Complications of Tracheotomy

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The history of tracheotomy stretches over several centuries as one of the oldest of surgical procedures. A tracheotomy was even pictured on Egyptian tablets in 3600 BC. However it was Asclepiades of Persia in 100 BC who is credited as the first person to perform this procedure. The procedure was originally used for the emergency management of upper airway obstruction although with limited success. Tracheotomy was known as the 'scandal of surgery' and a 'semislaughter' throughout much of the middle ages. It was not until 1718 that Lorenz Heister even coined the term tracheotomy.

Not until the early part of the 20th century, however, was the operative technique refined to an art as the result of the studies of Chevalier Jackson. He standardized the technique reducing the operative mortality rate from 25% to 2%. With the challenge of the polio epidemics of the 1940's, 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 synthetics, improved tubes, and low pressure, high volume cuffs have greatly reduced the morbidity associated with this procedure.In the modern era, the mortality rate has remained less than 5% with a total complication rate of 14% to as high as 66% as reported by Stauffer.

The complication rate varies widely depending on study design, patient follow up, and definition of the different complications. Numerous studies demonstrate a greater mortality rate and complication rate in emergency situations, ICU patients, and in children and infants.Tracheotomy in the pediatric population has consistently been associated with a greater mortality and complication rate. Furthermore, this trend continues to the preterm infant experiencing nearly double the complication rate of the full term infant. The very low birth weight infants suffer from a 11% mortality related to the tracheotomy.

The complications of tracheotomy may be categorized by the interval from the procedure to the onset of the complication. While these complications do not strictly obey the labels of early and late, this convention is convenient. These complications range from the dramatic to the ordinary and while the incidence of all may be reduced, their elimination is near improbable.

Major hemorrhage during the procedure is rare but even minor bleeding can be life-threatening if it interferes with the identification of the trachea or gaining access to the airway. The incidence of operative and early hemorrhage is reported to be approximately 5%. Bleeding during the performance of a tracheotomy is most commonly the result of errors in surgical technique. Even Jackson in 1909 recognized the need for meticulous technique. Frequent sites of bleeding are the anterior jugular veins, and the thyroid isthmus. Convention has been to divide and suture ligate the thyroid isthmus. However, a recent article by Calhoun, a study of 145 tracheotomies demonstrated no significant difference in blood loss between suture ligation and electrocautery of the isthmus. This study also emphasized the reduced operative time involved with electrocautery isthmus division. Other frequent sources of early and operative hemorrhage include a high innominate artery or a thyroid ima artery.

Pneumothorax and pneumomediastinum are well-recognized complications following tracheotomy. The incidence in adults has been reported at 2 to 5%. In children, the incidence may be as high as 17% and is the single most fatal complication. The exact cause of these conditions is not always readily apparent. The accepted mechanism is that, during the forceful inspiratory movements of respiratory obstruction, high negative intrathoracic pressures are developed. Through the incision of the skin and cervical fascia, an initial pathway is established for aspiration of air through the wound edges into the mediastinum. The air is trapped, and as sufficient pressures develop, rupture through the pleura causes a pneumothorax. Less common causes include the rupture of a lung bleb or direct injury to the apical pleura.

The higher incidence of intrathoracic complications in children is attributed to operative injury of the apical pleura because of their high position. In one study by Rabuzzi, the rate of intrathoracic complications in children aged 6 months to 2 years was nearly 70%.Prevention of pneumothorax and pneumomediastinum in tracheotomy begins with meticulous operative technique with emphasis on maintaining a midline dissection and minimizing the amount of dissection. Establishment of an adequate airway through a bronchoscope or endotracheal tube reduces the negative inspiratory force decreasing the risk of air dissection along fascial planes. Tight closure of the tracheotomy site or wound packing should be avoided to allow any air passing around the tracheotomy tube cuff to escape. A postoperative chest radiograph has been considered imperative to evaluate cannula position as well as to exclude pneumothorax or pneumomediastinum. A recent study by Barlow and Weymuller however, would suggest that a routine chest radiograph is indicated only in children, difficult or emergent tracheotomy, displaced tube, or sign or symptom of intrathoracic complication.

