Tracheostomy and its complications. A retrospective study of 794 tracheostomized patients.

The records of 794 tracheostomized patients were studied in order to discover complication associated with tracheostomy. Bacterial colonization was found in 92% of patients from whom tracheal secretions were cultured, crusted airways in 5%, tracheobronchitis is 16%, pneumonia in 22% and tracheobronchial bleeding in 22% of patients in the form of bloody secretions. Tracheo-arterial erosion with massive bleeding was confirmed in five patients and treatment was successful in one case only. Tracheo-oesophageal fistula was diagnosed in three patients at autopsy. After extubation, symptomatic tracheal stenosis developed in nine patients, two of whom died. The overall mortality rate was 46% reflecting the seriousness of patients' diseases. Tracheostomy related mortality rate was 1.4%. The study was divided into two periods, one before the introduction of an intensive care unit (ICU) and the second thereafter when most of the patients were treated in ICU. The total number of complications during tracheostomy operation was higher during the first period than that in the second period. During tracheostomy treatment, crusted airways were confirmed more often during the first period whereas tracheobronchitis was observed more frequently during the second period. In other respects the incidence of separate complications did not differ statistically. The total number of complications increased but the incidence of separate complications did not increase, although there was a greater number of patients who were tracheostomized or received respirator treatment for a long period.

Tracheal stenosis after tracheostomy and after orotracheal cuffed intubation.

Tracheal stenosis occurred in 9 cases in a series of 812 tracheostomized patients, an incidence of 1.1%. Two additional stenoses had developed after orotracheal cuffed intubation. Two suprastomal, two stomal and seven infrastomal stenoses were confirmed. The stenosis was diagnosed within 10 weeks of extubation in 10 patients and 5 months after extubation in 1 case. The airway results were good after segmental resection and end to end anastomosis in 5 patients; satisfactory in 4 patients after various dilatation procedures and poor in 1 case after removal of granulation tissue. The mortality rate was 18%. One patient died on account of missed diagnosis and another of tracheo-innominate artery erosion with massive bleeding after tracheal resection. The present report indicates that the best airway results are achieved by segmental resection. Various dilatation procedures, however, produced satisfactory airway results and should be used as primary treatment when the stage of the stenosis makes resection inappropriate. When planning surgical treatment, X-ray examinations, tomography or tracheo-graphy are necessary for evaluation of the site and length of the stenosis. The stage of the stenosis can best be evaluated by tracheoscopy. The use of large, low-pressure thin-walled cuffs and avoidance of overinflation of the cuff are the most important measures for preventing the cuff-induced tracheal injury which may lead to tracheal stenosis.

Healing of lesions caused by cuffed tracheostomy tubes and their late sequelae; a follow-up study.

The healing of tracheostomy and cuff-induced tracheal injury was followed up in 48 tracheostomized patients (44 men and 4 women). The patients were studied by means of tracheoscopy, fluoroscopy and tracheography, with a positive contrast medium. At extubation, tracheoscopy revealed 12 mild, 23 moderate and 13 severe injuries at the cuff level. Three months after extubation, the stoma had closed in 89% of the patients studied. In 85% of the patients, the side wall of the stoma was found to have collapsed inwards and in 71% scars were observed at the cuff level. No significant changes took place after the follow-up study at 3 months. At tracheography it was found that narrowing of the tracheal diameter at the stomal level was of only mild or moderate degree (i.e. 0-33%). There was not a single instance of severe stenosis. At the cuff level, a slight inward collapse of the side wall was observed in one patient, and in all the other patients the lumen was normal. Fluoroscopy did not reveal severe tracheomalacia in any patient. Increased mobility of the stomal scar, especially in connection with coughing was seen in some patients. One tracheo-innominate artery erosion and one bleeding granulation tissue at the stoma were confirmed during follow-up. Surgical trauma to the trachea at the stoma seems to be a more potent cause of subsequent narrowing of the trachea than the cuff. Even though severe injuries may also heal with few sequelae, the use of tracheostomy tubes with large, low-pressure cuffs, which have been shown to cause less damage to the trachea, is indicated.

