Complications to Tracheostomy and Long-Term Intubation: A Follow-Up Study

Hospital records of 79 patients treated with tracheostomy or long-term intubation from 1969 to 1971 were reviewed, and the 43 surviving patients were examined by laryngoscopy, x-ray and spirometry for complications subsequent to these treatments. Early complications included one tube occlusion and one case of postextubation stridor in each group, one dislocated tube, one bilateral pneumothorax, and one case of fatal innominate arterial hemorrhage in the tracheostomy group, and two cases of atelectasis in the long-term intubation group. Necropsy findings included necrotic ulcers in the larynx of intubated patients and eroded tracheal mucosa in both groups. Late complications in surviving patients were prolonged hoarseness in six patients treated with prolonged intubation, two of whom had also had tracheostomy. Radiologically verified tracheal stenosis (40-60%), four at the stoma level and one at the cuff level, all occurred in the tracheostomy group.     

PercuTwist: a new alternative to Griggs and Ciaglia's techniques

BACKGROUND AND OBJECTIVE: Tracheostomy is one of the most common procedures in intensive care units worldwide. In this study we aimed to compare three different tracheostomy techniques with respect to duration of procedure and complications. METHODS: One hundred and thirty patients requiring endotracheal intubation for more than 10 days due to acute respiratory distress syndrome, infections or cerebrovascular events were consecutively selected to undergo the percutaneous dilatational tracheostomy technique (PDT n = 44), the guide-wire dilating forceps technique group (GWDF n = 41) or the PercuTwist technique (n = 45). The time taken to perform the procedure (skin incision to successful placement of tracheostomy tube) and complications were recorded. RESULTS: The operating times were found to be 9.9 +/- 1.1, 6.2 +/-1.4 and 5.4 +/- 1.2 min in PDT, GWDF and PercuTwist groups, respectively. The duration of the procedure was significantly shorter in the PercuTwist group as compared to the percutaneous dilatational tracheostomy (P < 0.01) and guide-wire dilating forceps (P < 0.05) groups. During postoperative bronchoscopy, eight cases of longitudinal tracheal abrasion (four in the PDT group, two in the GWDF group and two in the PercuTwist group), two cases of posterior tracheal wall injury (one in PDT and one in GWDF) and one case of tracheal ring rupture in the PDT group were seen. CONCLUSIONS: Percutaneous tracheostomy techniques have their own advantages and complications. PercuTwist, a new controlled rotating dilatation method, was associated with minimal complications, appears to be easy to perform and a practical alternative to percutaneous dilatational tracheostomy and guide-wire dilating forceps techniques.     

Evaluation of a new technique for bedside percutaneous tracheostomy

BACKGROUND: Percutaneous tracheostomy as described by Ciaglia is accepted as a safe technique with minimal associated morbidity. Recent modification of the technique to a single-step dilator prompted us to evaluate this in the critically injured patient. METHODS: A comparison of patients undergoing percutaneous tracheostomy was performed. From May 1998 to May 1999, patients underwent surgery using the sequential multidilator technique (MDT), and from July 1999 to July 2000, patients underwent surgery using the single dilation technique (SDT). RESULTS: Ninety-three tracheostomies were performed, 49 MDT and 44 SDT. Time to tracheostomy and total ventilator days was similar between the groups. Three complications occurred. In the MDT group, 1 patient experienced delayed tracheal hemorrhage not requiring transfusion. In the SDT group, 1 patient had transient right lower lobe collapse, and another patient had unexplained extubation requiring emergent cricothyroidotomy. CONCLUSIONS: Percutaneous tracheostomy using the single-step Rhino dilator technique is technically easier than the currently accepted multidilator technique with equivalent complications.     

