealth, especially where geography, mobility, or service fragmentation make face-to-face follow-up quite tricky. Certainly this paper reminds us that tracheostomy outcomes are shaped just as much by what happens after discharge as during that index admission. And I know certainly where I work, follow-up could always be better. Final paper this month comes from an ENT department in Oxford in the United Kingdom, and it looks at how we educate airway teams. Specifically, they looked at whether virtual reality simulation can improve tracheostomy teaching, and crucially, could it help staff retain knowledge over time? This is a small, prospective educational study of 26 healthcare professionals, so a pretty small group. Everyone in the group received standard face-to-face training, and the team published their standard tracheostomy teaching program uh in their journal article. What was different was they took a subgroup of 17 learners and they had an additional 40-minute hybrid virtual reality simulation using a system called Google Minds. What they guys did was they the session included a 10-minute sort of pre-brief, 20 minutes in an interactive simulation, and then a 10-minute debrief. They followed the NTSP emergency algorithms and they assessed knowledge before and after with an MCQ. They repeated that MCQ at 30 days to look at follow-up. So immediately after teaching, the group that had had the interactive virtual reality training had a higher score, so 7.2 out of 8 on average compared to 6.3 in the standard group. But probably more importantly is the retention. So at 30 days, the VR train group maintained a mean score of 6.9. Whereas a conventional study group who had didn't have the VR element, their scores fell to 4.7 out of 8. And even despite these really small sample sizes, all these differences were actually quite significant. Since that probably suggests that VR is doing more than adding novelty, it appears to improve how knowledge is encoded, rehearsed, and then retrieved over time in these learners. So in the discussion, the paper highlights three potential mechanisms. Firstly, immersion. So staff are placed into realistic emergency scenarios that demand active decisions rather than just passive listening. The second element is repetition. So virtual reality enables deliberate, repeated practice in physiologically and psychologically safe environments without obviously any risk to patients. And third, VR offers immediate feedback, and that can help learners rapidly correct errors and strengthen their right response to these various pathways dealing with tracheostomy emergencies. So VR lends itself to sort of areas just like tracheostomy emergencies where these events are infrequent but the consequences are pretty high stakes for the patient and for the team. And so this combination of what VR can bring is particularly powerful for these rare but significant events. The next step for studies like this, of course, is moving beyond MCQ knowledge retention and looking at behavioural performance, team response times, and ultimately patient safety outcomes. And we know from some of the work that we've done with the NTSP that we know if we can train staff with some of the courses that we've established over the last 20 years, we know that that can translate into better outcomes for our patients. That's it for this episode. We've covered surgical tracheostomies and antiplatelets, we've looked at the cost of care, we've looked at appropriate follow-up, and we've looked at virtual reality training and all these areas that look potential to influence care. Hope you found that interesting. Please, as ever, follow us on our various platforms and social media and feel free to comment on the discussions. As ever, the views aren't my own and they don't represent any of the organisations for which I work. Thanks for listening. Bye for now.