1
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Ward K, Hinchman-Dominguez D, Stokes L, Norton EL, Narveson JR, Punja VP. A Systematic Review of Mortality Associations in Patients who Develop Tracheoinnominate Artery Fistula Following Tracheostomy. Am Surg 2024; 90:1648-1656. [PMID: 38217444 DOI: 10.1177/00031348241227211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2024]
Abstract
OBJECTIVE Tracheoinnominate artery fistulas (TIFs) are a rare but deadly complication of tracheostomy. Tracheoinnominate artery fistula cases in the literature were summarized in order to understand mortality associations. METHODS MEDLINE was searched for studies reporting individual characteristics of patients with TIFs after tracheostomy, excluding cases without tracheostomy or with additional procedures at the tracheostomy site. This study followed PRISMA guidelines. RESULTS 121 TIF patients from 18 case series and 46 case reports were included. The median age was 40 years, and 52.9% were male. The overall mortality rate was 64.5%. There were differences in mortality between cases that presented initially with vs without sentinel bleeding (odds ratio [OR] .34; CI [confidence interval] .16-.73; P = .006). The mortality rate also differed in whether or not the tracheostomy cuff was over-inflated for temporary hemostasis during resuscitation (OR 3.57 (CI 1.57-8.09); P = .002). Treatment compared to no treatment had lower mortality rates (OR .11 (CI 0.04-.32); P < .001); no differences were found if treatment was endovascular vs open surgical. CONCLUSIONS Mortality is a major concern after detection of a TIF and resuscitation paired with endovascular or open surgical intervention is imperative. Rapidly investigating sentinel bleeds and intervening upon hemorrhage with temporary cuff over inflation may lead to improved outcomes.
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Affiliation(s)
- Katherine Ward
- School of Medicine, Creighton University, Omaha, NE, USA
| | | | - Laura Stokes
- School of Medicine, Creighton University, Omaha, NE, USA
| | | | - Joel R Narveson
- Department of Trauma Surgery and Critical Care, Creighton University Medical Center, Omaha, NE, USA
| | - Viren P Punja
- Department of Trauma Surgery and Critical Care, Creighton University Medical Center, Omaha, NE, USA
- Department of Surgery, Creighton University School of Medicine, Omaha, NE, USA
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2
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Hosaka T, Furuno S, Terada M, Hamano Y, Komatsu K, Okubo K, Koyama Y, Suzuki T, Tsuji H, Tamaoka A, Mizutani T. Tracheoarterial fistula in a patient with amyotrophic lateral sclerosis successfully managed by overinflation of the tracheostomy tube cuff alone: a case report. J Med Case Rep 2023; 17:65. [PMID: 36829250 PMCID: PMC9960659 DOI: 10.1186/s13256-023-03799-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 01/31/2023] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND Tracheoarterial fistula is the most devastating complication after tracheostomy, and its mortality, without definitive treatment, approaches 100%. In general, the combination of bedside emergency management, that is, overinflation of the tracheostomy tube cuff, and definitive treatment such as surgical or endovascular intervention is necessary to prevent the poor outcome. Patients with neuromuscular diseases such as amyotrophic lateral sclerosis are susceptible to tracheoarterial fistula because of long-term mechanical ventilation and muscle weakness. CASE PRESENTATION We describe a case of tracheoarterial fistula in a Japanese 39-year-old patient with amyotrophic lateral sclerosis with long-term ventilator management. The patient was clinically diagnosed with a tracheoarterial fistula because of massive bleeding following sentinel hemorrhage. The massive hemorrhage was controlled by overinflation of the tracheostomy tube cuff alone, without definitive treatment. CONCLUSIONS This case suggests overinflation of the tracheostomy tube cuff alone plays an important role, semi-permanently, in the management of tracheoarterial fistula, especially in cases where surgical or endovascular intervention is not indicated. Clinicians taking care of patients with tracheostomy undergoing long-term mechanical ventilation should be aware that tracheoarterial fistula might occur following tracheostomy.
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Affiliation(s)
- Takashi Hosaka
- Division of Clinical Medicine, Department of Neurology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, 305-8575, Japan. .,Department of Internal Medicine, Ibaraki Western Medical Center, University of Tsukuba Hospital/Jichi Medical University Joint Ibaraki Western Regional Clinical Education Center, Chikusei, Ibaraki, 308-0813, Japan. .,Department of Internal Medicine, Ibaraki Western Medical Center, Chikusei, Ibaraki, 308-0813, Japan.
| | - Shintaro Furuno
- Department of Internal Medicine, Ibaraki Western Medical Center, Chikusei, Ibaraki 308-0813 Japan
| | - Makoto Terada
- grid.20515.330000 0001 2369 4728Division of Clinical Medicine, Department of Neurology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki 305-8575 Japan ,grid.20515.330000 0001 2369 4728Department of Internal Medicine, Ibaraki Western Medical Center, University of Tsukuba Hospital/Jichi Medical University Joint Ibaraki Western Regional Clinical Education Center, Chikusei, Ibaraki 308-0813 Japan ,Department of Internal Medicine, Ibaraki Western Medical Center, Chikusei, Ibaraki 308-0813 Japan
| | - Yumiko Hamano
- Department of Otolaryngology, Ibaraki Western Medical Center, Chikusei, Ibaraki 308-0813 Japan
| | - Kenichi Komatsu
- Department of Internal Medicine, Ibaraki Western Medical Center, Chikusei, Ibaraki 308-0813 Japan
| | - Katsuichiro Okubo
- Department of Internal Medicine, Ibaraki Western Medical Center, Chikusei, Ibaraki 308-0813 Japan
| | - Yasuaki Koyama
- grid.412814.a0000 0004 0619 0044Department of Emergency and Critical Care Medicine, University of Tsukuba Hospital, Ibaraki, 305-8576 Japan ,grid.414178.f0000 0004 1776 0989Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Ibaraki 317-0077 Japan
| | - Tetsu Suzuki
- grid.20515.330000 0001 2369 4728Division of Clinical Medicine, Department of Neurology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki 305-8575 Japan
| | - Hiroshi Tsuji
- grid.20515.330000 0001 2369 4728Division of Clinical Medicine, Department of Neurology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki 305-8575 Japan
| | - Akira Tamaoka
- grid.20515.330000 0001 2369 4728Division of Clinical Medicine, Department of Neurology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki 305-8575 Japan
| | - Taro Mizutani
- Department of Anesthesiology, Ibaraki Western Medical Center, Chikusei, Ibaraki 308-0813 Japan
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Tom Z, Woo KK, Lanks C. A 73-Year-Old Woman With a Bounding Barrier to Tracheostomy. Chest 2023; 163:e101-e103. [PMID: 36759114 DOI: 10.1016/j.chest.2022.01.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/30/2022] [Indexed: 02/10/2023] Open
Affiliation(s)
- Zachary Tom
- Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA.
| | - Kenneth K Woo
- Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA
| | - Charles Lanks
- Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA; Lundquist Institute for Biomedical Innovation, Torrance, CA
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4
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Perri JL, Plichta RP. Too big to fail?-An aggressive strategy for a dire problem. J Card Surg 2022; 37:5475-5476. [PMID: 36150130 DOI: 10.1111/jocs.16911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 08/23/2022] [Indexed: 01/06/2023]
Abstract
Tracheo-innominate fistula (TIF) is a reported complication of tracheostomy that typically presents with a herald bleed. The phenomenon of an aortotracheal fistula has similar pathology and presentation to TIF, but no standard surgical repair. In the manuscript by Musgrove et al. in the Journal of Cardiac Surgery, the authors propose a surgical treatment that is reproducible for the correct anatomic configuration-an ascending and aortic arch replacement, pericardial patch of the tracheal defect, and omental flap coverage. While this intervention is a large undertaking for a small defect, it is a safe and durable repair.
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Affiliation(s)
- Jennifer L Perri
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Durham, North Carolina, USA
| | - Ryan P Plichta
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Durham, North Carolina, USA
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5
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Yoo B, Lee B, Park JD, Kwon SK, Kwak JG. Prevention of Tracheo-Innominate Artery Fistula Formation as a Complication of Tracheostomy: Two Case Reports. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9111603. [PMID: 36360331 PMCID: PMC9688328 DOI: 10.3390/children9111603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/08/2022] [Accepted: 10/21/2022] [Indexed: 01/25/2023]
Abstract
Tracheo-innominate artery fistula (TIF) is a rare complication of tracheostomy and refers to the formation of a fistula between the trachea and innominate artery. Because TIF is fatal, prevention rather than treatment is very important. Here we report the cases of two high-risk patients who underwent tracheostomy, and in whose cases attempts were made to lower the risk of TIF. In the first patient who developed a chest deformity with Duchenne muscular dystrophy, a tracheostomy was performed with a high-level (cricothyroid level) approach compared with the standard tracheostomy. In the second patient, the thoracic cage was relatively small due to a giant omphalocele, and the risk of a fistula forming was decreased by wrapping the innominate artery with an opened polytetrafluoroethylene vascular graft after resolving crowding of the intrathoracic cavity by total thymectomy. There was no TIF occurrence at the outpatient follow-up in either case. We expect that our approaches may be effective intervention measures for preventing TIF.
