Fatal complications of tracheotomy

The Need for Early Tracheostomy in Patients with Traumatic Cervical Cord Injury

Background

In patients who need sustained endotracheal intubation and mechanical ventilation due to respiratory failure after traumatic cervical spinal cord injury, tracheostomy can be performed to reduce the duration of mechanical ventilation and respiratory complications. The purpose of this study was to determine criteria and timing of tracheostomy in patients with severe traumatic cervical spinal cord injury accompanied by motor weakness.

Methods

We reviewed 22 patients who underwent tracheostomy (study group) and 27 patients who did not (control group) from January 2005 to March 2016. We assessed the American Spinal Injury Association (ASIA) impairment scale score and investigated accompanying thoracic injury, paradoxical respiration, postoperative endotracheal intubation and other clinical parameters. The study group was also subdivided into the early tracheostomy group and late tracheostomy group depending on whether the tracheostomy was performed within or later than 7 days after surgery.

Results

Twenty-two patients in the study group had a mean ASIA impairment scale score of 14.1 points, which was lower than the control group's 23.4 points. Paradoxical respiration was observed in 77% of the patients in the study group compared to 18% in the control group. Postoperative intubation was maintained in 68% in the study group; 32% underwent endotracheal intubation due to respiratory failure within 4 days after surgery and had a tracheostomy. In the control group, postoperative intubation was maintained in 22%, and all of them were weaned off intubation within 4 days after surgery. The duration of intensive care unit hospitalization was 11.4 days for the early tracheostomy group, which was shorter than the late tracheostomy group's 19.7 days.

Conclusions

In patients with severe traumatic cervical spinal cord injury, tracheostomy may be needed when the motor grade of the ASIA scale is low, above the C4 segment is injured, or paradoxical respiration occurs after injuries. In addition, if endotracheal extubation is not feasible within 4 days after surgery, an early tracheostomy should be considered.

Chest radiographs after dilatational percutaneous tracheotomy: are they necessary?

BACKGROUND

The efficacy of routinely obtaining chest radiographs after standard open tracheotomy has been questioned. Recent literature would suggest that after a routine, uncomplicated tracheotomy, chest radiography is a low-yield procedure that incurs unnecessary expense. Percutaneous dilatational tracheotomy (PDT) is rapidly replacing open tracheotomy as the intensive care unit procedure of choice for airway management. Complication rates are equivalent between the two procedures.

OBJECTIVE

We examined the value and cost-effectiveness of routine postoperative chest radiographs in patients undergoing PDT.

STUDY DESIGN AND SETTING

The study was a prospective analysis of 54 consecutive PDTs performed at a tertiary care academic institution.

RESULTS

Eighteen (33%) patients had chest radiographs obtained within 1 hour of PDT (6 at the request of the otolaryngology service); 35 (66%) underwent radiography more than 2 hours later at the request of the intensive care unit for reasons other than PDT. There were no incidents of pneumothorax, pneumomediastinum, or tracheotomy tube malposition in any patient. Patients undergoing chest radiography within 1 hour of the PDT also had chest radiographs within 12 hours at the request of ICU staff for their underlying disease.

CONCLUSIONS

Routine chest radiography after PDT is of low yield. Because most of these patients require chest radiographs for their underlying disease within 12 hours, a cost savings of approximately $13,500 would be realized in this patient population.

SIGNIFICANCE

Routine chest radiography after PDT is unwarranted in most cases.

Management of the airway in oral and oropharyngeal resections

A tracheostomy is the traditional method of maintaining an airway after major oral and oropharyngeal resections. Postoperative endotracheal intubation was used for 19 patients who underwent major oral and oropharyngeal resections over a 3-year period at the Royal Adelaide Hospital. This appears to be a safe alternative to tracheostomy if intensive care facilities are available.

Ballooned trachea as a consequence of intubation

A case of iatrogenic tracheal dilatation is presented. This potentially fatal complication of endotracheal intubation may escape early detection. It is well demonstrated by CT scanning.

Comparisons in the treatment of facial trauma

In 1980 a survey was conducted of the methods employed by OMF surgeons in the United Kingdom on the treatment of facial injuries. In 1986 a similar questionnaire was circulated in the UK with the addition of questions about clinical management. Towards the end of 1986 at a meeting in Amsterdam, arrangements were made for similar questionnaires to be circulated in The Netherlands, the USA and later in India and Hong Kong. The results recorded were as follows: UK: 164; The Netherlands: 94; USA: 1999; India: 20; Hong Kong: 5. This survey has revealed differences in the treatment of maxillofacial injuries in the countries concerned. There were differences in the means of fixation of fractured mandibles and in the types of anaesthesia used. The Americans were more likely to use extra oral surgical approaches for their lower border wirings or platings and were liable to operate on fractured mandibular condyles. The acceptability of patients being sent from the operating room with jaws wired together is confirmed by the fact that 95% of British and American OMF surgeons do this. The British OMF surgeons are much more likely to use fixation other than IMF in middle third injuries and are likely to use extra oral cranial fixation. Both the Dutch and the Americans are not so concerned about maxillary mobility and when they do employ fixation almost always use internal skeletal fixation. The approach to the reduction of a fractured malar is markedly different. The British are mainly using the Gillies approach, whereas the Dutch use the facial hook and the Americans a lower lid or brow approach.(ABSTRACT TRUNCATED AT 250 WORDS)

