Accuracy of finger-tip palpated tracheostomy tube cuff pressure readings among otolaryngologists

The tracheal mucosa is very a delicate structure, and pressure-ischaemia problems following the use of cuffed tracheostomy tubes are well documented. Iatrogenic tracheal stenosis is one of the consequences of mucosal ischaemia and is very difficult to treat. In this study the accuracy of finger-tip tested tracheostomy tube cuff inflation pressure, as judged by consultants and non-consultants, was assessed by comparison with manometric pressure readings. The estimated pressure readings from the consultant group were more accurate than those from the non-consultant group, but a high standard deviation and very big difference between low and high readings in both these groups showed the real extent of the problem. Participants who performed 10 or more tracheostomies a year obtained more accurate results. No definite correlation was observed between the readings and the experience of the participants in otolaryngology or the size of the tube used. The authors recommend that instrumental monitoring of cuff pressure be considered good practice among junior otolaryngologists.     

Canine model of subglottic stenosis secondary to prolonged endotracheal intubation

Acquired subglottic stenosis is usually a consequence of prolonged endotracheal intubation. The present study describes a canine model of subglottic stenosis which is congruent with the known and suspected pathogenesis of the disease in man. Eighteen young pups (Canis familiaris) were used. A modified cuffed endotracheal tube was placed within the subglottis and secured by inflating the cuff. The capillary tube supplying the cuff was sealed and cut so as to lie below the epiglottis. Three animals died of tracheal rupture or collapse prior to or on the thirteenth day following intubation. In the remaining animals, the cuffed tube was removed and the subglottis was examined. All exhibited ulcerations and exuberant polyploid granulations at the level of the subglottis and trachea. A 4 mm uncuffed endotracheal tube was introduced and secured within the subglottis and trachea of a number of the pups to provide an airway. After a 3-week period, the tube was removed and the dogs were sacrificed. Examination of the specimens showed various degrees of “hard” cicatricial stenosis of the subglottis and trachea. Histologic studies showed destruction of the cartilage with replacement by scar tissue and partial epithelialization. This model may be useful to investigations of the prevention and treatment of the disease.     

Resection of tracheal stenosis with end to end anastomosis

The aim of the study was evaluation of early results of tracheal resection with end to end anastomosis. Tracheal resection was performed in 5 patients with tracheal stenosis resulting from prolonged intubation. Three patients were admitted without tracheostomy, in two patients tracheostomy was performed in another hospital. Diagnostic tracheoscopy was performed in all the patients and the tracheal stenosis was found in a distance of 2.5-4 cm from the vocal cords. The diameter of stenosis was 1-4 mm, and the length of stenosis was as long as 3-5 cartilages of trachea. Three cartilages were resected in one patient, 4 cartilages in two patients and 5 cartilages in two patients. End to end anastomosis was performed using absorbable sutures (Vicryl 2-0). The intubation tube was removed just after the surgery. Four patients had no complication after the operation and one patient had temporary subcutaneous emphysema in the neck. For 4-11 months follow up after operation all the patients have had good breathing. Tracheal resection with end to end anastomosis is effective method of treatment of tracheal stenosis.     

Tracheo-graft fistulae following pharyngo-laryngo-oesophagectomy. A cause and its prevention.

Tracheo-graft fistulae developed in two patients who required intermittent positive pressure ventilation and intubation with conventional cuffed tracheostomy tubes following resection of post-cricoid carcinomata by pharyngolaryngo-oesophagectomy. Pressure necrosis of the posterior tracheal muscle and the anterior wall of the graft occurred as a direct result of compression of these structures between the tracheostomy cannula and air cuff, and the vertebral bodies at the thoracic inlet. This post-operative complication has not been encountered in subsequent resections since the introduction and routine use of a modified cuffed tracheostomy tube. The adjustable neck plate guards against trauma to the tracheostome, inadvertent intubation of one of the major bronchi in each individual patient and the siting of the cuff beyond the thoracic inlet. Unintentional over-inflation of air cuffs remains a hazard whereas only ambient air re-expands the foam cuff. This property of the cuff also ensures against surgical injury to the posterior tracheal wall during the operation. Pressure necrosis of the posterior tracheal wall by the main tracheostomy cannula is minimised by suitably modifying the curvature and length of the cannula for use in patients with end-tracheostomies.     

