We read with great interest the recent quality improvement initiative by Urquhart et al,1 focused on preventing tracheotomy-related pressure injuries (TRPIs). The authors addressed an important gap in tracheostomy research, and we are encouraged to see that with the TRPI-prevention bundle, the daily rate of TRPIs decreased by 50%. Although this is a strong improvement in patient care, this effort also indicates that a TRPI-prevention bundle alone may not be enough to prevent TRPIs in patients with tracheostomies.

What the initiative did not include was the type of tracheostomy tube used and whether enhanced tracheostomy tube design can impact the incidence of TRPI. Adverse events and outcomes for tracheostomy patients are relatively understudied, particularly for conditions such as skin infections and TRPI. Although pressure injuries are defined by the CMS as "never events," previous literature has suggested that approximately 11% to 13% of patients requiring a tracheostomy develop TRPIs.2,3 With the arrival of newer tracheostomy tube designs, it is possible that the incidence of some adverse events may decrease. For example, the Shiley flexible tracheostomy tube has a clear, soft flange, which was designed to reduce contact with the stoma site and increase air flow. This enhanced feature may help clinicians detect skin breakdown through visualization of the underlying skin, which could enable clinicians to intervene earlier to prevent TRPI. Other tracheostomy tube manufacturers have developed similar design features and warrant evaluation in a clinical setting.

We hope additional clinical research will build off of the work of Urquhart et al and examine adverse events such as TRPIs while incorporating how modern tracheostomy tube designs may impact patient outcomes.

-Ulf Borg; Adrian D'Angelo, MSN, RN, FNP; and

Katherine E. Liu, PhD

Medtronic, Boulder, Colorado

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