Obstruction of the tracheotomy tube is a common postoperative complication occurring in both adults and in the pediatric population. Obstruction in the first 24 hours is most commonly the result of tube impingement on the posterior tracheal wall, partial displacement into the mediastinum, a blood clot, or mucous plug. Obstruction and decannulation are the most common serious early complication in children. The gravity of decannulation in the first 24 hours is emphasized in the fact that this event is associated with a 25% mortality.Prevention of tracheotomy tube obstruction consists of: selection of a tracheotomy tube whose curvature and size are such that the opening does not press against the tracheal walls, and proper nursing care, suctioning and humidification. Because inner cannulas are not commonly used in children, sufficient humidification and suctioning should be emphasized.To prevent decannulation, it is recommended that tracheotomy ties be tied around the neck as well as suturing the tracheostomy plate to the peristomal skin. The thyroid isthmus, if not previously divided, may also force tube dislodgment and should decannulation occur, may inhibit easy reinsertion. Stay sutures and an inferiorly based tracheotomy flap fixed to the stomal edge have been recommended in all patients and in particular those at risk for decannulation.

A tracheotomy is considered a clean contaminated wound. The reported incidence of infection is highly dependent upon the criteria of infection of the individual study. While the rate of stomal infection has been reported to be as high as 36% by Stauffer, the incidence of cellulitis and purulence has generally been reported at 3 to 8%. Stomal infection usually manifests as an indolent infection, mild cellulitis or granulation tissue. Serious infections such as mediastinitis, fasciitis, abscess, and clavicular osteomyelitis are rare.Studies have demonstrated that the bacterial colonization of the tracheotomy changes over time. Castling reported a 75% chance of Pseudomonas colonization ten days after tracheotomy. Prescott demonstrated the changing colonization of the stoma with a rise is the colonization with Streptococcus and Pseudomonas.The roll of antibiotic prophylaxis is highly controversial. It is believed that the tracheotomy results in a contaminated wound, secondarily infecting a larynx injured from an endotracheal tube or other acute process resulting in chronic mucosal ulceration. This predisposes to scar formation, granuloma formation and stricture. The amount of scar tissue is related directly to the length of time for wound healing and the presence or absence of local infection. Sasaki demonstrated in animal studies that perioperative prophylaxis with systemic antibiotics and povidine-iodine reduced the bacterial growth and laryngeal damage. This article offers compelling evidence for topical antibacterial agents. Other studies concluded that perioperative antibiotics merely selected for resistant organisms. Serious tracheotomy wound infections have been associated with closure of the tracheotomy incision, tube fixation, and severe neurologic injury.In contrast to the early complications, the late complications are frequently much more notorious. Again, it should be noted that there is overlap in the time frame in which these early and late complications present.

The etiology of tracheal damage after tracheotomy has been studied by several investigators. It has been demonstrated that direct pressure necrosis by high pressure cuffs is responsible for most post-tracheotomy injuries. Weymuller also demonstrated that while capillary flow in the larynx can be occluded at pressures greater than 30 mm Hg, the tube itself can exert transient pressures in excess of 400 mm Hg. Within 3 to 5 days, shallow ulcers develop which can lead to cartilage exposure. Bacterial colonization then contributes to cartilage destruction leading to necrosis and formation of fibrous stricture or tracheal malacia. With shorter periods of exposure to high pressure cuffs, mucosal damage may occur without destruction of the cartilaginous rings. The typical stenosis occurs at the site of the tube cuff or tip, 1 to 3.5 cm below the stoma and is 0.5 cm to 4 cm in length. Stenosis at the level of the stoma is caused by excessive traction on the tracheostomy tube by connection tubing or patient motion. Light flexible connectors have minimized the mechanical trauma to the tracheotomy site.Some investigators believe that the tracheal incision plays a roll in tracheal stenosis at the stoma. Most authors agree that, in children, a vertical incision is least likely to contribute to tracheal stenosis. In adults, several studies indicate that vertical incisions lead to an increase in tracheal stenosis while inferiorly based or Bjork flaps and transverse incisions offered a functional advantage. The literature would also suggest avoiding excision of the tracheal wall as this has been shown to lead to an increased incidence of tracheal stenosis. Bryant suggested that those incisions that disturb the anatomy least are best.The management of tracheal stenosis depends upon its severity. In minimally symptomatic children, the patient will frequently outgrow his lesion. Conservative therapy with repeated dilations and T-tubes offers a temporary treatment option. Carbon dioxide laser excision has proved successful in thin diaphragm-like stenosis with success in 73% of patients in one series.In a landmark series of 216 patients by Grillo, resection and anastamosis for all types of tracheal stenosis achieved a 90% success rate, with a 2% mortality rate. He emphasized that treatment be individualized. But in general, resection and anastamosis of 3 to 4 cm of trachea could be accomplished with only neck flexion. Suprahyoid release or hilar release could allow the resection of an additional 1.5 to 2 cm.