Tracheostomy in children: there is a place for acceptable risk

BACKGROUND: Tracheostomy in children remains controversial regarding the risk of complications. METHODS: Forty-six trauma patients (35 male and 11 female, mean age = 6.8 years) were admitted to the intensive care unit between 1987 and 1991 with severe head injury plus coma. Tracheostomy was performed with standard technique after 5.9 days (range, 2-12 days) of intubation. RESULTS: There were no deaths from tracheostomy, but six deaths resulted from severe head injury. One child was discharged with tracheostomy. The 39 survivors remained with tracheostomy 16.14 days (range, 4-71 days) in the intensive care unit. After cannula removal, 31 remained asymptomatic; 8 had respiratory distress: 2 were normal, 5 had endoscopic treatment for subglottic granulomas/stenosis from intubation, and 1 had tracheomalacia from tracheostomy. In 1997, the 18 patients located for follow-up were asymptomatic. At endoscopy, 8 were normal, 9 had subglottal granulomas from intubation, and 1 had 20% tracheal stenosis from tracheostomy. CONCLUSION: Most complications after tracheostomy result from intubation. Tracheostomy has an acceptable risk in children with severe head injury who need prolonged ventilatory support.     

Endotracheal intubation following thyroidectomy

Thirty-five patients requiring tracheostomy or endotracheal intubation, following thyroidectomy are reviewed. Conditions included 30 patients with multinodular goitre, three patients with Graves's disease and two patients with carcinoma of the thyroid. Early in the series, emergency tracheostomy was performed in three patients with airway obstruction following thyroidectomy. Ten patients were deemed at extremely high risk of developing airway obstruction and underwent prophylactic tracheostomy. Endotracheal intubation has been used in preference to tracheostomy in the latter part of the series. Emergency endoctracheal intubation was performed on one patient and prophylactic intubation was carried out in 20 patients. The morbidity and length of hospital stay in this latter group was considerably less than those requiring tracheostomy. It is concluded that patients with potential airway obstruction following thyroidectomy should have prophylactic endotracheal intubation, in preference to tracheostomy.     

Percutaneous tracheostomy by forceps dilation: report of 162 cases

A prospective, observational clinical study evaluated the safety of percutaneous single-step dilatational tracheostomy over a 43-month period. One hundred and sixty-two patients were deemed suitable for the procedure. The mean duration of tracheal intubation prior to tracheostomy was 6 days. The mean duration of the procedure was 9.3 min. Intra-operative complications occurred in 27 patients (16.6%), most of which were minor technical difficulties without morbidity. Postoperative complications, some of which were associated with morbidity, occurred in 16 patients. There were two deaths secondary to premature decannulation, one case of severe bleeding and five pneumothoraces. Long-term complications were assessed in 81 patients; there were four tracheal stenoses requiring surgery or laser therapy and seven patients with granulation tissue at the stoma site which did not require treatment. Forceps dilatational percutaneous tracheostomy appeared to be a convenient bedside procedure. However, complications do occur and further studies should address late sequellae, such as tracheal stenosis.     

喉癌手术的麻醉处理

目的：讨论喉癌手术患者的特殊性和麻醉中应该注意的问题。 方法：回顾分析2006年2月至2007年2月我院行单纯喉切除术病人病案资料。 结果：2006年2月至2007年2月我院共行单纯喉切除麻醉138例。138例病例中有84例为直接气管切开后插入气管内导管，其余54便为静脉快速导后插管术中气切换管。依据麻醉顺序将84例先行气切的病例分为A、B两组，A组为在气切前给予麻醉药物，B组为气切插管后马上给予麻醉药物。麻醉前两组间情况无显著差异。静脉麻醉诱导后气切插管前收缩压（SBP），舒张压（DBP），心率（HR）较麻醉前明显降低（P〈0.05），气切插管后，喉癌切除时、手术结束时各参数有些变化，但其波动大小基本上在正常范围之内。两组患者不同顺序麻醉气切，B组血液动力学参数变化较A组大，但两组患者术中、术毕各参数基本平稳正常，组间比较（P〉0.05），无明显差异。 结论：讨论了些类患者的特殊性和麻醉中应该注意的问题，包括麻醉前评估喉癌患者的病变范围和是否存在气道阻塞及其程度，老年男性患者术前，术中呼吸循环系统并发症的处理，不同分型的肿瘤插管方式的选择，术中术后呼吸道管理的特殊性，术后拔管应该注意的问题。     

