Saudi Journal of Otorhinolaryngology Head and Neck Surgery

ORIGINAL ARTICLE
Year
: 2001  |  Volume : 3  |  Issue : 1  |  Page : 11--15

Tracheostomy in ICU patient at al adan hospital a six years retrospective study (from Jan 1st 1994 to Dec 31st 1999)


Hussein J Al Shammari1, Jamal M Alharbi2, Vladimir Sykora3, Adel R Butros3,  
1 Department of ENT, Al Adan Hospital, Kuwait
2 Department of ENT, Al Sabah Hospital, Kuwait
3 Department of Anasthesia and ICU, Al Adan Hospital, Kuwait

Correspondence Address:
MD Hussein J Al Shammari
Al Shammari, Department of ENT AI Adan Hospital, P.O. Box 1605, 40167 Mishref
Kuwait

Abstract

Objective: To study the clinical data related to tracheostomy in ICU patients and the recommended methods to get its benefits with the highest margin of safety. Settings: ICU, AI Adan Hospital. State of Kuwait. Patients and methods: A retrospective study reviewing the files of the recorded trachcostomised ICU patients during a 6 years period from January 1st 1994 to December 31st 1999. The patient, ventilation and tracheostomy related data were collected and analyzed. Results: The recorded number of the trachcostomised ICU patients during the study period were 181, i.e. the ICU & population annual mean were 30.1 and 7.5/100 000 respectively and the male to female ratio was 2:1. Road traffic accidents with head injury was the commonest tracheostomy indication in young age groups specially males, while cere- brovasacular accidcnts and chronic obstructive airway disease were the commonest tracheostomy indications among the old age group patients. In comparison to the total, the number of 61-80 years age group patients constituted the highest percentage (33.5%) followed by 21-40 years age group (25.4%). This study revealed that duration of the pre-tracheosto- my endotracheal intubation is relatively short (mean 10.5 days). All tracheostomies were elective and performed under general anaesthesia where patients were in their optimal medical conditions. One hudred sixty tracheostomies were performed in the operation theater, while the remaining 20 were performed at bedside. One hundred sixty three tracheostomies were performed by the classic surgical technique while the remaining 18 were performed by percutaneous dilatation technique. The all over tracheostomy related complications incidence was 12.5%. Conclusion: Road traffic accidcnts was the commonest tracheostomy indication among patients below 40 years specially males, while ccrebrovasacular accidents and chronic obstructive airway disease were the commonest tracheostomy indications in-patients above 40 years. Although tracheostomy has many benefits but is not an absolutely safe procedure. All efforts, such as optimizing the prc-opcrativc patients condition, meticulous surgical techniques, close postoperative observation, care of tracheostomy wound, frequent cuff pressure adjustment to get its benefits with the highest margin of safety, should be made.



How to cite this article:
Al Shammari HJ, Alharbi JM, Sykora V, Butros AR. Tracheostomy in ICU patient at al adan hospital a six years retrospective study (from Jan 1st 1994 to Dec 31st 1999).Saudi J Otorhinolaryngol Head Neck Surg 2001;3:11-15


How to cite this URL:
Al Shammari HJ, Alharbi JM, Sykora V, Butros AR. Tracheostomy in ICU patient at al adan hospital a six years retrospective study (from Jan 1st 1994 to Dec 31st 1999). Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2001 [cited 2021 Jun 25 ];3:11-15
Available from: https://www.sjohns.org/text.asp?2001/3/1/11/289351


Full Text



 Introduction



Historically tracheostomy has been known since ancient times as evidenced by Abydos & Sakara ( 3600 BC) engravings in Egypt.[1] Although both endotracheal intubation and tracheostomy for respiratory support of critically ill patients are a life saving procedures, tracheostomy -offers several benefits over long term endotracheal intubation. The lower airway resistance facilitates easy weaning from the ventilator, decreases dead space, less movements of the tube within the trachea, greater patient comfort, the ability to provide oral feeding, more efficient suctioning, the ability to speak and a more secure airway,[2] The reported tracheostomy surgical technique, location of surgery, type of anesthesia used, incidence and forms of tracheostomy complications varies from country to country and from hospital to hospital.[3],[4].[5] The literature reveals a marked variations in tracheostomy indicating incidences. These incidences are influenced by age and sex beside the surgical and medical indications for tracheostomy.[5],[6],[7]. The aim of this work was to study the clinical data related to tracheostomy carried out upon ICU patients in Al Adan Hospital, Kuwait and the recommended beneficial methods with the highest margin of safety.