Perhaps one of the most dramatic and fatal of complications of tracheotomy is massive hemorrhage. The cause of massive hemorrhage is usually related to erosion of the innominate artery although erosion of the right carotid artery has also been reported. The incidence of tracheoinnominate artery fistula has been reported to be 0.4 to 4.5%. Innominate artery rupture has been associated with tracheal necrosis secondary to infection and from erosion from the tracheotomy tube. While the most frequent site of fistula formation is at the distal end of the tube, low placement of the tracheotomy as well as a high innominate artery is also associated with tracheoinnominate artery fistula. In a series of ten and a review of the literature containing 127 documented cases, Jones noted that 50% of the cases had sentinel bleeds and that one-half of those which had tracheotomy bleeding of greater than 10 ml at 48 hours or later after surgery would have a tracheoinnominate artery fistula. The peak incidence of tracheoinnominate artery bleeds was at one to two weeks and 72% occurred by three weeks.Suspicion of a tracheoinnominate artery fistula mandates removal of the tracheostomy tube and bronchoscopy. Angiography is not helpful and may dangerously delay definitive treatment. In the face of massive hemorrhage, prompt tamponade is necessary to prevent exsanguination prior to surgical repair. Finger pressure on the innominate through the jugular notch was successful in 89% of cases while inflation of the balloon on the tracheal tube was successful in 85% of cases according to Jones. Definitive surgical intervention was 100% successful with resection of the innominate artery and muscle flap interposition. In only one case was there significant neurologic complication from this procedure. In contrast, attempts at repair of the artery or grafting resulted in a mortality rate of greater than 85%. Of the 175 cases documented in the literature in 1991, there were only 24 long term survivors.

Tracheoesophageal fistula complicating tracheotomy occurs with an incidence of 0.01%. While not nearly as dramatic as the preceding complication, it has the same potential morbidity. These fistula may result from incidental damage to the posterior tracheal wall at the time of surgery, or as the result of pressure necrosis of the tracheoesophageal wall by the tracheotomy tube and a stiff NG tube. It may be manifested as marked increase in tracheal secretions or coughing while eating. Patients may develop gastric distention and a paralytic ileus as a result of ventilated air crossing into the esophagus. It may be diagnosed by barium swallow or by endoscopy. There is no evidence that these fistula ever close spontaneously and there is a 100% mortality rate in those not operated. Surgical management is with direct closure and muscle flap interposition, staged closure, or esophageal diversion.

Occasionally, a tracheal stoma fails to close spontaneously. The reported incidence is between 3.3 and 29% and is directly related to the duration of cannulation. Kulber reported that cannulation longer than 16 weeks resulted in a 70% occurrence of tracheocutaneous fistula while those cannulated less than 16 weeks closed spontaneously. While not nearly as threatening as the prior complications, a persistent tracheocutaneous fistula results in difficulty with phonation, skin irritation from secretions, susceptibility to respiratory infections, and dysphagia.Management of the persistent tracheocutaneous fistula involves excision of the epithelialized tract and either closure by secondary intention or primary closure, muscle flap interposition and placement of a wound drain. Fisher reports success with perichondrial flap interposition and drainage in persistent high fistula.Finally and most subtly, laryngeal function may be inhibited by the tracheotomy. The tracheotomy inhibits rostrocaudal excursion of the trachea preventing supraglottic closure and increasing the risk of aspiration. Pressure from the tube upon the posterior tracheal wall causes dysphagia further increasing the risk of aspiration. Buckwalter has also demonstrated by measuring the action potentials of the intrinsic musculature that the adductor reflex threshold increases with prolonged tracheotomy also increasing the risk of aspiration. Also, when spontaneous breathing is shunted through the tracheotomy, abductor activity diminishes and disappears. Phasic abductor activity is re-established in 3 to 5 minutes following the return of normal airflow. This points out obvious implications in plugging a patient's tracheotomy tube.

No discussion of tracheotomy would be complete without a mention of cricothyroidotomy. Jackson's article in 1921, which effectively abolished cricothyroidotomy for most of this century, rebukes the procedure saying that 'no end of laryngeal stenosis is the result of these high operations.' While not all of these 'high operations' were cricothyroidotomies it was not until 1976 when one of Jackson's students, J.B. Grow along with C.O. Brantigan, reintroduced cricothyroidotomy reporting a lower early and late complication rate. This study was flawed by its retrospective nature and poor follow-up. Numerous follow up studies point out that this procedure is to be absolutely avoided in acute laryngeal pathology and in those patients with a professional voice or high voice demands. Furthermore, many investigators agree that while the operative simplicity is an advantage over tracheotomy, the slightly higher incidence of tracheal stenosis and more difficult surgical repair make this procedure undesirable except in the emergency setting. Incidentally, it is of interest to note that in a controlled situation on cadavers, only 33% of non-surgeons were able to successfully cannulate the trachea.