Association of Oversized Tracheal Tubes and Cuff Overinsufflation With Postintubation Tracheal Ruptures

Objectives

Postintubation tracheal ruptures (PTR) are rare but cause severe complications. Our objective was to investigate the tracheal pattern of injury resulting from cuff inflation of the tracheal tube, to study the two main factors responsible for PTR (cuff overinsufflation and inapplicable tube sizes), and to explain the context, why small women are particularly susceptible to PTR.

Methods

Experimental study performed on 28 fresh human laryngotracheal specimens (16 males, 12 females) within 24 hours post autopsy. Artificial ventilation was simulated by using an underwater construction and a standard tracheal tube. Tube sizes were selected according to our previously published nomogram. Tracheal lesions were detected visually and tracheal diameters measured. The influence of body size, sex difference and appropriate tube size were investigated according to patient height.

Results

In all 28 cases, the typical tracheal lesion pattern was a longitudinal median rupture of the posterior trachea. Appropriate tube sizes according to body size caused PTR with significantly higher cuff pressure when compared with oversized tubes. An increased risk of PTR was found in shorter patients, when oversized tubes were used. Sex difference did not have any significant influence.

Conclusion

This experimental model provides information about tracheal patterns in PTR for the first time. The model confirms by experiment the observations of case series in PTR patients, and therefore emphasizes the importance of correct tube size selection according to patient height. This minimizes the risk of PTR, especially in shorter patients, who have an increased risk of PTR when oversized tubes are used.     

Fistula between the trachea and innominate artery--a rare complication following tracheostenosis treatment with silastic tubes

BACKGROUND: Fistulas between the trachea and innominate artery are rare but devastating complications that usually occur following tracheotomies. METHODS: One case a fistula after long-term treatment of a tracheal stenosis with an Montgomery silastic tube was analyzed. A literature review of the different strategies in diagnosis and treatment of this complication was undertaken. RESULTS: In the present case, the fistula occurred after long-term treatment of tracheal stenosis with silastic tubes (Montgomery). Summarizing our experience with this case and a review of the literature, it can be concluded that: Fistulas most frequently occur following tracheostomy or tracheal reconstructive surgery. Frequent bronchoscopic examination during long-term treatment of tracheal stenosis with silastic tubes is essential. Even minor tracheal hemorrhage in such cases must be thoroughly examined. In case of fistula hemorrhage, the most effective treatment consists of direct local compression, best obtained with a well placed respiration tube. CONCLUSION: Fistulas between the trachea and innominate artery constitute a rare but possible complication after tracheal stenosis treatment.     

New design of a tracheostomy-cricothyroidostomy tube

In an attempt to minimize late airway stenosis, a new tube with an oval cross-section has been developed. Two to three tracheal cartilage arches are usually incised anteriorly, partially excised or inadvertently broken to fit a tracheostomy tube. The risk of post-tracheostomy stenosis seems to be greater when several cartilages have been involved. If an oval tube with the shortest diameter in its symmetry plane is used, the tissue defect along the longitudinal axis of the trachea will be shorter than that caused by a round tube. When such a stoma is healing, the adjacent intact tracheal cartilages, which are located fairly close to each other, will support the bridging scar tissue, thereby preventing collapse of the tracheal wall. The tubes come in three lengths to fit most neck sizes. An oval trial tube with the same length as the shortest one has been used for cricothyroidostomy--the aim being to spread the cricoid and thyroid cartilages apart as little as possible. A series of 23 patients were treated with this tube. At follow-up, no stenosis was found at flexible fiberoptic laryngo-tracheoscopy. Fifteen patients reported no voice change, and five, who were singers, experienced lower pitch, but four of them were still singing. None of these five patients had speech problems. The other three patients had voice problems when speaking. One of these had chronic bronchitis and another had had a stroke. The third one had a rough voice. The voice problems were milder than those reported from previous series.     