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Affiliation(s)
- Byungsun Yoo
- Department of Pediatrics, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Bongjin Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul 03080, Korea
- Correspondence: ; Tel.: +82-2-2072-3568
| | - June Dong Park
- Department of Pediatrics, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Seong Keun Kwon
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Jae Gun Kwak
- Department of Thoracic and Cardiovascular Surgery, Seoul National University College of Medicine, Seoul 03080, Korea
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6
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Ryan D, Miller K, Capaldi C, Pasquarello C, Yang Q, Hirose H. Massive hemoptysis bridged with VV ECMO: A case report. Front Cardiovasc Med 2022; 9:997990. [PMID: 36247439 PMCID: PMC9561465 DOI: 10.3389/fcvm.2022.997990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 08/29/2022] [Indexed: 11/15/2022] Open
Abstract
Objective Extracorporeal membrane oxygenation (ECMO) can provide full pulmonary support when a patient is completely apneic. The combination of veno-venous (VV) ECMO and induced apnea can be utilized to control significant hemoptysis. We present a case of massive hemoptysis that developed while on VV ECMO and was treated with temporary discontinuation of the ventilator and serial declotting bronchoscopies. Methods A 42-year-old male with recent acute ST elevation myocardial infarction status post cardiac stent developed aspiration pneumonia that progressed to acute respiratory distress syndrome. The patient's biventricular function was preserved. VV ECMO was placed for lung rescue on hospital day #7, and tracheostomy was performed for ventilator dependence on hospital day #12. On hospital day #18, the patient developed significant hemoptysis despite the discontinuation of anticoagulation. Bronchoscopy revealed massive bleeding from bilateral bronchi. To facilitate tamponade within the tracheobronchial tree, the ventilator was temporarily discontinued while VV ECMO provided full respiratory support. After 48 h, mechanical ventilation was resumed, and daily bronchoscopies were performed to remove clots from both bronchi until a chest x-ray showed improvement in bilateral opacifications. Bronchoscopy was performed a total of 14 times. There was no recurrence of bronchial bleeding, the patient's respiratory status improved, and VV ECMO was weaned off on hospital day #37. The patient was transferred to a long-term rehabilitation facility 36 days after successful VV ECMO decannulation on hospital day #73. Conclusions This patient's survival of massive hemoptysis was facilitated largely by the utilization of serial declotting bronchoscopies with VV ECMO providing full pulmonary support during temporary discontinuation of mechanical ventilation.
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7
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Yun JS, Song SY, Na KJ, Kim E. Successful Surgical Management of a Tracheo-Innominate Artery Fistula in a Patient with Duchenne Muscular Dystrophy: A Case Report. J Chest Surg 2021; 55:88-90. [PMID: 34963672 PMCID: PMC8824643 DOI: 10.5090/jcs.21.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/28/2021] [Accepted: 11/10/2021] [Indexed: 11/20/2022] Open
Abstract
Tracheo-innominate artery fistula (TIF) is a rare, life-threatening complication of tracheostomy that makes it difficult to secure the airway due to massive bleeding, constituting a medical emergency. Therefore, most successful surgical treatments include innominate artery debridement and tracheal fistula repair. Herein, we report a case of successful surgical treatment of a TIF while maintaining cerebral blood flow through an artificial vascular graft.
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Affiliation(s)
- Ju Sik Yun
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hwasun Hospital, Chonnam National University School of Medicine, Hwasun, Korea
| | - Sang Yun Song
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hwasun Hospital, Chonnam National University School of Medicine, Hwasun, Korea
| | - Kook Joo Na
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hwasun Hospital, Chonnam National University School of Medicine, Hwasun, Korea
| | - Eunchong Kim
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
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8
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Obara K. Prevention of Tracheo-Innominate Artery Fistula by Using an Adjustable Tracheostomy Tube. Cureus 2021; 13:e20043. [PMID: 34873556 PMCID: PMC8631480 DOI: 10.7759/cureus.20043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2021] [Indexed: 12/02/2022] Open
Abstract
Tracheo-innominate artery fistula (TIF) is a severe complication associated with a long-term tracheostomy, and TIF-associated bleeding has a high mortality rate. Here, we report two patients who were considered to be at high risk of developing TIF due to retrocollis after tracheostomy. The patients were an 82-year-old woman with Parkinson’s disease (PD) and a 64-year-old man with multiple system atrophy (MSA). Both patients underwent tracheostomy at an advanced stage and later showed retrocollis. Colored and 3D-reconstructed computed tomography (CT) showed tracheal deformation into a C curve, with the tip of the tracheostomy tube attached to the anterior wall, where the innominate artery transverses. Since they were considered to be at high risk of developing TIF, we used an adjustable tracheostomy tube. Follow-up CT revealed that the tip of the new tracheostomy tube had separated from the tracheal anterior wall. Although retrocollis is rare in PD and MSA, it can develop at the end stage of these diseases. An adjustable tracheostomy tube may be an option for preventing TIF development in cases where surgical intervention would be difficult.
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Affiliation(s)
- Koji Obara
- Neurology, National Hospital Organization Akita National Hospital, Yurihonjo, JPN
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9
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Morimoto N, Maekawa T, Kubota M, Kitamura M, Takahashi N, Kubota M. Challenge for management without tracheostomy tube after laryngo-tracheal separation in children with neurological disorders. Laryngoscope Investig Otolaryngol 2021; 6:332-339. [PMID: 33869766 PMCID: PMC8035946 DOI: 10.1002/lio2.534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/26/2020] [Accepted: 01/20/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES The present study analyzed surgical outcomes of laryngotracheal separation (LTS) in children with neurological disorders. The purpose of this study was to investigate respiratory impairment and severe complications after LTS in children, and identify the possibility of permanent tracheostomy without a tracheostomy tube as the safest respiratory management method. METHODS Twenty-eight patients (male:female = 16:12) with neurological disorders (6 months to 32 years) who underwent LTS between January 2012 and April 2018 were reviewed. Tracheal diameter, Cobb angle, and sternocervical spine distance (SCD) were measured to assess the potential risk and possibility of removing tracheostomy tube management. RESULTS Tracheostomy tube could be removed shortly after LTS in 57% (16/28). However, nine of these patients developed respiratory problems that required tracheostomy tube placement 2 years after LTS. New requirements for a tracheostomy tube as a stent were strongly correlated with SCD (P < .05, odds ratio > 1) as well as tracheal deformity. CONCLUSIONS Respiratory management in neurologically impaired children after LTS without a tracheostomy tube is challenging because thoracic deformity during physical growth affects tracheal disfiguration. Thoracic deformities and progression of scoliosis should be considered in respiratory management approaches in children with neurological disorders, and long-term follow-up by computed tomography is necessary. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Noriko Morimoto
- Department of OtolaryngologyNational Center for Child Health and DevelopmentTokyoJapan
| | - Takanobu Maekawa
- Department of General Pediatrics and Interdisciplinary medicineNational Center for Child Health and DevelopmentTokyoJapan
| | - Masaya Kubota
- Department of NeurologyNational Center for Child Health and DevelopmentTokyoJapan
| | - Masayuki Kitamura
- Department of RadiologyNational Center for Child Health and DevelopmentTokyoJapan
| | - Nozomi Takahashi
- Department of OtolaryngologyNational Center for Child Health and DevelopmentTokyoJapan
| | - Mitsuru Kubota
- Department of General Pediatrics and Interdisciplinary medicineNational Center for Child Health and DevelopmentTokyoJapan
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10
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Yoshimura T, Colley N, Komizunai S, Ninomiya S, Kanai S, Konno A, Yasuda K, Taguchi H, Hashimoto T, Shimizu S. Construction of a detachable artificial trachea model for three age groups for use in an endotracheal suctioning training environment simulator. PLoS One 2021; 16:e0249010. [PMID: 33780512 PMCID: PMC8007018 DOI: 10.1371/journal.pone.0249010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 03/09/2021] [Indexed: 11/18/2022] Open
Abstract
Tracheal suctioning is an important procedure to maintain airway patency by removing secretions. Today, suctioning operators include not only medical staff, but also family caregivers. The use of a simulation system has been noted to be the most effective way to learn the tracheal suctioning technique for operators. While the size of the trachea varies across different age groups, the artificial trachea model in the simulation system has only one fixed model. Thus, this study aimed to construct multiple removable trachea models according to different age groups. We enrolled 20 patients who had previously received proton beam therapy in our institution and acquired the treatment planning computed tomography (CT) image data. To construct the artificial trachea model for three age groups (children, adolescents and young adults, and adults), we analyzed the three-dimensional coordinates of the entire trachea, tracheal carina, and the end of the main bronchus. We also analyzed the diameter of the trachea and main bronchus. Finally, we evaluated the accuracy of the model by analyzing the difference between the constructed model and actual measurements. The trachea model was 8 cm long for children and 12 cm for adolescents and young adults, and for adults. The angle between the trachea and bed was about 20 degrees, regardless of age. The mean model accuracy was less than 0.4 cm. We constructed detachable artificial trachea models for three age groups for implementation in the endotracheal suctioning training environment simulator (ESTE-SIM) based on the treatment planning CT image. Our constructed artificial trachea models will be able to provide a simulation environment for various age groups in the ESTE-SIM.