In conclusion, while the complications of tracheotomy may be severe, with proper precautions and prompt management, the mortality and morbidity of this procedure may be minimized.

A 24-year-old C4 quadriplegic was referred from the Physical Medicine and Rehabilitation service for a persistent tracheocutaneous fistula. The patient was injured in November of 1991 in a motorcycle accident at which time he suffered a C4 burst fracture. The patient initially underwent an exploratory laparotomy and cervical stabilization. Within the first week of hospitalization, he also underwent placement of a gastrostomy tube and tracheotomy. He had a complicated recovery and remained in the intensive care unit for approximately three months. Initially, he required ventilatory assistance at night for central paralysis of his left hemidiaphragm.He was subsequently transferred for further rehabilitation in March of 1992. Upon discharge in April, he required a full time attendant and his tracheotomy remained cannulated with a #8 Shiley tracheotomy tube. The patient returned frequently for follow up appointments with the Physical Medicine and Rehabilitation service and the Pulmonary Clinic. By June of 1992, the patient no longer required ventilatory support and his tracheotomy tube was changed to a #5 metal tube that the patient required for management of his pulmonary secretions. The patient's tracheotomy site was decannulated in July of 1993. The patient did well although he continued to require full time nursing assistance.He was referred to the Otolaryngology Clinic in July of 1994 for his complaints of difficulty phonating, a persistent tracheocutaneous fistula, and difficulty with stomal hygiene. Nasopharyngoscopy and flexible endoscopy through the patient's tracheostoma were performed. The patient had bilaterally mobile vocal cords, normal supraglottic anatomy, and was without evidence of subglottic stenosis. Primary closure with sternocleidomastoid muscle interposition and the placement of a Penrose drain was performed and well tolerated. The drain was removed after three days, and one month after the procedure the patient had a satisfactory cosmetic and functional result.

Bibliography

Ameye F, Mattelin W, Ingels K, Bradwell R. Bilateral pneumothorax after emergency tracheotomy: two case reports and a review of the literature. J Laryngol Otol 1994;108:69-70.

Arcand P. Pediatric tracheostomies: changing trends. J Laryngol Otol 1988;17:121-124.

Astrachan DI, Kirchner JC, Goodwin WJ, Jr. Prolonged intubation vs. tracheotomy: complications, practical and psychological considerations. Laryngoscope 1988;98:1165-1169.

Barlow DW, Weymuller EA, Wood DE. Tracheotomy and the role of postoperative chest radiography in adult patients. Ann Otol Rhinol Laryngol 1994;103:665-668.

Berenholz LP, Vail S, Berlet A. Management of tracheocutaneous fistula. Arch Otolaryngol Head Neck Surg 1992;118:869-871.

Brantigan CO, Grow JB. Cricothyroidotomy: elective use in respiratory problems requiring tracheotomy. J Thoracic Cardiovasc Surg 1976;71:72-81.

Brantigan CO, Grow JB. Subglottic stenosis after cricothyroidotomy. Surgery 1982;91:217-221.

Bretteville G, Söberg R, Boysen M. An improved technique for treating tracheostomal stenosis following laryngectomy. Clin Otolaryngol 1992;17:44-48.

Bryant LR, Mujia D, Greenberg S, Huey JM, Schechter FG, Albert HM. Evaluation of tracheal incisions for tracheostomy. Am J Surg 1978;135:675-679.

Buckwalter JA, Sasaki CT. Effect of tracheotomy on laryngeal function. Otolaryngol Clin North Am 1984;17:41-48.

Burkey B, Esclamado R, Morganroth M. The role of cricothyroidotomy in airway management. Clin Chest Med 1991;12:561-571.

Calhoun KH, Weiss RL, Scott B, Guendert D, Hokanson JA. Management of the thyroid isthmus in tracheostomy: a prospective and retrospective study. Otolaryngol Head Neck Surg 1994;111:450-452.

Chew JY, Cantrell RW. Tracheostomy. Complications and their management. Arch Otolaryngol 1972;96:538-545.

Crysdale WS, Feldman RI, Naito K. Tracheotomies: a 10-year experience in 319 children. Ann Otol Rhinol Laryngol 1988;97:439-443.

Dempster JH, Dykes EH, Brown WC, Raine PA. Tracheostomy in childhood. J Royal Coll Surg Edinburgh 1986;31:359-362.

Fisher SR. Closure of tracheocutaneous fistula with perichondrial flap following cricothyroidotomy. Laryngoscope 1991;101:684-685.