The use of tracheostomy T-tube in the treatment of tracheal stenosis

The aim of the study was evaluation of the use of tracheostomy T-tube in patients with tracheal stenosis. The advantages of closed T-tube over open tracheotomy are: 1/ normal breathing through the nose, 2/ normal speech without necessity to close the tube with a finger, 3/ no spitting during cough. Silicone tracheostomy T-tube was used in 12 patients with tracheal stenosis. The stenosis resulted in 7 patients from prolonged intubation, in 4 patients from defective tracheostomy and in one patient from failure of tracheal resection. In all the patients rigid tracheoscopy and/or flexible bronchoscopy revealed the length of the stenosis and the distance from vocal cords. T-tube was placed under local anesthesia. The patients used to wear closed T-tube from 1-12 years. The tube was exchanged every 2-4 years. The only adverse effect was recurrent granulation around tracheostomy in two patients. 7 of 12 patients were decannulated with good result in 3 months - 5 years follow up. In two decannulated patients stenosis recurred. One patient was retracheostomized and in another patient stenosis was resected with end to end anastomosis. Three patients were not decannulated. Tracheostomy T-tube can be used temporary in patients with tracheal stenosis before planned stenosis resection or as a sole treatment with good chances for successful decannulation. When stenosis resection is not possible, T-tube can be placed for long time.     

Airway complications in patients with closed-head injuries

The neurologic deficits in the closed-head injury population present special problems when managing the airway. Many of these closed-head injury patients require long-term intubation with endotracheal tube or tracheostomy to treat their central respiratory problems and control oral and pulmonary secretions. Four hundred sixty-seven closed-head injury patients were seen over a five-year period. Seventy-two of these patients required long-term endotracheal intubation, tracheostomy, or both. A prospective study by direct endoscopic examination prior to decannulation showed 23 of these 72 patients (32%) had important laryngeal or tracheal findings. The principal abnormalities observed were vocal cord paralysis, tracheal stenosis, subglottic stenosis, glottic stenosis, and tracheomalacia. This study suggests also that severely mentally impaired patients (cognitive function II and III) should retain their tracheostomy because of the high morbidity and mortality among these patients (31%) when they are decannulated. This mortality was directly related to poor pulmonary toilet, with pneumonia and sepsis being the major causes of death. This study did not show that the use of steroids or ventilators in the initial management adversely effected airway complications.     

A case of idiopathic tracheal stenosis

Idiopathic tracheal stenosis (ITS) is an extremely rare disease. We report the case of a 32-year-old woman with ITS. She had no history of previous surgery, endotracheal intubation, neck trauma, granulomatous disease, or any other severe respiratory tract infections. She presented with progressive dyspnea on effort and had been treated for bronchial asthma for 3 years. Chest radiography and laboratory examinations revealed no abnormalities. Bronchoscopy demonstrated almost circumferential tracheal stenosis extending for 10 mm from about 20 mm below the vocal cords. Luminal diameter was about 4 mm at the narrowest. Bronchoscopic biopsy revealed increased fibrous tissue and chronic inflammatory cell infiltration (nonspecific inflammatory tissue). These finding are compatible with idiopathic stenosis as reported by Grillo et al. After tracheostomy, the patient was treated by tracheal segmental resection (two rings) with end-to-end anastomosis of the cartilaginous trachea. Symptoms of tracheal stenosis were completely relieved and no recurrence has been observed as of 3 years postoperatively.     