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Affiliation(s)
- Takaaki Yoshimura
- Department of Health Sciences and Technology, Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
- Department of Medical Physics, Hokkaido University Hospital, Sapporo, Japan
| | - Noriyo Colley
- Department of Comprehensive Development Nursing, Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
- * E-mail:
| | - Shunsuke Komizunai
- Division of System Science and Informatics, Graduate School of Information Science and Technology, Hokkaido University, Sapporo, Japan
| | - Shinji Ninomiya
- Department of Medical Science and Technology, Faculty of Health Sciences, Hiroshima International University, Hiroshima, Japan
| | - Satoshi Kanai
- Division of System Science and Informatics, Graduate School of Information Science and Technology, Hokkaido University, Sapporo, Japan
| | - Atsushi Konno
- Division of System Science and Informatics, Graduate School of Information Science and Technology, Hokkaido University, Sapporo, Japan
| | - Koichi Yasuda
- Department of Radiation Oncology, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroshi Taguchi
- Department of Radiation Oncology, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Takayuki Hashimoto
- Department of Radiation Medical Science and Engineering, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Shinichi Shimizu
- Department of Medical Physics, Hokkaido University Hospital, Sapporo, Japan
- Department of Radiation Medical Science and Engineering, Faculty of Medicine, Hokkaido University, Sapporo, Japan
- Global Center for Biomedical Science and Engineering, Faculty of Medicine, Hokkaido University, Sapporo, Japan
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11
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Dahill KE, Dempsey G. Tracheocarotid artery fistula in a patient who had tracheostomy successfully treated with a saphenous vein graft. BMJ Case Rep 2021; 14:14/3/e237854. [PMID: 33782063 PMCID: PMC8009233 DOI: 10.1136/bcr-2020-237854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Tracheoarterial fistula is a complication of tracheostomy with a high associated mortality. A 25-year-old male patient with Duchenne's muscular dystrophy underwent a percutaneous tracheostomy using the single tapered dilator (Blue Rhino) technique to facilitate weaning from mechanical ventilation. Nine weeks after the procedure, he developed significant upper airway bleeding, leading to haemodynamic instability. A CT angiogram of the neck and thorax did not reveal a source of the bleeding. The patient was subsequently transferred to the operating theatre where a 1 cm defect in the right common carotid artery was found and repaired with a graft from the left short saphenous vein. Clinicians who undertake tracheostomy formation should be aware of the possibility of tracheoarterial defect and may wish to discuss it at tracheostomy formation. It should be considered early in the event of a significant bleed. This case identifies deep tissue infection and misplacement of the tracheostomy tube as major contributing factors to fistula formation.
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Affiliation(s)
| | - Ged Dempsey
- Critical Care, University Hospital Aintree, Liverpool, UK
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12
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O'Malley TJ, Jordan AM, Prochno KW, Saxena A, Maynes EJ, Ferrell B, Guy TS, Entwistle JW, Massey HT, Morris RJ, Abai B, Tchantchaleishvili V. Evaluation of Endovascular Intervention for Tracheo-Innominate Artery Fistula: A Systematic Review. Vasc Endovascular Surg 2021; 55:317-324. [PMID: 33529132 DOI: 10.1177/1538574420980625] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND While the standard of care for suspected tracheo-innominate artery fistula (TIF) necessitates sternotomy, perioperative mortality remains high. Endovascular interventions have been attempted, but reports have been anecdotal. The aim of this systematic review was to evaluate the outcomes of endovascular management of TIF by pooling the existing evidence. METHODS An electronic database search of Ovid MEDLINE, Scopus, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Controlled Trials Register was performed to identify all studies examining endovascular treatment of TIF. Patients greater than 14 years of age who underwent endovascular intervention for TIF were included. 25 studies consisting of 27 patients met the inclusion criteria. RESULTS 48.1% (13/27) of patients were male and median age was 39.0 [IQR 16.0, 47.5] years. Tracheostomy was present in 96.3% (26/27) of cases. Median duration from tracheostomy to TIF presentation was 2.2 months [0.5, 42.5]. On presentation, 84.6% (22/26) had tracheal hemorrhage, and 22.8% (6/27) were hemodynamically unstable. 96.3% (26/27) underwent covered stent graft placement while 1 patient (3.8%) had coil embolization. 18.5% (5/27) of patients required repeat endovascular intervention for recurrent bleeding, while 11.1% (3/27) required rescue sternotomy. Median hospital length of stay was 30 days [16.0, 46.5], and overall mortality was 29.6% (8/27) with a median follow-up time of 5 months [1.2, 11.5]. CONCLUSION While uncommon, endovascular treatment of TIF may be a feasible alternative to sternotomy. The approach may be useful in those who are unable to undergo surgery or are likely to have adhesions from prior chest operations.
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Affiliation(s)
- Thomas J O'Malley
- Division of Cardiac Surgery, 6529Thomas Jefferson University, Philadelphia, PA, USA
| | - Andrew M Jordan
- Division of Cardiac Surgery, 6529Thomas Jefferson University, Philadelphia, PA, USA
| | - Kyle W Prochno
- Division of Cardiac Surgery, 6529Thomas Jefferson University, Philadelphia, PA, USA
| | - Abhiraj Saxena
- Division of Cardiac Surgery, 6529Thomas Jefferson University, Philadelphia, PA, USA
| | - Elizabeth J Maynes
- Division of Cardiac Surgery, 6529Thomas Jefferson University, Philadelphia, PA, USA
| | - Brandon Ferrell
- 12230Georgetown University School of Medicine, Washington, DC, USA
| | - T Sloane Guy
- Division of Cardiac Surgery, 6529Thomas Jefferson University, Philadelphia, PA, USA
| | - John W Entwistle
- Division of Cardiac Surgery, 6529Thomas Jefferson University, Philadelphia, PA, USA
| | - H Todd Massey
- Division of Cardiac Surgery, 6529Thomas Jefferson University, Philadelphia, PA, USA
| | - Rohinton J Morris
- Division of Cardiac Surgery, 6529Thomas Jefferson University, Philadelphia, PA, USA
| | - Babak Abai
- Division of Vascular and Endovascular Surgery, 6529Thomas Jefferson University, Philadelphia, PA, USA
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13
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Richards N, Herath J. Death Due to Obstruction of Airways by a Hyperplastic Polyp: An Unusual Complication of Treated Desmoid Fibromatosis. Acad Forensic Pathol 2020; 10:97-103. [PMID: 33282044 DOI: 10.1177/1925362120964084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 09/09/2020] [Indexed: 11/17/2022]
Abstract
Desmoid fibromatosis (DF) is a rare, locally aggressive but benign clonal fibroblastic lesion of deep soft tissue. It can occur at any age. Extra-abdominal lesions are more common in the pediatric population, with equal sex predilection. Desmoid fibromatosis of the head and neck, particularly the anterior neck, is more difficult to manage because of the proximity to vital structures and may eventually require definitive airway management with insertion of a tracheostomy tube. Indwelling tracheostomy tubes carry their own set of complications. This is the case of a 21-month-old boy who died suddenly due to tracheal obstruction by a hyperplastic polyp. He was diagnosed with DF of the neck before he was 1 month old and required an indwelling tracheostomy tube as a result. Chronic tracheostomy intubation can be complicated by granulation tissue polyp or, less commonly, fibroepithelial polyp formation that can become large enough to cause airway obstruction. To the authors' knowledge, this is the first case of hyperplastic polyp causing fatal airway obstruction.
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14
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Anesthetic Management for Emergent Repair of Tracheoinnominate Fistula. Case Rep Anesthesiol 2020; 2020:8865303. [PMID: 32908712 PMCID: PMC7471825 DOI: 10.1155/2020/8865303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 08/09/2020] [Accepted: 08/12/2020] [Indexed: 11/17/2022] Open
Abstract
We present a case of a 30-year-old female, who had tracheostomy revision complicated by false passage into the subcutaneous space and pneumothorax. Six days later, she developed massive bleeding from the mouth, nose, and tracheostomy site. Approximately 2 liters of blood was lost. With high suspicion for tracheo-innominate fistula, she was emergently brought to the operating room for fistula repair. Her anesthetic management was initially focused on maintaining spontaneous ventilation with inhalation agents until surgical exposure was adequate. An endotracheal tube was then placed under guidance of a video-laryngoscope. The tracheostomy tube was then removed over a Cook catheter to maintain secure passage in case of airway collapse. The oral endotracheal tube was then inserted distal to the arterial and tracheal defect. The patient's bleeding was stopped, the fistula was repaired, and she was transferred back to the intensive care unit, but she died several days later due to multi-organ failure.
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15
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Kondajji A, Dombrowska A, Allemang M, Santoscoy T. Emergent Management of a Tracheoinnominate Fistula in the Community Hospital Setting. Cureus 2020; 12:e8403. [PMID: 32637282 PMCID: PMC7331894 DOI: 10.7759/cureus.8403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Tracheoinnominate fistula is a rare but highly lethal complication of tracheostomy. Early recognition and interventions are key to patient survival. A 63-year-old woman had undergone tracheostomy for respiratory failure secondary to disseminated histoplasmosis. She presented to the community hospital intensive care unit from a long-term acute care facility for presumed gastrointestinal bleeding. A tracheoinnominate fistula was suspected when there was bleeding around the tracheostomy. The patient underwent a median sternotomy with innominate artery ligation. The article will discuss the presentation, evaluation, and emergent management of this lethal complication of tracheostomies. The patient survival is dependent on high clinical suspicion, rapid diagnosis, and emergent surgical management.
