Abstract
This prospective study assessed the morbidity and mortality associated with 192 consecutive tracheotomies. Complications were assessed including intraoperative and/or postoperative bleeding, infection, tracheoinnominate fistulae, tracheoesophageal fistulae, dislodgement of the tracheotomy tube, pneumothorax, wound infection and obstruction of the airway. 16% of the tracheotomy procedures resulted in complications. 22 tracheotomy procedures (11%) resulted in postoperative bleeding, 6 procedures (3%) had intraoperative bleeding which exceeded an estimated blood loss of 5 cc and 2 procedures (1%) developed a tracheoesophageal fistula. One patient (0.5%) experienced airway distress related to obstruction of the airway proximal to the tracheotomy tube. No patients required a return to the operating room to manage their complication, no patients developed a tracheoinnominate fistula and none of the tracheotomy sites became infected. The post tracheotomy ventilator wean to trach-collar supplemental oxygen protocol was accomplished with a mean of 6 days in 119 patients for whom data was available. Results demonstrate that the open tracheotomy procedure is a safe and frequently life saving manoeuvre in situations with an unsecured airway, and it provides better outcomes in patients requiring long term ventilatory support. Mortality rates are low and its potential morbidity is exceeded by its benefits.
Tracheotomy is a commonly performed elective procedure that is indicated in patients experiencing prolonged tracheal intubation for mechanical ventilatory support or as an emergent procedure in the event of the sudden loss of an airway that cannot be secured by conventional methods. Reports of serious adverse events related to tracheotomy procedures are variable in the literature. The history of the tracheotomy procedure encompasses several centuries and it is one of the oldest performed surgical procedures. A tracheotomy was depicted on Egyptian tablets in 3600 BC. In 100 BC Asclepiades of Persia was credited as the first person to perform this procedure. It was originally used for the emergency management of upper airway obstruction, although with limited success according to the first detailed reports of Galen and Aretaeus. In a rare mention in the thirteenth century, tracheotomy is termed the ‘scandal of surgery’ and as ‘semislaughter’ throughout most of the Middle Ages. It was not until 1718 that Lorenz Heister coined the term tracheotomy.
The operative technique of tracheotomy was refined as the result of studies by Chevalier Jackson, who standardized it, reducing the mortality rate from 25% to 2%. With the challenge of the polio epidemics of the 1940s, Galloway further expanded the indications for the procedure to include the treatment of respiratory paralysis and the management of secretions. In more recent times, the development of synthetic materials, improved tracheotomy tubes and low pressure/high volume cuffs have greatly reduced the morbidity associated with this surgical procedure. In the modern era, the mortality rate has remained less than 5% with a total complication rate of 14–66% as reported by Stauffer et al.
The complication rate associated with the tracheotomy procedure varies widely depending on study design, patient follow up and the definition of complications. Numerous studies demonstrate a greater mortality rate and complications in emergency situations. Complications may be categorized according to the timing of onset (intraoperative or postoperative), and by their magnitude, which may range from relatively insignificant to life threatening. While their incidence may be reduced, their elimination is not possible.
Materials and methods
A prospective analysis was performed of 192 consecutive open tracheotomies performed in 191 patients at the University of Tennessee Medical Center by one surgeon (ERC) between 2003 and 2010. Institutional Review Board (IRB) approval was secured to conduct this study. The age range of the patients was 14–92 years (median 55 years) and their weight ranged from 76 to 756 lbs ( Table 1 ). 187 (97%) of the tracheotomies were elective, and the remaining 5 (3%) were emergencies ( Table 1 ). 147 (76%) of the tracheotomies were performed for the treatment of chronic respiratory failure in patients requiring long-term ventilatory support, 27 (14%) were performed in patients with complex maxillofacial trauma, 15 (8%) were related to the management of head and neck cancer, and 3 (2%) were performed to secure the airway in patients with maxillofacial deep space infections ( Table 2 ).