Subglottic stenosis following percutaneous tracheostomy: a single centre report as a descriptive study

Tracheal stenosis is a potential complication of tracheostomy. The present study aimed to describe the epidemiologic profile of subglottic stenosis in a referral medical centre. During a 4-year period, all patients who had been admitted in an Intensive Care Unit of Imam Khomeini Hospital (affiliated to Tehran University of Medical Sciences) and had undergone percutaneous tracheostomy during 7-10 days after endotracheal intubation were enrolled in the study. After removing the tracheostomy tube, patients were evaluated regarding development of tracheal stenosis using fiberoptic bronchoscopy and multi-slice computed tomography scan. During the study period, percutaneous tracheostomy was performed in 140 patients with a mean age of 38 years. Overall 54 patients died due to the severity of the disorder during hospitalization. In the remaining 86 patients, 54 cases needed permanent or long-term mechanical ventilation and were excluded from the study. Twelve patients died during the first 3 months and 20 patients were left for final assessment. Multi-slice computed tomography scan imaging showed subglottic stenosis in 17 cases (85%). Of these, 9 patients (52%) had tracheal stenosis of < 50%. Tracheal stenosis of 25- 40% was found in 5 cases (25%). Patients in whom the tracheostomy tube had been removed in the first 3 weeks after tracheostomy did not present tracheal stenosis (n = 3, 15%). The present study revealed that subglottic stenosis is frequent in patients who have undergone percutaneous tracheostomy in the Intensive Care unit setting. However, the stenosis is generally mild and is not associated with serious and/ or life-threatening clinical manifestations.     

Factors associated with staged reconstruction and successful stoma closure in tracheal resection and end-to-end anastomosis

BACKGROUND: By analyzing the rate of successful decannulation in patients who underwent tracheal resection and end-to-end anastomosis, we tried to find the factors affecting the surgical outcome of tracheal stenosis. We also tried to discover the factors affecting the need for staged reconstruction. DESIGN AND SETTING: Retrospective study in a tertiary care center. PATIENTS: From 1988 to 2001, 117 tracheal resections and primary end-to-end anastomoses in 110 patients were carried out. The statistical analysis was done from the data of 81 patients in whom the stenosis was caused mainly by internal trauma such as long-term intubation or tracheostomy. MAIN OUTCOME MEASURES: The success of surgery was defined as successful stoma closure; staged reconstructions were defined as cases in which the stoma was left open intentionally during the end-to-end anastomosis. RESULTS: The stoma could be successfully closed primarily in 67 (83%) of the 81 cases, and staged reconstructions were needed in 22 (26%) of the patients. Older patients (>60 years) and patients with a higher grade of stenosis showed a significantly lower success rate. Staged operations were more frequently needed in cases with total stenosis and with combined stenosis of the trachea and the subglottis. CONCLUSIONS: In patients older than 60 years or with severe stenosis, the rate of successful stoma closure was low. A staged operation should be considered in cases with severe stenosis or stenosis not confined to the trachea.     

End-to-end anastomosis in chronic tracheal stenosis

Objective: This study assessed the efficacy and safety of end-to-end anastomosis of the trachea following segmental resection in chronic tracheal stenosis. Methods: End-to-end anastomoses of the trachea were performed in 35 patients with chronic tracheal stenosis; 18 patients with tracheal invasion of thyroid cancer and 17 patients with long-term intubation and blunt injuries of the trachea. Results: All operations were successful, except one whose unilateral recurrent nerve had not been identified in the recurrent thyroid cancer invasion with trachea. Conclusion: This operation provides a one-step cure for the stenosed trachea and can be applied to the resection of less than six tracheal segments.     