Endoscopic guided percutaneous tracheostomy: early results of a consecutive trial

Percutaneous tracheostomy is increasingly being used for patients needing prolonged ventilatory support. The purpose of this study was to assess the feasibility of widespread application of endoscopic guided percutaneous tracheostomy. Sixty-one consecutive ICU patients requiring prolonged mechanical ventilation underwent bedside endoscopic guided percutaneous tracheostomy. Using a modified Ciaglia technique, a #6-10 tracheostomy tube was introduced between the second and third tracheal rings. Bronchoscopic transillumination facilitated identification of the appropriate tracheostomy site, and verified satisfactory placement of dilators and tracheostomy tube. There was one procedure-related death due to arrhythmia. Procedure-related complications included (n = 7): bleeding (controlled with local pressure), two infections, two cuff tears, and two obstructions of the tracheal tube. The tracheostomy was eventually removed in 13 patients. Bronchoscopic evaluation of three patients at 4 months post-tracheostomy removal was normal and there has been no clinical evidence suggestive of tracheal stenosis in the remaining ten extubated patients. There was a 50% reduction in cost when compared to operative tracheostomy. Percutaneous tracheostomy is a simple, safe, cost-effective bedside procedure for critically ill ventilator-dependent patients. Endoscopic guidance appears to increase the safety of this procedure and may prevent complications of pneumothorax, subcutaneous emphysema, and paratracheal false passage previously reported with blinded percutaneous methods.     

Airway injury from the presence of endotracheal tubes and the association with subglottic secretion drainage: a prospective observational study

Purpose

Laryngeal and tracheal injuries are known complications of endotracheal intubation. Endotracheal tubes (ETTs) with subglottic suction devices (SSDs) are commonly used in the critical care setting. There is concern that herniation of tissue into the suction port of these devices may lead to tracheal injury resulting in serious clinical consequences such as tracheal stenosis. We aimed to describe the type and location of tracheal injuries seen in intubated critically ill patients and assess injuries at the suction port as well as in-hospital complications associated with those injuries.

Methods

We conducted a prospective observational study of 57 critically ill patients admitted to a level 3 intensive care unit who were endotracheally intubated and underwent percutaneous tracheostomy. Investigators performed bronchoscopy and photographic evaluation of the airway during the percutaneous tracheostomy procedure to evaluate tracheal and laryngeal injury.

Results

Forty-one (72%) patients intubated with ETT with SSD and sixteen (28%) patients with standard ETT were included in the study. Forty-seven (83%) patients had a documented airway injury ranging from hyperemia to deep ulceration of the mucosa. A common tracheal injury was at the site of the tracheal cuff. Injury at the site of the subglottic suction device was seen in 5/41 (12%) patients. There were no in-hospital complications.

Conclusions

Airway injury was common in critically ill patients following endotracheal intubation, and tracheal injury commonly occurred at the site of the endotracheal cuff. Injury occurred at the site of the subglottic suction port in some patients although the clinical consequences of these injuries remain unclear.