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Affiliation(s)
- Abhiram Kondajji
- General Surgery, Cleveland Clinic South Pointe Hospital, Warrensville Heights, USA
| | | | - Matthew Allemang
- Digestive Disease and Surgical Institute, Cleveland Clinic, Cleveland, USA
| | - Thomas Santoscoy
- Heart, Vascular, Thoracic Institute, Cleveland Clinic, Cleveland, USA
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16
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Noguchi S, Saito J, Kawaguchi J, Kushikata T, Hirota K. Successful respiratory management of a Marshall-Smith syndrome patient with a tracheo-innominate artery fistula. JA Clin Rep 2020; 6:37. [PMID: 32444904 PMCID: PMC7244218 DOI: 10.1186/s40981-020-00343-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 05/12/2020] [Indexed: 11/16/2022] Open
Abstract
Background Tracheo-innominate artery fistula (TIF) is a life-threatening complication of tracheostomy. We describe perioperative management for innominate artery transection in a case with TIF. Case presentation A 4-year-old Japanese female with Marshal-Smith syndrome presented for management of TIF. She underwent tracheostomy at the age of 3 months and an uncuffed tracheostomy tube was inserted. One month before admission to our hospital, intermittent tracheal bleeding, suggesting TIF, occurred. Although we considered to change to a cuffed endotracheal tube, craniofacial abnormality suggested difficult oral intubation, and there was a possibility of rebleeding. Finally, innominate artery transection was performed under total intravenous anesthesia without changing the tracheostomy tube. Surgery completed uneventfully and she received mechanical ventilation under sedation for a day, followed by weaning without complications. Conclusions A cuffed tracheostomy tube should have been inserted before surgery for effective hemostasis against sudden bleeding from TIF even though conversion to oral intubation was difficult.
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Affiliation(s)
- Satoko Noguchi
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan.
| | - Junichi Saito
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Jun Kawaguchi
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Tetsuya Kushikata
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Kazuyoshi Hirota
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
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17
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Panuganti BA, Weissbrod PA, Somal J. Critical Care and Postoperative Management of the Head and Neck Patient. Otolaryngol Clin North Am 2020; 52:1141-1156. [PMID: 31677648 DOI: 10.1016/j.otc.2019.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Head and neck surgical patients, at times, can represent a challenging population to manage in the intensive care unit postoperatively. Close interaction between the critical care and surgical teams, awareness of potential surgery-specific complications, and utilization of protocol-driven care can reduce risk of morbidity significantly in this population and enhance outcomes. Given the relative complexity of otolaryngologic surgery and the unique risk that head and neck pathologies can pose to patient airway, breathing, and circulation, these collective circumstances warrant detailed discussion in the interest of minimizing patient morbidity and mortality.
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Affiliation(s)
- Bharat Akhanda Panuganti
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of California San Diego, 200 West Arbor Drive, MC# 8895, San Diego, CA 92103, USA
| | - Philip A Weissbrod
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of California San Diego, 200 West Arbor Drive, MC# 8895, San Diego, CA 92103, USA
| | - Jaspreet Somal
- Department of Anesthesiology and Critical Care, University of California San Diego, San Diego, CA, USA.
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18
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Pawar P, Rajendra N, Jagan J, Sukumar S, Raju R. Tracheostomy creation leading to innominate artery pseudoaneurysm: A case report. Indian J Anaesth 2020; 64:159-161. [PMID: 32139940 PMCID: PMC7017670 DOI: 10.4103/ija.ija_654_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/04/2019] [Accepted: 10/27/2019] [Indexed: 11/24/2022] Open
Affiliation(s)
- Pranay Pawar
- Department of Vascular Surgery, Sri Ramachandra Medical College, Chennai, Tamil Nadu, India
| | - Naveen Rajendra
- Department of Vascular Surgery, Sri Ramachandra Medical College, Chennai, Tamil Nadu, India
| | - Jithin Jagan
- Department of Vascular Surgery, Sri Ramachandra Medical College, Chennai, Tamil Nadu, India
| | - Senthilkumar Sukumar
- Department of Anaesthesiology, Sri Ramachandra Medical College, Chennai, Tamil Nadu, India
| | - Radhakrishnan Raju
- Department of Vascular Surgery, Sri Ramachandra Medical College, Chennai, Tamil Nadu, India
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19
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Draeger TB, Andaz SK, Gibson VR. A novel reconstruction technique of a tracheal defect in the emergent setting using a thymus flap in a patient with tracheoinnominate artery fistula. Surg Case Rep 2020; 6:21. [PMID: 31938896 PMCID: PMC6960273 DOI: 10.1186/s40792-019-0763-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 12/11/2019] [Indexed: 11/28/2022] Open
Abstract
Background There is a very high mortality associated with a tracheoinnominate artery fistula; however, when patients survive, they often require reconstruction of the eroded tracheal defect after the bleeding has been controlled. Case presentation This is the case of an 83-year-old male with a tracheoinnominate artery fistula who was stabilized in the operating room and underwent repair of his trachea. A novel technique of using the thymus gland as a pedicled flap to repair a large tracheal defect was executed after achieving hemostasis. The patient’s defect was repaired successfully following control of the fistula. Conclusions We have shown that the thymus gland can be used successfully as a pedicled flap for repair of a tracheal defect in the setting of a tracheoinnominate artery fistula.
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Affiliation(s)
- Tyler B Draeger
- Department of Surgery, Icahn School of Medicine at Mount Sinai South Nassau, Oceanside, NY, USA
| | - Shahriyour K Andaz
- Division of Cardiothoracic Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai South Nassau, Oceanside, NY, USA
| | - Vanessa R Gibson
- Division of Cardiothoracic Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai South Nassau, Oceanside, NY, USA.
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20
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Palchik E, Bakken AM, Saad N, Saad WAE, Davies MG. Endovascular Treatment of Tracheoinnominate Artery Fistula: A Case Report. Vasc Endovascular Surg 2019. [DOI: 10.1177/10847138062895141] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Tracheoinnominate fistula is a rare but lethal condition that requires emergent surgical intervention to prevent ensuing exsanguinating hemorrhage. In clinical situations where the risk of open surgery is prohibitively high, endovascular repair may provide a life-saving alternative to control hemorrhage and serve as a temporizing or definitive solution based on a given clinical scenario. The authors report successful endovascular repair of the bleeding tracheoinnominate fistula with a stent in a liver transplant patient with high comorbidities and review the current literature.
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Affiliation(s)
- Eugene Palchik
- Center for Vascular Disease, Department of Surgery, University of Rochester, Rochester, New York
| | - Andrew M. Bakken
- Center for Vascular Disease, Department of Surgery, University of Rochester, Rochester, New York
| | - Nael Saad
- Department of Imaging Sciences, University of Rochester, Rochester, New York
| | - Wael A. E. Saad
- Department of Imaging Sciences, University of Rochester, Rochester, New York
| | - Mark G. Davies
- Center for Vascular Disease, Department of Surgery, University of Rochester, Rochester, New York,
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Abstract
Acute respiratory distress syndrome (ARDS) is a disease associated with both short- and long-term complications. Acute complications include refractory respiratory failure requiring prolonged dependence on mechanical ventilation and the subsequent need for tracheostomy and gastrostomy tubes, protracted immobilization, and lengthy stays in the intensive care unit resulting in delirium, critical illness myopathy, and polyneuropathy, as well as secondary nosocomial infections. Chronic adverse outcomes of ARDS include irreversible changes such as fibrosis, tracheal stenosis from prolonged tracheostomy tube placement, pulmonary function decline, cognitive impairment and memory loss, posttraumatic stress disorder, depression, anxiety, muscle weakness, ambulatory dysfunction, and an overall poor quality of life. The degree of disability in ARDS survivors is heterogeneous and can be evident even years after hospitalization. Although survival rates have improved over the past 4 decades, mortality remains significant with rates reported as high as 40%. Despite advancements in management, the causes of death in ARDS have remained relatively unchanged since the 1980s with sepsis/septic shock and multiorgan failure at the top of the list.
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22
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Donaldson L, Raper R. Successful emergency management of a bleeding tracheoinnominate fistula. BMJ Case Rep 2019; 12:12/12/e232257. [PMID: 31852691 DOI: 10.1136/bcr-2019-232257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
In this case, we describe a novel approach to achieving temporary haemostasis in acute massive haemorrhage from a bleeding tracheoinnominate fistula. We report the case of a 42-year-old man admitted to hospital after suffering 80% body surface area burns. Thirty days following the percutaneous insertion of a tracheostomy, spontaneous massive haemorrhage occurred via the tracheostomy stoma, the tracheostomy tube and the mouth. After hyperinflation of the tracheostomy cuff which controlled airway contamination, effective tamponade was achieved using a hyperinflated balloon on a Foley catheter that was introduced by direct laryngoscopy into the upper larynx above the tracheotomy stoma. This provided temporary control of the bleeding until definitive management through ligation of the innominate artery via median sternotomy.