 Patients and Methods



A six years (from January 1st 1994 to December 31st 1999) retrospective study was carried out by reviewing the files of ICU patients who were subjected to tracheostomy at A1 Adan Hospital, A1 Ahmadi Health Region, State of Kuwait. The hospital provides medical health service to a population of 420,000 people. The tracheostomised patients file were reviewed and patients, ventilation and tracheostomy related data were collected and analyzed. The following data were recorded :the commonest age group, sex, indications, surgical technique, type of anesthesia, location of surgery, tracheostomy complications beside the average onset of weaning from ventilator after tracheostomy and condition of tracheostomised patients on discharge from ICU.

 Results



Our study consisted of 181 of ICU patients who underwent tracheostomy during a 6 years study. Their age ranged from 3-95 years. One hundred twenty four were males and 57 were females with a male to female ratio of 2:1 [Table 1]. Head injury due to road traffic accidents (RTA) was the principle indication (23%) for tracheostomy. It was followed by cerebrovascular accidents (CVA) (21%), chronic obstructive airway disease (COAD) (14%), post cardiac arrest (13%), polytrauma due to RTA (11%), other less common medical indications (as drug overdose, meningitis, encephalitis, medias- tinitis) (10%) and fall from height (8%). Tracheostomy for medical patients (105) was more than that for surgical patients (76 patients) while CVA was the commonest medical indication and head injury due to RTA was the commonest surgical indication.[Table 2]{Table 1}{Table 2}

According to the incidence of the tracheostomy and the male to female ratio among the various age group, the 61-80 years old age group constituted the highest percentage (33.5%) followed by 21-40 years (25.4%), 41-60 years(24.5%), 1-20 years (15%) and 81-100 years(4%) years old groups. The male to female ratio was inversely proportional with age i.e. the highest ratio 6:1 is in 1-20 age group and the lowest ratio 1:1 is in 81-100 age group.The incidence of the commonest tracheostomy surgical indications (RTA with head injury and polytrauma) were inversely proportional with age while the incidences of the commonest tracheostomy medical indications are directly’proportional with age. The patients with the commonest surgical indications constitute 70% and 0% of 1-20 and 81- 100 years old group patients respectively. In contrast, patients with the commonest medical indications constitute 100% and 8% of 81-100 and 1-20 years old age group patients respectively. This study also revealed that the duration of endotracheal intubation prior to tracheostomy ranged from 2-57 days (mean=10.52). All tracheostomies were elective and performed under general anesthesia when patients were in their optimal medical conditions. One hundred sixty one tracheostomies were performed in the operation theater, while the remaining 20 were performed at bedside in the intensive care unit. One hundred sixty three tracheostomies were done by classic surgical technique while the remaining 18 were performed by percutaneous dilatation technique. High volume low-pressure cuff tracheostomy tubes were used in all patients. A minimal leak cuff occlusion pressure was used during mechanical ventilation in all patients. The complications related to tracheostomy are shown in [Table 3]. Out of the 181 tracheostomised patients, 166 (91.7%) survived and were transferred from ICU to the wards breathing spontaneously either with metal tracheostomy tube or after closure of the tracheostomy wound. The remaining 15 patients died in ICU. Severe illnesses which were incompatible with life were the cause of death in 14 patients, while failure of airway re- establishment after early accidental tube displacement (tube is pulled out by patient at night) was the cause of death in one 75 years male patient with multiple terminal stage diseases.[Table 3]{Table 3}