Near-fatal complications of tracheotomy infections and their prevention

Infectious complications of tracheotomy range from minor to potentially fatal. Three cases are presented: clavicular osteomyelitis; innominate artery blowout with mediastinitis; and the first reported case of necrotizing fasciitis involving the chest wall related to tracheotomy infection. All patients were debilitated, with one diabetic and another steroid-dependent. Infectious sequelae occurred as late as 8 weeks following tracheotomy. The mechanism, treatment, and prevention of tracheotomy infections are reviewed. Indications for the creation of a permanent but reversible tracheostome should be expanded to prevent infections in debilitated or immunosuppressed patients in whom decannulation is unlikely.

Cricothyroidotomy, a useful alternative to tracheostomy in maxillofacial surgery

Tracheostomy and prolonged intubation are traditionally used in maintaining the airway, particularly after extensive maxillofacial surgery. The literature reports significant morbidity and mortality from both these procedures. Cricothyroidotomy is proposed as a useful alternative in certain circumstances. Recent documentation suggests that traditional fears of subglottic stenosis after cricothyroidotomy are ill-founded. Cricothyroidotomy may also benefit the patient by quicker rehabilitation and in early mobilisation, compared with prolonged intubation. The surgical procedure is quick and easily performed, making it suitable for emergency airway control. Cricothyroidotomy is not appropriate in children or in patients with inflammation to the trachea, since these may predispose to subglottic stenosis.

Use of cricothyroidostomy in oral and maxillofacial surgery

Surgical entry into the upper airway is not only important in emergency situations but also in the treatment of certain elective maxillofacial procedures. The procedure of choice by which surgical access is gained has traditionally been a tracheostomy. Although a cricothyroidostomy is easier and quicker to perform, with a higher degree of safety, it has generally been relegated to only emergency situations. The purpose of this paper is to present the anatomy, indications, and surgical technique of cricothyroidostomy. It is concluded that cricothyroidostomy, and not tracheostomy, is the preferred procedure for surgical establishment of an upper airway, either in elective maxillofacial surgical procedures, or in an emergency situation.

Cricothyroidotomy for long-term tracheal access. A prospective analysis of morbidity and mortality in 76 patients

Cricothyroidotomy for long-term tracheal access was prospectively studied in 76 critically ill patients. Thirty patients (39%) survived and 46 (61%) died. Mean duration of follow-up computed in all survivors was 8.5 months. Postmortem examination of the airway was performed in 85% of the nonsurvivors. Five patients (7%) had major complications including one death, subglottic stenosis in two adolescent patients, reversible subglottic granulation with partial obstruction in one patient, and tracheomalacia in one patient. Minor complications occurred in 23 (30%) survivors. Eleven (28%) of the nonsurvivors examined post mortem had airway pathology, including ulceration, hemorrhage and abscess at the stoma or cuff site, subglottic erosion, and mucosal separation. There were no significant differences in any of the parameters studied between the group with and the group without airway pathology. The morbidity and mortality of cricothyroidotomy in adults are similar to that reported for tracheostomy. However, cricothyroidotomy should be avoided in children and adolescents because of the risk of subglottic stenosis.

Complications and consequences of endotracheal intubation and tracheotomy. A prospective study of 150 critically ill adult patients

A prospective study of the complications and consequences of translaryngeal endotracheal intubation and tracheotomy was conducted on 150 critically ill adult patients. Adverse consequences occurred in 62 percent of all endotracheal intubations and in 66 percent of all tracheotomies during placement and use of the artificial airways. The most frequent problems during endotracheal intubation were excessive cuff pressure requirements (19 percent), self-extubation (13 percent) and inability to seal the airway (11 percent). Patient discomfort and difficulty in suctioning tracheobronchial secretions were very uncommon. Problems with tracheotomy included stomal infection (36 percent), stomal hemorrhage (36 percent), excessive cuff pressure requirements (23 percent) and subcutaneous emphysema or pneumomediastinum (13 percent). Complications of tracheotomy were judged to be more severe than those of endotracheal intubation. Follow-up studies of survivors revealed a high prevalence of tracheal stenosis after tracheotomy (65 percent) and significantly less after endotracheal intubation (19 percent)(p < 0.01). Thirty-nine of 41 (95 percent) patients with endotracheal intubation and 20 of 22 (91 percent) patients with tracheotomy had laryngotracheal injury at autopsy. Ulcers on the posterior aspect of the true vocal cords were found at autopsy in 51 percent of the patients who died after endotracheal intubation. There was no significant relationship between the duration of endotracheal intubation or tracheotomy and the over-all amount of laryngotracheal injury at autopsy, although patients with prolonged endotracheal intubation followed by tracheotomy had more laryngeal injury at autopsy (P = 0.06) and more frequent tracheal stenosis (P = 0.05) than patients with short-term endotracheal intubation followed by tracheotomy. Adverse effects of both endotracheal intubation and tracheotomy are common. The value of tracheotomy when an artificial airway is required for periods as long as three weeks is not supported by data obtained in this study.