     

A new technique for complete intraluminal repair of iatrogenic posterior tracheal lacerations

Tracheal laceration is a rare complication of endotracheal intubation. Early surgical treatment is mandatory in cases of pneumomediastinum with difficulty in ventilation to prevent mediastinitis and stricture. Surgical access to the posterior tracheal wall is via a right posterolateral thoracotomy, transcervical tracheotomy or tracheostomy, each of which is associated with specific morbidities. We developed a new optical needle holder consisting of a 12° HOPKINS telescope in a fixed attachment with an endoscopic needle holder to allow for complete intraluminal repair of posterior tracheal wall lacerations. Four patients were admitted with an iatrogenic tracheal laceration due to emergency intubation. In all cases, the repair of the tracheal laceration started with the introduction of a 14-mm rigid tracheoscope and subsequent jet-ventilation. Three of the tears were successfully repaired endotracheally with a running suture. In one case, the repair had to be converted to an open closure via posterolateral thoracotomy. Two patients were discharged extubated for further treatment of their underlying diseases. One patient died from a third cardiac infarction two days after the tracheal repair. We think that an exclusively endoluminal repair of longitudinal tracheal lacerations is feasible. This repair has convincing advantages including little surgical trauma, lack of scars and diminished postoperative pain.     

Spontaneous Pneumothorax

During the past ten years, 20 patients with acute penetrating tracheal injury (15 cervical and 5 thoracic) have been treated at Grady Memorial Hospital. Ten of the 20 patients had other major associated injuries: 6 had esophageal wounds, 5 had arterial injuries, and 2 had additional wounds.In the first 5 patients treatment of the tracheal injuries consisted of tracheostomy alone. Later on, the tracheal wounds were managed according to type, site, size, and the type of other organ injury. Repair of the tracheal wound and tracheostomy were done in 3 patients, repair of the tracheal wound and temporary tracheal intubation in 4 patients, tracheocutaneous stoma in 1 patient, temporary tracheal intubation alone in 4 patients, and observation alone in 3 patients.Seventeen patients recovered from their injuries and 3 died from sepsis, respiratory insufficiency, or cerebrovascular accident. All 3 deceased patients had other major injuries.This experience suggests that the treatment of penetrating tracheal injury should depend upon the type, size, and site of the wound and the type of coexistent injury to other organs, and that primary repair of the tracheal wound can be carried out in the majority of the patients.     

Submental tracheal intubation for a panfacial fracture patient

Panfacial fractures represent a unique challenge to the surgical and anesthetic team. Often nasal and oral intubations interfere with surgical procedure, while tracheotomies include a number of potential complications as well as the formation of poor scarring in a highly visible area. Tracheal intubation through the floor of the mouth, mentioned as submental tracheal intubation, is a simple quick and effective alternative to oral and nasal tracheal intubation or tracheostomy in the surgical management of selected patients with panfacial fractures. In this case report, with successful submental tracheal intubation, the potential complications associated with a tracheotomy were avoided.     

Extensive posterior-lateral tracheal laceration complicating percutaneous dilational tracheostomy

BACKGROUND: An extensive posterior-lateral longitudinal tracheal laceration is an uncommon but serious complication of percutaneous dilational tracheostomy (PDT). We report the successful management of three ventilator-dependent patients whose percutaneous tracheostomy was complicated by an extensive longitudinal posterior-lateral tracheal laceration requiring operative repair. METHODS: A retrospective review of 134 cases of PDT with concurrent bronchoscopy was performed between April 1997 and July 1999 and compared with a review of 124 cases of open tracheostomy. Tracheal lacerations were primarily repaired and augmented with intercostal muscle pedicle buttress. RESULTS: Three cases of an extensive posterior-lateral longitudinal tracheal laceration that required operative repair were reported in the PDT group. None were reported in the open tracheostomy group. The 3 patients were managed with an adult high-frequency oscillating ventilator or pressure control ventilation during the postoperative period to limit barotrauma, and all healed without evidence of tracheal leak or stenosis. CONCLUSIONS: The increasing popularity of PDT, particularly among nonsurgical disciplines, may generate an increasing number of complications requiring operative attention. Thoracic surgeons need to be cognizant of the pitfalls of PDT technique and be prepared to manage these difficult clinical scenarios.     

Upper airway sequelae in burn patients requiring endotracheal intubation or tracheostomy.