Down syndrome: analysis of airway size and a guide for appropriate intubation

OBJECTIVES/HYPOTHESIS: The purpose of this study is to prospectively evaluate the airway size of children with Down syndrome (DS). Previous studies have observed an increase in postintubation stridor in children with DS. Anesthetic literature suggests using a smaller endotracheal tube in children with DS, but more specific recommendations are not offered. With this study, recommendations are presented for the appropriate endotracheal tube size to use in children with DS undergoing intubation. STUDY DESIGN: A prospective, nonrandomized study was performed on a cohort of 42 children with DS and 32 control subjects. Sizing of the airway was assessed through measurement of an air leak around the endotracheal tube at intubation. The size of the airway was also evaluated through measurements of the tracheal diameter at the "tracheotomy point" on magnetic resonance imagine (MRI) studies of the head and neck which were performed on a group of children with DS. These were compared with normative values of the tracheal diameter in children. METHODS: The proper size of endotracheal tube in a population of children with DS and in a group of normal controls was determined. The "proper size" of an endotracheal tube was defined as that size of tube which allowed an audible air leak around the tube between 10 and 30 cm of H2O pressure. Anesthetic technique was controlled and identical for all study subjects. Participants had no previous history of airway compromise, stridor, or previous intubation. Weight and age were recorded and evaluated for their influence on the results. A retrospective evaluation was made of MRI studies of the neck that were performed on children with DS. Using measurement techniques described by Reed et al., the tracheal diameters at the "tracheostomy point" were compared with normative values for children. Measurements were both obtained by the author and confirmed by a pediatric radiologist. RESULTS: Using this prescribed method to determine the proper size of endotracheal tube, the control group used endotracheal tubes that were predicted from established anesthesia charts and formulas. However, children with DS required endotracheal tubes at least two sizes smaller. Age was found to be a more reliable factor in predicting the endotracheal tube size. A table of endotracheal tube sizes for intubation in children with DS is presented. Evaluation of the tracheal diameter at the tracheotomy point revealed that children with DS have a smaller trachea when compared with control children. It is not only the subglottis that is smaller; the tracheal diameter as well must be assumed to be of a smaller diameter in children with DS. CONCLUSIONS: Children with DS have smaller airways than other children. This is because of an overall decrease in the diameter of the tracheal lumens. Initial intubation of a child with DS should be performed with an endotracheal tube at least two sizes smaller than would be used in a child of the same age without DS, to avert potential trauma to the airway.     

Tracheal stenosis: conservative surgery as a primary mode of management

Tracheal and laryngeal stenosis has become increasingly common following prolonged intubation or tracheostomy for mechanical ventilation and is directly related to trauma. Tracheal resection up to 4 to 5 cm. with an end to end anastomosis is the generally accepted treatment. However, tracheal resection carries the danger of mortality and considerable morbidity. From 1974 to 1979 all patients in our series with tracheal stenosis, even with laryngeal involvement, regardless of etiology and age were intiially treated by conservative surgical management consisting of dilation, severance of the stenotic ring, intralesional injection of triamcinolone acetonide, and stenting with a silicone T tube for 90 days. Sixteen of 19 patients obtained good results and enjoy an adequate airway without a tracheostomy tube. The longest follow-up period was five years and the shortest, six months. Intralesional injection of triamcinolone acetonide is essential for successful treatment. No mortality or serious complications resulted from this treatment. Our experience indicates that patients with tracheal and laryngeal stenosis should undergo a primarily conservative surgical management. This technique appears worthy of trial prior to contemplating a more extensive procedure.     

Peristomal complications of paediatric tracheostomy.

Failure of decannulation after paediatric tracheostomy, once the underlying disorder has resolved, is almost always due to peristomal complications. Granulation tissue formation in the raw tissue of the stoma and its subsequent fibrosis requires removal (50 of the 293 tracheostomies from the Red Cross War Memorial Children's Hospital). It is suggested that this can be avoided by creating a formal skin-to-trachea stoma at the time of tracheostomy. Suprastomal depression of the anterior wall of the trachea (52/293) appears to be unavoidable when using standard tracheostomy tubes. Localised stomal site tracheomalacia and stenosis (numbers of this complication are unknown) results from damage to cartilage of the trachea either by incision or by necrosis from pressure of the tracheostomy tube. Trauma to the cartilage needs to be minimised by careful design of the tracheal incision. It is suggested that consideration should be given to creating a formal tracheostomy stoma for any paediatric tracheostomy that is likely to be required for more than a short period of time.     