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Affiliation(s)
- Lachlan Donaldson
- Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Raymond Raper
- Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
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23
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Taechariyakul T, Keller FS, Jahangiri Y. Endovascular Treatment of Tracheoinnominate Artery Fistula: Case Report and Literature Review With Pooled Cohort Analysis. Semin Thorac Cardiovasc Surg 2019; 32:77-84. [PMID: 31425754 DOI: 10.1053/j.semtcvs.2019.08.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 08/12/2019] [Indexed: 11/11/2022]
Abstract
To pool data from published cases of tracheoinnominate artery fistula (TIF) treated with surgical or endovascular techniques along with reporting a case of similar presentation. A total of 261 cases in 137 published case reports and case series were identified through a comprehensive systematic literature review. Data regarding patient characteristics, treatment, and follow-up were extracted. A local case of a 14-year-old boy with TIF due to longstanding tracheostomy treated with stent-graft placement was added to the data. Comparison of the complication rates between surgical vs endovascular interventions was done with the chi-square test. Factors associated with longer survival were assessed by the Cox regression analysis. Thirty-three (12.6%) of the reported cases were treated endovascularly, 137 (52.3%) were treated surgically, and 92 (35.1%) were reported with no definitive treatment. Mean age was 34 ± 22 years, and 61% were males. The mean time interval between tracheotomy placement and bleeding was 1 ± 2.5 years. A lower procedure-related complication (30% vs 50%, P = 0.045) and 30-day mortality (9% vs 23%, P = 0.008) rates had been reported with percutaneous approaches compared to surgery. No percutaneous procedure was reported prior to year 2000. In multivariate analysis stratified by publication year, a shorter tracheostomy-to-bleeding time (year) was significantly associated with higher hazards of death (hazard ratio: 1.22, P = 0.017). Type of intervention (percutaneous vs surgery) was not associated with postintervention survival (adjusted hazard ratio: 0.78, P = 0.558). Endovascular stent grafting can have a comparable postprocedural survival and lower complication rates vs open surgical repair in treatment of TIF.
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Affiliation(s)
| | - Frederick S Keller
- Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, Oregon
| | - Younes Jahangiri
- Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, Oregon.
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24
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Abstract
BACKGROUND A tracheoarterial fistula (TAF) is an uncommon but life-threatening complication after tracheostomy. Only an immediate and targeted treatment provides a chance to survive. OBJECTIVE Surgical treatment of TAF. METHODS Selective review of the literature and case description. RESULTS A TAF leads to an acute bleeding complication with displacement of the respiratory tract. The mortality rate is nearly 100% without a surgical intervention. In the literature various interventional and surgical treatment procedures are described. Rapid control of bleeding via manual compression and overinflation of the tracheal cuff are the most important steps of treatment. Subsequent emergency surgery with ligation or resection of the TAF and covering of the tracheal lesion should be performed. Extracorporeal membrane oxygenation (ECMO) and a heart-lung machine can sometimes be necessary. CONCLUSION Despite all treatment options the mortality rate of TAF remains high. The critical steps are a quick diagnosis of TAF, securing the airway and immediate bleeding control.
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Affiliation(s)
- M Ried
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland.
| | - B Reger
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - H-S Hofmann
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
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25
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Machado ADT, Barroso MCRD. Endovascular management of tracheo-innominate artery fistula: a case report and literature review. J Vasc Bras 2019; 17:348-352. [PMID: 30787956 PMCID: PMC6375266 DOI: 10.1590/1677-5449.003418] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Tracheo-innominate artery fistula (TIF) is a rare complication of tracheostomy, with incidence ranging from 0.1 to 1%, but mortality is high in untreated cases. Early signs range from self-limited bleeding to massive hemorrhage with hypovolemic shock. The caliber of the tracheostomy cannula, its position in contact with the tracheal wall, and tracheal cuff pressure can traumatize the mucosa and trigger development of a TIF. We describe the case of a 14-year-old female patient who had been tracheostomized at the age of eight because of head trauma. She later developed subglottic stenosis requiring dilation sessions for six years. During the fifth year of these sessions, she presented repetitive hemoptysis, initially treated by surgery to implant an expanded polytetrafluoroethylene graft. One year later, she had an intense hemorrhage, which was controlled using endovascular techniques followed by definitive surgery, performed electively. The patient was followed up for six months, without complications.
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26
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Park J, Chung W, Song S, Kim YH, Lim CS, Ko Y, Yun S, Park H, Park S, Hong B. Identifying the ideal tracheostomy site based on patient characteristics during percutaneous dilatational tracheostomy without bronchoscopy. Korean J Anesthesiol 2019; 72:233-237. [PMID: 30744310 PMCID: PMC6547237 DOI: 10.4097/kja.d.18.00276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 02/11/2019] [Indexed: 11/26/2022] Open
Abstract
Background We previously reported that percutaneous dilatational tracheostomy (PDT) can be safely performed 2 cm below the cricothyroid membrane without the aid of a bronchoscope. Although our simplified method is convenient and does not require sophisticated equipment, the precise location for tracheostomy cannot be confirmed. Because it is recommended that tracheostomy be performed at the second tracheal ring, we assessed whether patient characteristics could predict the distance between the cricothyroid membrane and the second tracheal ring. Methods Data from 490 patients who underwent three-dimensional neck computed tomography from January 2012 to December 2015 were analyzed, and the linear distance from the upper part of the cricoid cartilage (CC) to the lower part of the second tracheal ring (2TR) was measured in the sagittal plane. Results The mean CC-to-2TR distance was 25.26 mm (95% CI 25.02–25.48 mm). Linear regression analysis showed that the predicted CC-to-2TR distance could be calculated as −5.73 + 0.2 × height (cm) + 1.22 × sex (male: 1, female: 0) + 0.01 × age (yr) −0.03 × weight (kg) (adj. R2 = 0.55). Conclusions These results suggest that height and sex should be considered when performing PDT without bronchoscope guidance.
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Affiliation(s)
- Jiho Park
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Woosuk Chung
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea.,Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Seunghyun Song
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Yoon-Hee Kim
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea.,Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Chae Seong Lim
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea.,Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Youngkwon Ko
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea.,Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Sangwon Yun
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Hyunwoo Park
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Sangil Park
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Boohwi Hong
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea.,Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Daejeon, Korea
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27
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Lee DJ, Yang W, Propst EJ, Rosenblatt SD, Hseu A, Wolter NE. Tracheo-innominate fistula in children: A systematic review of literature. Laryngoscope 2019; 130:217-224. [PMID: 30632162 DOI: 10.1002/lary.27765] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Tracheo-innominate fistula (TIF) is a rare but fatal complication of tracheotomy. To date, there is a paucity of literature regarding pediatric TIFs. The objectives of this study were to conduct a systematic review of literature on pediatric TIF following tracheotomy and describe three demonstrative cases from our institutional experience. METHODS We conducted a systematic review using MEDLINE, Embase, Cochrane Database of Systematic Reviews, Web of Science, and CINAHL. All studies with pediatric patients (under 18 years of age) who developed TIF following tracheotomy were included. RESULTS Fifty-four publications met inclusion criteria, reporting on 77 cases. The most common indication for tracheotomy was prolonged intubation and the need for ventilatory support (38.6%), with neurological comorbidities being the most common indication (72.7%). The mean time to TIF was 395.7 days (95% confidence interval, 225.9-565.5). Fifty-four patients (70.1%) presented with massive hemorrhage, whereas 18 patients (23.3%) presented with a sentinel bleeding event. The most common diagnostic interventions were computed tomography scan with or without contrast and bronchoscopy (55.8%). A substantial number of patients did not have any investigations (41.6%). Surgical management occurred in 70.1% of patients. Mortality was 38.6% in reported cases with variable follow-up periods. CONCLUSION TIF may occur in long-term tracheostomy-dependent children, contrary to the conventionally described 3-week postoperative period. The mortality may not be as high as previously reported with timely intervention. Our results are limited by inherent risks of bias. Further research including well-designed cohort studies are needed to guide an evidence-based approach to TIF. LEVEL OF EVIDENCE NA Laryngoscope, 130:217-224, 2020.
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Affiliation(s)
- Daniel J Lee
- Department of Otolaryngology-Head & Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Weining Yang
- Department of Otolaryngology-Head & Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Evan J Propst
- Department of Otolaryngology-Head & Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Steven D Rosenblatt
- Department of Otolaryngology-Head & Neck Surgery, Weill Cornell Medicine, New York, New York
| | - Anne Hseu
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Boston, Massachusetts, U.S.A
| | - Nikolaus E Wolter
- Department of Otolaryngology-Head & Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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28
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Doherty C, Neal R, English C, Cooke J, Atkinson D, Bates L, Moore J, Monks S, Bowler M, Bruce IA, Bateman N, Wyatt M, Russell J, Perkins R, McGrath BA. Multidisciplinary guidelines for the management of paediatric tracheostomy emergencies. Anaesthesia 2018; 73:1400-1417. [PMID: 30062783 DOI: 10.1111/anae.14307] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2018] [Indexed: 01/09/2023]
Abstract
Temporary and permanent tracheostomies are required in children to manage actual or anticipated long-term ventilatory support, to aid secretion management or to manage fixed upper airway obstruction. Tracheostomies may be required from the first few moments of life, with the majority performed in children < 4 years of age. Although similarities with adult tracheostomies are apparent, there are key differences when managing the routine and emergency care of children with tracheostomies. The National Tracheostomy Safety Project identified the need for structured guidelines to aid multidisciplinary clinical decision making during paediatric tracheostomy emergencies. These guidelines describe the development of a bespoke emergency management algorithm and supporting resources. Our aim is to reduce the frequency, nature and severity of paediatric tracheostomy emergencies through preparation and education of staff, parents, carers and patients.