 Discussion



Generally, tracheostomy is preferred for any patient who needs a prolonged ventilatory support or prolonged pulmonary toilet because of neuromuscular disease, coma or severely decreased level of consciousness. From this 6 years retrospective study, conducted at A1 Adan Hospital ICU, State of Kuwait, it was found that a total of 181 elective tracheotomies were carried out i.e. the ICU and the population annual mean were 30 and 7.5/100,000 respectively. The overall male to female ratio was 2:1. These detected data are in disagreement with the reported findings of Fadl. [7] A 7.5 years retrospective study period conducted at King Fahad Specialist Hospital -KFSH( Qassim,Saudi Arabia) that provides a medical service to 500,000 inhabitants revealed that 120 elective tracheostomies were carried out i.e. the annual mean and the annual population incidences are 17 & 3.4/100,000 respectively with overall male to female ratio of 3:1.[7] Although both works were carried out in two hospitals providing medical services to people with more or less similar life style, the reported lower tracheostomy rate may be attributed to the relatively more preference of the treating doctor at KFSH to prolonged endotracheal intubation than tracheostomies in comparison with the treating doctors at A1 Adan Hospital. Also, the detected relatively higher female to male ratio 1:2 in comparison to the reported ratio of KFSH (1:3) which is partially attributed to the relatively higher rate of occurrence of RTA injury among females, because in contrast to Saudi Arabia, females in Kuwait State are licensed to drive cars, and partially due to the relatively higher percent of the tracheostomised medical patients especially of older age group in which the female to male ratio is relatively high (about 1:1). The non-dctected emergency tracheostomies of this study is due to the absence of failed intubation which is attributed to the well trained ICU doctors, besides the availability of the equipment that facilitate endotracheal intubation in difficult cases. These equipment are McKoy laryngoscope, Eschmann guide wire and fibro-optic bronchoscopy with trained doctors to use them. This study also revealed that 18 patients were tra- cheomised in ICU, using Cigalia percutaneous dilatation technique[8] without any associated complications. From this study, RTA was the principle indication for tracheostomy especially among the males of young age group, and this is in agreement with Fadl .[7] The reported incidences of tracheostomy complications vary from 6-51% .[3] This incidence is influenced by age, type of tracheostomy (elective or emergency), preceding period of endotracheal intubation and the pre-operativc patient’s condition.Tracheostomies in pacdiatric patients are associated with a significantly higher morbidity and mortality than in adults .[9],[10] The rate of complications with emergency tracheostomy is 2-5 times as high as elective tracheostomy. [ll]The detected lower incidence of tracheostomy complications (12.5%) was attributed to the relatively shorter preceding period for endotracheal intubation (mean 10.5 days), the optimal pre-oper- ative patient condition, absence of emergency tracheostomy and the few paediatric cases (8 cases). Inadvertent tracheostomy tube displacement within the first 5 days after surgery is hazardous because the tracheostomy wound has not yet developed a secure tract .[12] In our hospital, we used a tape to fix the tracheostomy tube, which is the classic method for tube fixation. After the occurrence of the fatal tube displacement in an old male medical patient, the tubes were fixed by suturing their flanges to the skin and we recommend this method. The reported incidence of delayed fatal post tracheostomy hemorrhage is low [13] and it is due to erosion of the major vessels by pressure necrosis from the cuff .[14],[15] During mechanical ventilation intra-cufT pressure must be low enough to allow tracheal capillary perfusion and high enough to prevent loss of tidal volume. Ischaemic damage will occur if cuff to tracheal wall pressure exceeds capillary perfusion pressure (20-30mmHg) for a significant time,[16]The damage include superficial erosion to tracheal perforation resulting in complications such as erosion of blood vessels, tracheal stenosis and tracheo-esophageal fistula. The use of high volume-low pressure cuffed tubes with cuff occlusion pressure below 25mmHg after each inflation or allowing an audible leak during inspiration eliminates a significant tracheal injury. [17],[18] Accidental over inflation of the cull is the main cause of mechanical injury during mechanical ventilation .[17] Even with appropriate management, only 25% of delayed post tracheostomy hemorrhage patients survive,[19]The appropriate management is blood transfusion, median sternotomy with repair of to affected artery .[19]The absence of delayed fatal post-tracheostomy haemorrhage from the detected complications of this study was attributed to the use of high volume-low pressure tube (endotracheal or tracheostomy) with minimal leak cuff occlusion pressure during mechanical ventilation in all patients.The major factor leading to pneumonia is the duration of mechanical ventilation. The incidence of pneumonia is higher in patients with tracheostomies because they arc ventilated for longer than patients with endotracheal intubation are.[20] The risk of nosocomial pneumonia was found to be 66% in patients with tracheostomy and mechanical ventilation with significant higher incidence after the fifth day of therapy. While no cases of nosocomial pneumonia occurred in patients on ventilator for less than 24hr .[21]When patients are placed on a ventilator all defensive mechanisms are circumvented and the alveoli are exposed directly to the outside environment. The prolonged use of mechanical ventilation results in infections of the lungs and tracheobronchial tree .[20] Aspirations, nebulisers, unsterile suction catheters beside the presence of infected pulmonary secretions in critically ill old patients also influence the incidence of tracheostomy pneumonia,[22]Critically ill tracheostomised patients develop more serious pneumonia with enteric gram negative bacilli especially pseudomonas species. [23] The detected relatively lower incidence of tracheostomy pneumonia in this study was attributed to the relatively short mechanical ventilation (10.5 days) after tracheostomy The replacement of the active humidifying method (nebulisers) by the passive one (filters), frequent changing of filters with new sterile ones besides aspiration of pulmonary secretions, dressing of tracheostomy wounds and changing of tracheostomy tubes under strict aseptic techniques also help.Tracheostomy related mortalities arc due to fatal haemorrhage [13],tube dislodgment within the first five post tracheostomy days [12] and severe pneumonia.The mortality rate of this study was 8% (15 patient), 14 patients died due to causes not related to tracheostomy while one old male medical patient died due to failure of reestablishment of airway after accidental dislodgment of the tube.