Post-mortem findings of tracheal injury after cuffed intubation and tracheostomy. A clinical and histopathological study.

The tracheas of 37 tracheostomized patients (31 men and 6 women) were studied in connection with obduction. Twenty-six patients had been intubated before tracheostomy and 29 of the tracheostomized patients were treated with a respirator. At autopsy, the damage caused to the tracheal wall by the cuff was studied macroscopically; the finding was photographed for later investigation and samples were taken from the damaged area for microscopic examination. The purpose of the study was to determine the damage caused to the tracheal wall by the low-volume cuff we have used during the last 4 years. The cuff diameter was nearly the same as that of the trachea. The injuries were grouped according to their extent and depth as mild, moderate or severe, and the groups contained, respectively, 5, 12 and 20 patients. It seemed that cuff pressure played a greater part in causing damage than the duration of cuff strain. Factors in the clinical condition of patients, like hypotension, uraemia, respiratory infections, sepsis and use of steroids, may have had an effect on the development of damage. The injuries caused by the cuff used are so severe that there is every reason to use instead the low-pressure, high-volume cuff, which has been shown to cause less damage, whenever long-term treatment is involved.

Tracheo-arterial erosion complicating tracheostomy.

Tracheo-arterial erosion occurred in 5 cases out of 816 tracheostomized patients, i.e. an incidence of 0.6%. The complication is serious and is nearly always fatal. In one case, treatment was successful, but the other four patients died as a result of massive haemorrhage. On the basis of these cases the factors leading to this complication and the possibilities of treatment are discussed. In one case the main cause of innominate artery erosion was the low lying tracheostomy. This patient was rapidly resuscitated, the blood volume was restored, bleeding controlled by direct finger pressure on the innominate artery and an emergency operation was performed immediately. The innominate artery was excluded from circulation and bypassed with an autogenous venous graft. The patient recovered and is doing well after a follow-up of two and half years.

Effect of different respirator adjustments on central haemodynamics in open-heart surgery patients.

Changes in cardiac index (CI) mean pulmonary artery pressure (PAP), mean pulmonary capillary wedge pressure (PCWP), central venous pressure (CVP), and pulmonary artery vascular resistance (PVR), associated with spontaneous respiration (SR) and two different types of intermittent positive pressure ventilation (IPPPV and IPNPV) were studied in a total of 17 patients undergoing aortic valve replacement or myocardial revascularization. Swan-Ganz thermodilution pulmonary artery cardiac output catheters were used and the aim was to determine: whether postoperative cardiac output may paradoxically be greater during IPPPV than during IPNPV or SR; whether the use of "negative" pressure in the expiratory phase during controlled ventilation may be responsible for bringing about the central haemodynamic conditions prevailing during spontaneous respiration; and whether, in weaning from postoperative IPPPV to SR, there is a risk of pulmonary congestion as a consequence of possible autotransfusion. IPPPV connected with anaesthesia induction caused a highly significant deterioration central haemodynamics. The use of positive end-expiratory pressure (PEEP) is not to be recommended for such patients at this stage. On the first postoperative day, the mean CI was lower during IPPPV than during IPNPV (P less than 0.1) or during SR (P less than 0.05). The changes observed in CI, were, however, so slight that the authors consider the routine use of PEEP to be beneficial during controlled ventilation following major open-heart surgery. In some patients, the CI was paradoxically higher during IPPPV than during IPNPV or SR. The mean CI was nearly the same during IPNPV (3.32) as during SR (3.38). However, PAP, PCWP and PVR values were significantly higher during SR than during IPNPV. Thus, according to this study, the use of "negative" end-expiratory pressure during controlled ventilation did not in these patients produce central pressure conditions corresponding to spontaneous respiration. The present study supports the finding that in weaning from controlled ventilation with PEEP to SR there is a danger of pulmonary congestion. This could be predicted by measurement of pulmonary wedge pressure, but not by measurement of central venous pressure.