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Affiliation(s)
- C Doherty
- Department of Paediatric Anaesthesia, Manchester University NHS Foundation Trust, Manchester, UK
| | - R Neal
- Paediatric Intensive Care Medicine, Paediatrics, Birmingham Children's Hospital, Birmingham, UK
| | - C English
- Department of Paediatric ENT, Manchester University NHS Foundation Trust, Manchester, UK
| | - J Cooke
- Department of Paediatric Otolaryngology, Great Ormond Street Hospital, London, UK
| | - D Atkinson
- Department of Anaesthesia and Intensive Care Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - L Bates
- Department of Anaesthesia and Intensive Care Medicine, Royal Bolton Hospital, Bolton, UK
| | - J Moore
- Department of Anaesthesia and Intensive Care Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - S Monks
- Department of Anaesthesia, East Lancashire Hospitals NHS Trust, Burnley, UK
| | - M Bowler
- Department of Paediatric Anaesthesia, Manchester University NHS Foundation Trust, Manchester, UK
| | - I A Bruce
- Department of Paediatric Otolaryngology, Royal Manchester Children's Hospital, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - N Bateman
- Department of Paediatric Otolaryngology, Royal Manchester Children's Hospital, Manchester, UK
| | - M Wyatt
- Department of Paediatric Otolaryngology, Great Ormond Street Hospital, London, UK
| | - J Russell
- Department of Paediatric ENT, Our Lady's Children's Hospital, Dublin, Ireland
| | - R Perkins
- Department of Paediatric Anaesthesia, Manchester University NHS Foundation Trust, Manchester, UK
| | - B A McGrath
- Department of Anaesthesia and Intensive Care Medicine, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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29
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Qureshi AZ. Fatal innominate artery hemorrhage in a patient with tetraplegia: Case report and literature review. J Spinal Cord Med 2018; 41:731-734. [PMID: 29323630 PMCID: PMC6217503 DOI: 10.1080/10790268.2017.1417802] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Context Hemorrhage is one of the potentially fatal complications of tracheostomy. A rare but lethal cause of tracheostomy related bleeding is hemorrhage from the innominate artery. This occurs following tracheo-innominate artery fistula (TIF) formation, which is associated with a mortality rate of more than 85%. Here, we report the case of an individual with tetraplegia and a tracheostomy who died as a result of innominate artery hemorrhage. This case highlights the possible causes and interventions associated with this complication, and provides insight into tracheostomy related bleeding in patients with spinal cord injury (SCI). Findings A 15-year-old boy with a diagnosis of incomplete SCI at the C5 level was admitted for rehabilitation 4 months after injury. He required a tracheostomy for ventilation, and underwent subglottic stenosis dilatation thrice. Multiple decannulation attempts were performed without success. He received intensive care on several occasions for respiratory failure. During the course of his rehabilitation, a minimal tracheostomy bleed was observed, which became profuse within a few hours and led to hypoxia with loss of consciousness. An urgent sternotomy identified bleeding from a TIF. He suffered severe brain damage following massive tracheal hemorrhage and died. Conclusion/clinical relevance Given the morbidity of TIF-related hemorrhage, it is important to increase awareness of this rare condition among health-care providers, especially those in non-acute settings. Patients with SCI and a tracheostomy pose unique challenges related to respiratory compromise, which may accentuate TIF formation.
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Affiliation(s)
- Ahmad Zaheer Qureshi
- Department of Physical Medicine and Rehabilitation, King Fahad Medical City, Riyadh, Saudi Arabia,Correspondence to: Ahmad Zaheer Qureshi, Department of Physical Medicine and Rehabilitation, King Fahad Medical City, PO Box 59046, Riyadh 11525, Saudi Arabia.
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Shamji FM, Deslauriers J, Nelems B. Recognition and Management of Life-Threatening Tracheovascular Fistulae and How to Prevent Them. Thorac Surg Clin 2018; 28:403-413. [PMID: 30054078 DOI: 10.1016/j.thorsurg.2018.05.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Formation of a fistula between trachea and a major artery or vein in the root of the neck threatens life quickly from combination of major external bleeding and hemorrhagic shock, and asphyxiation from flooding of the proximal airways with blood. This complication can occur after cervical tracheostomy open or percutaneous, tracheal resection, cervical exentration and anterior mediastinal tracheostomy, and laryngectomy. The recognition of its occurrence is clinical based on a high index of clinical suspicion. The life-saving operation for this complication carries potential risk for ischemic stroke. Impairment of arterial perfusion to the right arm and ischemia is another potential complication.
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Affiliation(s)
- Farid M Shamji
- Division of Thoracic Surgery, The Ottawa Hospital - General Campus, University of Ottawa, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada.
| | | | - Bill Nelems
- Department of Surgery, University of British Columbia, 2178 Pandosy Street, Kelowna, British Columbia V1W 1S8, Canada
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31
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Chauhan JC, Hertzog JH, Viteri S, Slamon NB. Tracheoinnominate Artery Fistula Formation in a Child with Long-Term Tracheostomy Dependence. J Pediatr Intensive Care 2018; 8:96-99. [PMID: 31093462 DOI: 10.1055/s-0038-1672153] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 08/15/2018] [Indexed: 10/28/2022] Open
Abstract
We report a fatal tracheoinnominate artery fistula (TIF) in a 13-year-old female patient with long-term tracheostomy tube dependence due to chronic respiratory failure. Thirteen years after placement of her tracheostomy tube, the patient experienced two separate episodes of sentinel bleeding prior to a fatal hemorrhagic event. Diagnostic evaluation after the sentinel events was mostly nonconclusive. This case highlights the risk of TIF in pediatric age group, even years after initial tracheostomy tube placement, and the need for a high index of suspicion for TIF when children present with unexplained tracheal bleeding.
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Affiliation(s)
- Jigar C Chauhan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware, United States.,Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - James H Hertzog
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware, United States.,Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Shirley Viteri
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware, United States.,Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Nicholas B Slamon
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware, United States.,Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, United States
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Bobka TW, Sukato DC, Kohli NV, Worku B, Gulkarov IM, D'Ayala M. Endovascular Management of Tracheo-Subclavian Fistula. Ann Vasc Surg 2018; 53:267.e1-267.e4. [PMID: 30012451 DOI: 10.1016/j.avsg.2018.04.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 04/13/2018] [Accepted: 04/19/2018] [Indexed: 10/28/2022]
Abstract
Tracheoarterial fistula is a rare complication of tracheostomy with an incidence of less than 1%. Survival of this disease entity is low, and it likely results from a major open operation in a high-risk surgical group. In our review of the literature, a tracheoinnominate artery fistula is the most commonly reported arterial fistula. However, we present a rare case of tracheo-left subclavian artery fistula. We have identified 1 previous case of tracheo-left subclavian fistula as a source of massive tracheal bleeding. In our case report, we describe the successful management of this disease by endograft placement. Owing to its rarity, there are no guidelines on the management approach to tracheoarterial fistulas, but given the difficulty of controlling this problem via median sternotomy, the placement of a covered stent may be the best therapy. Initially, case reports showed a role for endograft placement as a temporizing measure, but the risk of infection may be sufficiently low to justify this approach as a definitive therapy. Upon a 6-month follow-up, our patient remains without recurrence of bleeding or infection, and computed tomography angiography of the chest with 3D reconstruction has shown patency of the endovascular stent with resolution of the associated pseudoaneurysm.
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Affiliation(s)
- Thomas W Bobka
- Department of Surgery, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY.
| | - Daniel C Sukato
- Department of Otolaryngology, SUNY Downstate Medical Center, Brooklyn, NY
| | - Nikita V Kohli
- Department of Otolaryngology, SUNY Downstate Medical Center, Brooklyn, NY
| | - Berhane Worku
- Department of Surgery, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY; Department of Cardiothoracic Surgery, Weill Cornell Medical Center, New York, NY
| | - Iosif M Gulkarov
- Department of Cardiothoracic Surgery, Staten Island University Hospital, Staten Island, NY
| | - Marcus D'Ayala
- Department of Surgery, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY
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33
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Kaye C, MacLeod I, Dhillon M. Bleeding during percutaneous dilatational tracheostomy - What to do while waiting for the surgeon? J Intensive Care Soc 2018; 19:64-68. [PMID: 29456605 DOI: 10.1177/1751143717715970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
A patient suffered significant bleeding during an attempt at percutaneous dilatational tracheostomy due to an aberrant anterior jugular vein. Bleeding was controlled with pressure temporarily, but quickly returned necessitating conversion to an open technique. We present an algorithm for the management of significant peri-procedural bleeding during this procedure.
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Affiliation(s)
- C Kaye
- Aberdeen Royal Infirmary, UK
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Surgical Rescue in Medical Patients: The Role of Acute Care Surgeons as the Surgical Rapid Response Team. Crit Care Clin 2018; 34:209-219. [PMID: 29482901 DOI: 10.1016/j.ccc.2017.12.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Failure to rescue is death occurring after a complication. Rapid response teams developed as a prompt intervention for patients with early clinical deterioration, generally from medical conditions or complications. Patients with surgical complications or surgical pathology require prompt evaluation and management by surgeons to avoid deterioration; this is surgical rescue. Patients in the medical intensive care unit may develop intra-abdominal pathology that requires expeditious operative intervention. Acute care surgeons should serve as the surgical rapid response team to help assess and manage these complex patients. Collaboration between intensivists and surgeons is essential to rescue patients from complications and surgical disease.