Cuff induced tracheal injury in dogs following prolonged intubation

As the newer high volume low pressure endotracheal tube cuffs have replaced the high pressure cuffs commonly used in the past, there has been a marked decline in the incidence of severe complication due to cuff injury. Studies have shown, however, that the respiratory epithelium of the trachea at the cuff site undergoes squamous metaplasia following prolonged intubation with low pressure cuffs. An experimental model utilizing the canine trachea has been developed to study cuff induced squamous metaplasia and the present study was undertaken to determine the effect of the induced squamous metaplasia on tracheal mucous velocity as well as to determine whether the induced epithelial changes are reversible following removal of the cuffed tube.     

Ballooned trachea caused by cuffed tracheostomy tube

Despite the dramatic decrease in cuff-related complications with the introduction of high-volume low-pressure devices for intubation and tracheostomy, notable problems can still occur. A case is reported of a patient who developed persistent dilatation of the trachea after prolonged mechanical ventilation. This is an under-recognized, life threatening clinical entity occurring after cuffed intubation for prolonged time. At present there is no definitive treatment regarding the management of a dilated trachea on a ventilator-dependent patient and therefore emphasis is directed at prevention. The patient presented was managed with periodical alterations of the cuff level which although not achieving any reversal of the dilatation, have prevented further progression of tracheal damage. During the follow-up period, regular assessment with flexible endoscopy has provided more reliable information on the condition of the trachea than computed tomography (CT) scanning.     

Glottic and subglottic stenosis from endotracheal intubation

As a result of increased use of prolonged endotracheal intubation, complications of intubation are now being seen more often. Stenosis of the airway may develop at the level of the glottic or subglottic larynx, or in the trachea. Discussions of management do not always distinguish clearly between laryngeal stenosis and tracheal stenosis. Yet, these are two separate entities. Discussions of laryngeal stenosis usually deal with subglottic stenosis, with less emphasis on obstruction at the glottic level. Of 20 patients, 14 adults and six children, with stenosis of the larynx secondary to intubation, we were successful in establishing adequate airways in 16. An analysis of these 20 patients leads to the following conclusions:

• 1 Scarring in the glottic posterior commissure between the arytenoid cartilages is a frequent cause of laryngeal stenosis after intubation.
• 3 Endoscopic management can be successful in many cases if it is started early enough, and repeated as often as is necessary. The earlier it is begun, the better the results will be.
• 3 Indwelling stents which are extremely valuable in laryngeal stenosis from external trauma, may not be as useful in stenosis from endotracheal tube trauma.

     

Airway salvation after failed anterior graft in a child with long segment stenosis

Objectives

1-Recognize difficulties and review techniques in long-segment laryngotracheal stenosis repair. 2-Contribute to increasing clinical and surgical skills in pediatric airway reconstruction through reporting our experience with a novel reconstruction technique involving use of a failed anterior graft and prolonged postoperative stenting.

Methods

Case report: 10 year old male with history of burn injury who required a tracheostomy due to prolonged intubation/inhalational injury in 2005. Subglottic/tracheal stenosis was identified and he subsequently underwent anterior costal cartilage grafting involving the thyroid cartilage, cricoid cartilage, and trachea. He remained tracheostomy dependent for six years due to failed graft and postoperative complications despite several attempts to improve the airway with CO2 laser and balloon dilation. In 2011, preoperative CT with 3D reconstruction revealed a 32 mm long segment of complete stenosis. The patient underwent suprahyoid release and single stage reconstruction with cricotracheal resection and partial preservation of the anterior costal cartilage graft found in the luminal scar tissue.

Results

Postoperatively the patient was stented with a nasal endotracheal tube for 2 weeks. Bronchoscopy showed mild tracheal collapse inferior to the site of anastamosis and granulation tissue at the site of anastomosis. Granulation tissue was removed and the subglottic anastomosis site was stented with a 2 cm Dumon stent for 6 months.

Conclusion

The problem of long segment stenosis after failed cartilage graft reconstruction of the airway is evaluated and a novel technique of laryngotracheal reconstruction involving a pre-existing failed anterior graft and short segment stenting is described.