 Conclusion



This study revealed that at Al Adan Hospital, ICU and the main treating doctors prefer tracheostomy to prolonged endotracheal intubation. This appears from the relatively shorter preceding period of endotracheal intubation (mean=10.5 days) and the relatively high ICU and population annual rates.In general, RTA with head injury and polytrauma is the commonest indication for tracheostomy especially in young age group (below 40 years) with male to female ratio of about 2:1. CVA, COAD and post cardiac arrest are the commonest tracheostomy indications in medical patients especially those of older age of group (above 40 years) with male to female ratio of about 1:1.Although, tracheostomy has several benefits that overcome prolonged endotracheal intubation but this study showed that it is not absolutely safe as it is associated with some related complications. So, all efforts and clinical measurements should be made to get its benefit with the highest margin of safety. These measurements are optimizing the pre-operative patient general condition, meticulous surgical technique, close post-operative observation, care of tracheostomy wound to keep it always dry, frequent adjustment of cuff pressure during mechanical1 ventilation and cuff deflation during spontaneous breathing etc.

References

1Shehata MA. History of laryngeal intubation. Middle East J Anacsth 1981; 6:49-55
2Lewis RJ. Tracheostomies. Clin Chest Med 1992; 13:137-149.
3Dane TEB, King EC. A prospective study of complications after tracheostomy for assisted ventilation. Chest 1975; 76: 398- 404.
4Gary LW, Mark F, Mario V John G. Bedside tracheostomy in the intensive care unit. Arch Surg 1996; 131: 552-554.
5Ubadhyay A, Maurer J,Turner J.Tiszenkel H. Elective bedside tracheostomy in the intensive care unit. J Am Coll Surg 1996; 183:51-55.
6Mark DP,Bernard CF. Safety and efficiency of elective tracheostomy performed in the intensive care unit. J Oral Maxillofac Surg 1995; 53:895-897.
7Fadl AF. Tracheostomy: Seven years hospital experience. The Saudi J Oto-Rhino- Laryngol Head Neck Surg 2000;2:26-28.
8Ciaglia P, Firsching R, Syniec C. Elective percutaneous dilatational tracheostomy: A new simple bedside procedure; preliminary report. Chest 1985; 87: 715-719.
9Orlowski JP, Ellis NG, Amin NP, Crumrinc RS. Complications of airway intrusion in 100 consecutive cases in pediatric FCU. Crit Care Med 1980; 8:324-331.
10Climore BB, Mickelson SA. Pediatric tracheostomy. Controversies in management. Otolaryngol Clin North Am 1986; 19: 141-151.
11Skaggs JA. Tracheostomy management, Mortality and complications. Am Surg 1969; 35: 393-396.
12Gunawaidana R H. Experience with tracheostomy in medical intensive care patients. Postgrad Med J 1992; 68: 338-341.
13Mathog R H. delayed massive hemorrhage following tracheostomy. Laryngoscope 1971; 81: 107-119.
14Carroll R, Hedden M, Safar B. Intratracheal cuffs: performance and characteristics. Anaesthesiol 1969, 31:275-277.
15Cooper JD, Grello HC. The evolution of tracheal injury due to ventilatory assistance through cuffed tubes. Ann Surg 1969; 169: 334-336.
16Nordin U. The trachea and cuff induced tracheal injury. Acta Otoryngol Stokh 1977, (supp 345):7-56.
17Ching NBH, Ayres SM., Spina RC, NealonTF. Endotracheal damage during continuous ventilatory support. Ann Surg 1974, 179:123-127.
18Bernhard WN, Yost L, Joynes D, Cothalis S.Turndof H. IntraculTpressures in endotracheal and tracheostomy tubes related cuff physical characteristics. Chest 1985; 87: 720-730.
19Jones JW, Reynolds M, Hewwitt R.L. Drapans T. Tracheo-innominate artery erosion: Successful surgical management of a devastating complications. Ann Surgl977; 184: 194-204.
20Zwillich CW, Picrson D J, Creagh CE, Sutton FD, Schatz E, Petty TL. Complications of assisted ventilation, A prospective study of 354 consecutive episodes. Am J Med 1984; 57: 161-170.
21Cross AS RoufB. Role of respiratory assistance devices in endemic nosocomial pneumonia. Am J Med 1981;70:681-685.
22El-Nagger M Sadagopan S, Levine H, Kantor H, Collins VJ. Factors influencing choice between tracheostomy and prolonged translaryngeal intubation in acute respiratory failure. Anacsth Anal 1976, 55:195-201.
23Neiderman MS Rafferty TD, Sasaki CT, Merrill WW, Mathay RA,Reynolds. Comparison of bacterial adherence to ciliated and squamous epithelial cells obtained from the human respiratory tract. Am Rev Resp Dis 1983,127: 85-90