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Reger B, Neu R, Hofmann HS, Ried M. High mortality in patients with tracheoarterial fistulas: clinical experience and treatment recommendations. Interact Cardiovasc Thorac Surg 2017; 26:12-17. [DOI: 10.1093/icvts/ivx249] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 07/02/2017] [Indexed: 11/14/2022] Open
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Yogo A, Komori M, Yano Y, Fujita K, Sando E, Kotani M, Sugimura H, Ochi A, Moody S, Yaegashi M. A case of tracheo-innominate artery fistula successfully treated with endovascular stent of the innominate artery. J Gen Fam Med 2017; 18:162-164. [PMID: 29264016 PMCID: PMC5675153 DOI: 10.1002/jgf2.37] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 07/29/2016] [Indexed: 11/07/2022] Open
Abstract
Tracheo‐innominate artery fistula (TIF) is a rare but life‐threatening complication of tracheostomy. We describe a 44‐year‐old man who was admitted for a pressure ulcer infection with a third tracheostomy in place. He showed massive hemoptysis from the TIF, followed by cardiopulmonary arrest. The cuff of the tube was hyperinflated; however, even a slight movement of the tube resulted in recurrent massive hemorrhage. Thus, an endovascular stent graft was placed. Our case shows that sentinel bleeding may be found prior to TIF, and an endovascular repair can be a lifesaving temporizing option, when the hemorrhage was not controlled by hyperinflating the cuff of the tube.
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Affiliation(s)
- Aoi Yogo
- General Internal Medicine Kameda Medical Center Kamogawa Chiba Japan
| | - Masafumi Komori
- General Internal Medicine Kameda Medical Center Kamogawa Chiba Japan
| | - Yudai Yano
- General Internal Medicine Kameda Medical Center Kamogawa Chiba Japan
| | - Koji Fujita
- General Internal Medicine Kameda Medical Center Kamogawa Chiba Japan
| | - Eiichiro Sando
- General Internal Medicine Kameda Medical Center Kamogawa Chiba Japan
| | - Mitsuhisa Kotani
- Cardiovascular Surgery Kameda Medical Center Kamogawa Chiba Japan
| | | | - Atsushi Ochi
- Otorhinolaryngology Kameda Medical Center Kamogawa Chiba Japan
| | - Sandra Moody
- General Internal Medicine Kameda Medical Center Kamogawa Chiba Japan
| | - Makito Yaegashi
- General Internal Medicine Kameda Medical Center Kamogawa Chiba Japan
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Klemm E, Karl Nowak A. Tracheotomy-Related Deaths. DEUTSCHES ARZTEBLATT INTERNATIONAL 2017; 114:273-279. [PMID: 28502311 PMCID: PMC5437259 DOI: 10.3238/arztebl.2017.0273] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 09/02/2016] [Accepted: 02/09/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Tracheotomies are frequently performed on ventilated patients in intensive care and sometimes lead to fatal complications. In this article, we discuss the causes and frequency of death associated with open surgical tracheotomy (OST) and percutaneous dilatational tracheotomy (PDT) on the basis of a review of the pertinent literature. METHODS We systematically searched the PubMed, EMBASE, and Cochrane Library databases and the Karlsruhe Virtual Catalog for publications (1990-2015) on tracheotomy-related deaths in adults, using the search terms "tracheotomy" and "tracheostomy." 39 relevant dissertations were included in the analysis as well. RESULTS 109 publications were included. Of the 25 056 tracheotomies described, there were 16 827 PDTs and 7934 OSTs; for 295 tracheotomies, the technique used was not stated. 352 deaths were reported, including 113 in patients treated with PDT, 49 in those treated with OST, and 190 deaths related to a tracheotomy without specification of the method used. The frequency of death among patients with OST and those treated with PDT was similar: 0.62% for OST (95% confidence interval [0.47; 0.82]) and 0.67% for PDT ([0.56; 0.81]). The most common causes of death and their frequencies, as a percentage of all tracheotomies, were hemorrhage (OST: 0.26% [0.17; 0.40], PDT: 0.26% [0.19; 0.35]), loss of airway (OST: 0.21% [0.13; 0.34], PDT: 0.20% [0.14; 0.28]), and false passage (OST: 0.11% [0.06; 0.22], PDT: 0.20% [KI 0.15; 0.29]). CONCLUSION Bias in the data cannot be excluded, as these were not epidemiologic data and the documentation was found to be incomplete. The likelihood of a fatal complication seems to be the same with both tracheotomy techniques as far as can be determined from the available evidence. Tracheotomy-related deaths can be avoided in several ways: by thorough training under the leadership of experienced physicians, by the use of the World Health Organization's Surgical Safety Checklist regardless of where the tracheotomy is performed, and by the continuous vigilance of nursing staff.
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Affiliation(s)
- Eckart Klemm
- Department of Otorhinolaryngology, Head and Neck Surgery, Plastic Surgery, Muncipial Hospital Dresden, Academic Teaching Hospital of the Technical University of Dresden
| | - Andreas Karl Nowak
- Department of Anesthesiology and Intensive Care Medicine, Emergency Medicine and Pain Therapy, Muncipial Hospital Dresden, Academic Teaching Hospital of the Technical University of Dresden
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38
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Postoperative Tracheotomie. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2016. [DOI: 10.1007/s00398-016-0120-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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39
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Bae MH, Lee YJ, Nam SO, Kim HY, Kim CW, Kim YM. Endovascular stenting of tracheoinnominate fistula after tracheostomy in a 14-year-old boy. KOREAN JOURNAL OF PEDIATRICS 2016; 59:S76-S79. [PMID: 28018452 PMCID: PMC5177719 DOI: 10.3345/kjp.2016.59.11.s76] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 04/11/2016] [Accepted: 04/18/2016] [Indexed: 11/27/2022]
Abstract
Tracheoinnominate artery fistula is a rare, fatal complication of tracheostomy, and prompt diagnosis and management are imperative. We report the case of tracheoinnominate artery fistula after tracheostomy in a 14-year-old boy with a history of severe periventricular leukomalacia, hydrocephalus, cerebral palsy, and epilepsy. The tracheoinnominate artery fistula was successfully treated with a stent graft insertion via the right common femoral artery. Endovascular repair of the tracheoinnominate artery fistula via stent grafting is a safe, effective, and minimally invasive treatment for patients in poor clinical conditions and is an alternative to traditional open surgical treatment.
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Affiliation(s)
- Mi-Hye Bae
- Department of Pediatrics, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Busan, Korea
| | - Yun-Jin Lee
- Department of Pediatrics, Pusan National University Children's Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Sang Ook Nam
- Department of Pediatrics, Pusan National University Children's Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Hye-Young Kim
- Department of Pediatrics, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Busan, Korea
| | - Chang Won Kim
- Department of Radiology, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Young Mi Kim
- Department of Pediatrics, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Busan, Korea
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Mahmood K, Wahidi MM. The Changing Role for Tracheostomy in Patients Requiring Mechanical Ventilation. Clin Chest Med 2016; 37:741-751. [PMID: 27842753 DOI: 10.1016/j.ccm.2016.07.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Tracheostomy is performed in patients who require prolonged mechanical ventilation or have upper airway instability. Percutaneous tracheostomy with Ciaglia technique is commonly used and rivals the surgical approach. Percutaneous technique is associated with decreased risk of stomal inflammation, infection, and bleeding along with reduction in health resource utilization when performed at bedside. Bronchoscopy and ultrasound guidance improve the safety of percutaneous tracheostomy. Early tracheostomy decreases the need for sedation and intensive care unit stay but may be unnecessary in some patients who can be extubated later successfully. A multidisciplinary approach to tracheostomy care leads to improved outcomes.
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Affiliation(s)
- Kamran Mahmood
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Duke University Medical Center, DUMC 102356, Durham, NC 27710, USA.
| | - Momen M Wahidi
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Duke University Medical Center, DUMC 102356, Durham, NC 27710, USA
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Naunheim MR, Song PC, Franco RA, Alkire BC, Shrime MG. Surgical management of bilateral vocal fold paralysis: A cost-effectiveness comparison of two treatments. Laryngoscope 2016; 127:691-697. [DOI: 10.1002/lary.26253] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 06/24/2016] [Accepted: 07/20/2016] [Indexed: 12/22/2022]
Affiliation(s)
- Matthew R. Naunheim
- Department of Otolaryngology-Head and Neck Surgery; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Phillip C. Song
- Department of Otolaryngology-Head and Neck Surgery; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Ramon A. Franco
- Department of Otolaryngology-Head and Neck Surgery; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Blake C. Alkire
- Department of Otolaryngology-Head and Neck Surgery; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Mark G. Shrime
- Department of Otolaryngology-Head and Neck Surgery; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
- Department of Global Health and Population; Harvard School of Public Health; Boston Massachusetts U.S.A
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Menen RS, Pak JJ, Dowell MA, Patel AR, Ashiku SK, Velotta JB. Treatment of Tracheoinnominate Fistula with Ligation of the Innominate Artery: A Case Report. Perm J 2016; 20:15-166. [PMID: 27352412 DOI: 10.7812/tpp/15-166] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Tracheoinnominate fistula, a rare complication of tracheostomy, carries high mortality regardless of treatment; therefore prevention and quick diagnosis is pertinent to survival. CASE PRESENTATION A 76-year-old man who underwent emergent tracheostomy placement presented on postoperative day 10 with massive hemorrhage concerning for tracheoinnominate fistula and was treated with median sternotomy and ligation of the innominate artery. DISCUSSION This presentation describes a concise diagnosis and treatment plan for a rare event. The key to good outcomes is quick diagnosis and urgent surgical intervention.