During a period of 11 1/2 months, 41 of 217 adult burn patients admitted to the U.S. Army Institute of Surgical Research Burn Center required endotracheal intubation or tracheostomy for management of the airway and/or ventilatory assistance. Permanent upper airway sequelae were recorded and related to presence of inhalation injury, duration of tube placement, cuff pressure, and pulmonary compliance. An "inhalation injury scoring system" based upon history, physical examination, bronchoscopic findings, and abnormalities at 133xenon lung scan correlated well with postinjury alteration in compliance and subsequent sequelae. Significant inhalation injury was found in 35 patients. Seventeen of the study patients survived (Group I) and 24 patients expired (Group II). Group I patients were screened for permanent airway sequelae by fiberoptic bronchoscopy, xeroradiograms, and spirometry undertaken an average of 11 weeks after extubation or decannulation. Four patients developed tracheal stenosis and five patients had significant tracheal scar granuloma formation. Sequelae were generally more frequent and more severe after tracheostomy than after translaryngeal intubation, and duration of tube placement and presence of a tracheal stoma were the most important etiological factors in permanent damage. For initial respiratory support, we favor the use of translaryngeal (nasotracheal) tubes for periods up to 3 weeks. Fiberoptic bronchoscopic examination is the most reliable follow-up method for detecting anatomic damage in such patients. Spirometry can be used as a noninvasive screening test and xeroradiograms are helpful in assessing the degree of tracheal stenosis.     

Tracheostomy timing in traumatic spinal cord injury

The study conducted is the retrospective study and the main objective is to evaluate the benefits and safety of early versus late tracheostomy in traumatic spinal cord injury (SCI) patients requiring mechanical ventilation. Tracheostomy offers many advantages in critical patients who require prolonged mechanical ventilation. Despite the large amount of patients treated, there is still an open debate about advantages of early versus late tracheostomy. Early tracheostomy following the short orotracheal intubation is probably beneficial in appropriately selected patients. It is a retrospective clinical study and we evaluated clinical records of 152 consecutive trauma patients who required mechanical ventilation and who received tracheostomy. The results show that the early placement (before day 7 of mechanical ventilation) offers clear advantages for shortening of mechanical ventilation, reducing ICU stay and lowering rates of severe orotracheal intubation complication, such as tracheal granulomas and concentric tracheal stenosis. On the other hand, we could not demonstrate that early tracheostomy avoids neither risk of ventilator-associated pneumonia nor the mortality rate. In SCI patients, the early tracheostomy was associated with shorter duration of mechanical ventilation, shorter length of ICU stay and decreased laryngotracheal complications. We conclude by suggesting early tracheostomy in traumatic SCI patients who are likely to require prolonged mechanical ventilation.     

Complete upper airway obstruction during awake fibreoptic intubation in patients with unstable cervical spine fractures

PURPOSE: To describe the presentation and management of complete upper airway obstruction with life threatening arterial oxygen desaturation that occurred during attempted awake fibreoptic intubation in two patients presenting with unstable C-spine injury. CLINICAL FEATURE: Complete upper airway obstruction occurred during awake fibreoptic intubation of two men (ASA II; 68 & 55 yr old) presenting with unstable C-spine fractures. In both cases, bag and mask ventilation with CPAP failed to relieve the progressive hypoxemia. A surgical airway was established urgently to oxygenate the two patients who were suffering progressive life-threatening oxygen desaturation. One patient had trans-cricothyroid jet ventilation performed through a 16G intravenous cannula prior to an urgent tracheostomy. In the other patient, an emergency tracheostomy was inserted. Interestingly, both patients had been sedated in the Neurosurgical Intensive Care Unit with morphine and benzodiazepines before their scheduled surgeries. The most likely etiology for the complete upper airway obstruction was laryngospasm due to inadequate topicalization of the airway and additional sedation given in the operating room. Neither patients suffered any new neurological deficits following these events. They went on to have uneventful surgeries. CONCLUSION: This case report suggest that prior to awake fibreoptic intubation, oxygenation, adequate topicalization with testing to verify the lack of pharyngeal and laryngeal responses and careful assessment of sedation levels in the operating room are prudent for a safe endoscopic intubation.     