| Dates of treatment | 1/2003 to 1/2010 |
| Total number of patients | 191 |
| Total number of tracheotomies | 192 |
| Age | 14–92 |
| Male:female | 108:83 |
| Weight (lbs) | 76–756 |
| Elective tracheotomies | 187 (97%) |
| Emergent tracheotomies | 5 (3%) |
| Chronic respiratory failure | 147 (76%) |
| Trauma | 27 (14%) |
| Head and neck cancer | 15 (8%) |
| Deep space infections | 3 (2%) |
Complications were categorized at the beginning of the study as intraoperative and postoperative bleeding, infection, tracheoesophageal fistula, tracheoinnominate fistula, dislodgement of the tracheotomy tube, pneumothorax, wound infection, and airway obstruction.
All the tracheotomies were performed in the operating room under general anaesthesia. Patients transported from the intensive care unit (ICU) remained in their ICU bed to minimize problems such as cardiovascular compromise or endotracheal tube displacement associated with transfer to the operating room table. Non-ICU patients were transferred from a hospital bed to the operating room table. The tracheotomy procedure was performed according to standard surgical guidelines for the development of an open procedure. A preoperative qualitative assessment of the index of difficulty of the procedure was determined after which time a decision was made regarding whether a vertical or horizontal incision would be created. The authors performed vertical incisions in 28 of the 192 patients. Vertical incisions were made in the inferior neck in obese patients and horizontal incisions were made approximately two fingerbreadths above the manubrial notch in non-obese patients. The definition of obesity was developed qualitatively by the senior surgeon at the initiation of the surgical procedure. The vertical incision afforded greater protection of the anatomic position of the anterior jugular veins that were not easily visualized during the dissection, thereby resulting in less intraoperative blood loss. Following development of the skin incision, sharp dissection of the subcutaneous tissues and platysma muscle occurred. Thereafter a routinely vertical dissection was performed to identify the sternothyroid muscles that were retracted laterally. Further sharp dissection of the pretracheal fascia occurred and the trachea was identified. The trachea was entered by creating vertical cartilaginous flaps laterally and the trachea was cannulated.
The size of the patient resulted in the placement of either a #8 Shiley, cuffed and non-fenestrated tracheotomy tube, or a distal or proximal extended length (XLT) tracheotomy tube, depending on the thickness of the lower neck skin. The tracheotomy tube was secured to the skin with four corner 2–0 silk sutures and a Velcro strap.
Surgicel (Ethicon, New Brunswick, NJ, USA) was placed superficially in the wound surrounding the tracheotomy tube to assist in postoperative hemostasis, owing to many patients not being able to undergo preoperative discontinuation of their anticoagulation therapy. An antero-posterior chest radiograph was obtained immediately on return to ICU.
Results
31 tracheotomy procedures (16%) resulted in non-life threatening complications. Six tracheotomy procedures (3%) developed intraoperative bleeding, which was arbitrarily designated as those cases where the estimated blood loss exceeded 5 cc. None of the 5 emergent tracheotomies developed complications. The lack of complications probably stems from the authors’ realization that a routine tracheotomy does not require more time to perform than an emergency tracheotomy. Postoperative bleeding requiring local control with gauze packs occurred in 22 (11%) of the cases and it was most often associated with early initiation of the weaning protocol with lack of ventilator tolerance by the patient, elevation of blood pressure, and resumption of anticoagulation therapy. Bleeding was noted between postoperative days 1 and 16 and easily managed at the bedside with local measures. Tracheoesophageal fistulae were seen in 2 (1%) cases and no infections or tracheoinnominate fistulae developed ( Table 3 ). None of the patients developed a pneumothorax and no patients experienced tube dislodgement or decannulation requiring emergent management. No wound infections developed. One case of airway obstruction with Surgicel occurred that led to oxygen desaturation. Inferior migration of the Surgicel proximal to the tracheotomy was noted to have occurred and bronchoscopy was required for retrieval. Inadvertent cuff deflation was thought to have been responsible for the inferior migration of the Surgicel.