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Affiliation(s)
- Rhiana S Menen
- Surgeon at the University of California San Francisco-Eastbay in Oakland.
| | - Jimmy J Pak
- Vascular Surgeon at the Oakland Medical Center in CA.
| | - Matthew A Dowell
- Thoracic Surgery Physician Assistant at the Oakland Medical Center in CA.
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Chung W, Kim BM, Park SI. Simply modified percutaneous tracheostomy using the Cook® Ciaglia Blue Rhino™: a case series. Korean J Anesthesiol 2016; 69:301-4. [PMID: 27274380 PMCID: PMC4891547 DOI: 10.4097/kjae.2016.69.3.301] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 08/06/2015] [Accepted: 08/09/2015] [Indexed: 11/29/2022] Open
Abstract
When first introduced, percutaneous dilatational tracheostomy (PDT) was performed using a bronchoscope. The bronchoscope itself, however, has several disadvantages, including interruption of ventilation. Modifications of the standard PDT technique have suggested that PDT can be safely performed without a bronchoscope. However, the safety of these modifications is unclear and many modifications have yet to be widely adopted. This study retrospectively evaluated the safety of a simplified PDT technique using the Cook® Ciaglia Blue Rhino™ in 186 patients. After confirming the underlying structures by palpation, PDT was performed without a bronchoscope or blunt dissection, 2.0 cm below the cricothyroid membrane. Ultrasonography was used only when palpation was difficult. Except for bleeding in three patients with coagulopathy, none of the patients experienced any early or late complications, and there were no deaths related to PDT. These findings confirm that PDT can be safely performed using a simplified technique, which may be useful in situations with limited equipment and medical personnel.
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Affiliation(s)
- Woosuk Chung
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Byung Muk Kim
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Sang-Il Park
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
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44
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Long B, Koyfman A. Resuscitating the tracheostomy patient in the ED. Am J Emerg Med 2016; 34:1148-55. [PMID: 27073134 DOI: 10.1016/j.ajem.2016.03.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 03/18/2016] [Accepted: 03/19/2016] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Emergency physicians must be masters of the airway. The patient with tracheostomy can present with complications, and because of anatomy, airway and resuscitation measures can present several unique challenges. Understanding tracheostomy basics, features, and complications will assist in the emergency medicine management of these patients. OBJECTIVE OF REVIEW The aim of this review is to provide an overview of the basics and features of the tracheostomy, along with an approach to managing tracheostomy complications. DISCUSSION This review provides background on the reasons for tracheostomy placement, basics of tracheostomy, and tracheostomy tube features. Emergency physicians will be faced with complications from these airway devices, including tracheostomy obstruction, decannulation or tube dislodgement, stenosis, tracheoinnominate fistula, and tracheoesophageal fistula. Critical patients should be evaluated in the resuscitation bay, and consultation with ENT should be completed while the patient is in the department. This review provides several algorithms for management of complications. Understanding these complications and an approach to airway management during cardiac arrest resuscitation is essential to optimizing patient care. CONCLUSION Tracheostomy patients can present unique challenges for emergency physicians. Knowledge of the basics and features of tracheostomy tubes can assist physicians in managing life-threatening complications including tube obstruction, decannulation, bleeding, stenosis, and fistula.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, Houston, TX 78234.
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, TX 75390.
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45
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Affiliation(s)
- Y-C Hsu
- Department of Emergency Medicine, E-Da Hospital, No.1, Yida Road, Jiao-su Village, Yan-chao District, I-Shou University, Kaohsiung, Taiwan
| | - Y-C Huang
- Department of Emergency Medicine, E-Da Hospital, No.1, Yida Road, Jiao-su Village, Yan-chao District, I-Shou University, Kaohsiung, Taiwan
| | - C-W Hsu
- Department of Emergency Medicine, E-Da Hospital, No.1, Yida Road, Jiao-su Village, Yan-chao District, I-Shou University, Kaohsiung, Taiwan
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46
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Browne GA. Quick Response Tracheotomy: A Novel Surgical Procedure. J Intensive Care Med 2016; 31:276-84. [PMID: 26905541 DOI: 10.1177/0885066615627141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 12/23/2015] [Indexed: 11/16/2022]
Abstract
Quick response tracheostomy (QRT) is a novel open surgical technique to emergently establish an airway. The method is simple; the skills necessary to perform this procedure are rapidly acquired; and it is expedient, minimally traumatic, and remarkably devoid of complications often encountered with percutaneous dilatational tracheotomies, including those complications seen with cricothyroidotomies. Unlike all other tracheotomies in which considerable blunt dissection is required, QRT avoids tissue crushing because sharp dissection alone is used to acquire surgical access to the trachea. The QRT does not entail inserting a guidewire into the trachea, a standard feature for percutaneous tracheal access; it avoids any risk of unintended laceration of the posterior tracheal wall and proximal subjacent esophagus. The technique averts tracheal ring fracture and tracheoesophageal fistula complications. The QRT has a uniquely low incidence of inducing hemorrhage, and it requires no steps that cause temporary tracheal occlusion and will therefore not facilitate hypoxia. The QRT contributes minimally to conditions favorable for generating subglottic stenosis, and the procedure is swiftly executed with very low probability for external tracheal placement of the tracheostomy tube. The QRT is not a blind procedure. No special instruments are required for its execution nor is concurrent tracheoscopy required at any stage while performing a QRT as is specified for percutaneous tracheotomies.
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Affiliation(s)
- Graeme A Browne
- Department Emergency Medicine, Mayo Health Care System Austin, Austin, MN, USA
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47
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Akulian JA, Yarmus L, Feller-Kopman D. The role of cricothyrotomy, tracheostomy, and percutaneous tracheostomy in airway management. Anesthesiol Clin 2016; 33:357-67. [PMID: 25999008 DOI: 10.1016/j.anclin.2015.02.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Cricothyrotomy, percutaneous dilation tracheostomy, and surgical tracheostomy are cost-effective and safe techniques employed in the management of critically ill patients requiring insertion of an artificial airway. These procedures have been well characterized and studied in the surgical, emergency medicine, and critical care literature. This article focuses on the role of each of these modalities in airway management, specifically comparing the data for each procedure in regard to procedural outcomes. The authors discuss the techniques available and the relevant background data regarding choice of each method and its integration into clinical practice.
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Affiliation(s)
- Jason A Akulian
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, 8007 Burnett Womack, CB 7219, Chapel Hill, NC 27599-7219, USA
| | - Lonny Yarmus
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care, Johns Hopkins Hospital, Johns Hopkins University, 1800 Orleans Street, Suite 7125, Baltimore, MD 21287, USA
| | - David Feller-Kopman
- Bronchoscopy and Interventional Pulmonology, Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Johns Hopkins University, Baltimore, MD 21287, USA.
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Abstract
Background: The use of ultrasound to evaluate cervical anatomy and to guide tracheal puncture in real-time has been advocated to improve safety and efficacy of percutaneous dilatational tracheostomy (PDT) in intensive care. Objective: To review the potential role, attributed theoretical benefits and supporting literature for ultrasound during PDT. Results: A significant number of mostly observational studies and case series support this modality. Real-time guidance enables clear visualisation of anatomical landmarks and results in a consistently high success and low complication rate, with appropriate positioning of the tracheal puncture. Recognition of unconventional vascular anatomy enables selection of an appropriate alternative puncture site or an elective open surgical approach. Conclusion: Current literature supports that using ultrasound for percutaneous tracheostomy is quick, safe, reliable and offers a plausible advantage over the traditional landmark guided procedure, especially in select patient groups, such as those who are morbidly obese or have difficult to palpate cervical anatomy.
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Affiliation(s)
- Máté Rudas
- Intensive Care Unit Nepean Hospital PO Box 63 Penrith New South Wales Australia
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Surgically modified airways: What every anesthesiologist should know. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2015. [DOI: 10.1016/j.tacc.2015.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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50
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Post Tracheostomy Carotid-Tracheal Fistula. Indian J Otolaryngol Head Neck Surg 2014; 68:97-9. [PMID: 27066421 DOI: 10.1007/s12070-014-0813-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 11/28/2014] [Indexed: 10/24/2022] Open
Abstract
Tracheostomy is the life saving procedure in patients presenting with upper airway obstruction. The procedure is also performed in patients on chronic ventilatory support. It is generally considered a safe procedure with a low complication rate. Vascular injuries are the most serious and life threatening complications. Injury to a high lying innominate artery is the most frequent vascular injury in such cases. Injury to other vessels e.g. carotid arteries is less frequent. We are presenting one such rare type of vascular injury with a fistulous communication between trachea and carotid artery leading to massive hemoptysis.
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