Cricothyroidotomy: a short-term measure for elective ventilation in a patient with challenging neck anatomy

Cricothyroidotomy is a well established technique of airway management in emergency situations where translaryngeal intubation cannot be achieved. This case report describes a case where cricothyroidotomy was used for elective ventilation for short period of 48 hours in a patient who had a vocal cord palsy, supraglottic oedema and inflammation. Surgical tracheostomy was considered the preferred option, but this was deemed impossible due to the challenging neck anatomy in this case.     

Prolonged tracheal intubation in the trauma patient

Over a 15-month period, 74 trauma patients who were expected to require extended intubation were studied prospectively to evaluate the appropriateness of tracheostomy. Patients were randomized to receive either early (34) or late (40) tracheostomies. The patients also were grouped to determine the difference of early versus late tracheostomy on the development of laryngotracheal pathology and respiratory infections; length of intubation and type of patient injury were studied as possible differential factors. Fifteen per cent (11/74) of the patients developed major laryngotracheal pathology as identified by endoscopy, and respiratory infections developed in 54% (40/74), but there was no significant difference in the complication incidence between the early and late tracheostomy groups. Significantly more complications occurred in rigid-posture, head-injured patients than in any other trauma grouping, but there was no significant difference in the complication incidence between the two tracheostomy groups within that classification. We conclude that patients can undergo translaryngeal intubation for up to 2 weeks without significantly increasing complications relative to transtracheal intubation.     

An unusual aspect of tracheal stenosis. Case report

lnjury of the tracheal mucosa at the decubitus site of the endotracheal tube cuff during prolonged endotracheal intubation and resulting fibrin deposits may predispose for the development of tracheal stenosis. Frequent endoscopic control examinations, following the increased use of dilation tracheostomy techniques, have revealed a considerable number of these once misrecognized complications in laryngeal and tracheal structures alike. The case reported here appears to confirm this sequence of events. Timely operative endoscopy using a pair of pincers mounted on a rigid endoscope permitted the removal of the fibrin membrane causing the tracheal lumen stenosis and allowed us to achieve complete and definitive recalibration of the trachea, with restoration of spontaneous breathing. Cortisone therapy prolonged for 5 days probably prevented recurrence of the stenosis. Follow-up was carried out in 3 phases. The 1(st) phase included early control using tracheal endoscopy; 2(nd) comprised neck CT scan to examine the tracheal lumen 15 days after endoscopic control, and the 3rd phase involved medical examination after about 3 months and neck radiography in 2 projections.     

Reconstruction after mediastinal tracheostomy

Mediastinal tracheostomy has been associated with high morbidity and mortality, often due to skin necrosis, with resultant exposure of the great vessels and subsequent hemorrhage. During a 4 year period, 11 patients underwent mediastinal tracheostomy. Reconstruction included the use of a pectoralis major musculocutaneous flap to provide well-vascularized skin for anastomosis to the superior portion of the tracheostoma in nine patients. Whenever possible (eight patients), the trachea was transposed below the innominate artery to allow for slightly more mobility of the trachea and to remove the cartilaginous portion of the trachea from the artery. Among the eight elective operations reported herein, there were no postoperative deaths and only two minor wound-related complications. Among three patients who underwent emergency mediastinal tracheostomy, two patients died, one with an aneurysm of the innominate artery that ruptured several weeks postoperatively and the other with respiratory instability who could not be weaned from the respirator. These results suggest that use of the pectoralis major musculocutaneous flap and tracheal transposition decreases the risk of skin necrosis and resultant major vessel rupture. We advocate this approach in the reconstruction of the patient who requires mediastinal tracheostomy.