Flint PW. Complications of tracheostomy. In: Eisele D, ed. Complications in Head and Neck Surgery. St. Louis: Mosby, 1993.

Friedman EM, Healy GB, McGill TJ. Carbon dioxide laser management of subglottic and tracheal stenosis. Otolaryngol Clin North Am 1983;16:871-877.

Friman L, Hedenstierna G, Schildt B. Stenosis following tracheostomy: a quantitative study of long term results. Anaesthesia 1976;31:479-493.

Fry TL, Jones RO, Fischer ND, Pillsbury HC. Comparisons of tracheostomy incisions in a pediatric model. Ann Otol Rhinol Laryngol 1985;94:450-453.

Gianoli GJ, Miller RH, Guarisco JL. Tracheotomy in the first year of life. Ann Otol Rhinol Laryngol 1990;99:896-901.

Gilmore BB, Mickelson SA. Pediatric tracheotomy: controversies in management. Otolaryngol Clin North Am 1986;19:141-151.

Goldsmith AJ, Abramson AL, Myssiorek D. Closure of tracheocutaneous fistula using a modified cutaneous z-plasty. Am J Otolaryngol 1993;14:240-245.

Goldstein SI, Breda SD, Schneider KL. Surgical complications of bedside tracheotomy in an otolaryngology residency program. Laryngoscope 1987;97:1407-1409.

Grillo HC. Surgical treatment of postintubation tracheal injuries. J Thorac Cardiovasc Surg 1979;78:860-875.

Jones JW, Reynolds M, Hewitt RL, Drapanas T. Tracheo-innominate artery erosion: successful surgical management of a devastating complication. Ann Surg 1977;184:194-204.

Kato I, Uesugi K, Kikuchihara M, Iwasawa H, Iida J, Tsutsumi K, et al. Tracheostomy--the horizontal tracheal incision. J Laryngol Otol 1990;104:322-325.

Kulber H, Passy V. Tracheostomy closure and scar revisions. Arch Otolaryngol 1972;96:22-26.

Kuo M, Ho CM, Wei WI, Lam KH. Tracheostomal stenosis after total laryngectomy: an analysis of predisposing clinical factors. Laryngoscope 1994;104:59-63.

Kuriloff DB, Setzen M, Portnoy W, Gadaleta D. Laryngotracheal injury following cricothyroidotomy. Laryngoscope 1989;99:125-130.

Lewis FR Jr, Schlobohm RM, Thomas AN. Prevention of complications from prolonged tracheal intubation. Am J Surg 1978;135:452-457.

Lulenski GC, Batsakis JG. Tracheal incision as a contributing factor to tracheal stenosis: an experimental study. Am J Otol 1975;84:781-786.

Lulenski GC, Batsakis JG. Management of flap tracheostomy: an experimental study. Arch Otolaryngol 1979;105:260-263.

Morain WD. Cricothyroidostomy in head and neck surgery. Plast Reconstr Surg 1980;65:424-428.

Myers EN, Carrau RL. Early complications of tracheotomy. Incidence and management. Clin Chest Med 1991;12:589-595.

Ossoff RH, Tucker GF, Duncavage JA, Toohill RJ. Efficacy of bronchoscopic carbon dioxide laser surgery for benign strictures of the trachea. Laryngoscope 1985;95:1220-1223.

Prescott CA. Peristomal complications of paediatric tracheostomy. Int J Pediatr Otorhinolaryngol 1992;23:141-149.

Rabuzzi DD, Reed GF. Intrathoracic complications following tracheotomy in children. Laryngoscope 1971;91:939-946.

Sasaki CT, Horiuchi M, Koss N. Tracheostomy-related subglottic stenosis: bacteriologic pathogenesis. Laryngoscope 1979;89:857-865.

Schlessel JS, Harper RG, Rappa H, Kenigsberg K, Khanna S. Tracheostomy: acute and long-term mortality and morbidity in very low birth weight premature infants. J Pediatr Surg 1993;28:873-876.

Stauffer JL, Olson DE, Petty TL. Complications and consequences of endotracheal intubation and tracheotomy: a prospective study of 150 critically ill adult patients. Am J Med 1981;70:65-76.

Stock CR. What is past is prologue: a short history of the development of tracheostomy. Ear Nose Throat J 1987;66:60-64.

Swift AC, Rogers JH. The outcome of tracheostomy in children. J Laryngol Otol 1987;101:936-939.

Waki EY, Madgy DN, Zablocki H, Belenky WM, Hotaling AJ. An analysis of the inferior based tracheal flap for pediatric tracheotomy. Int J Pediatr Otorhinolaryngol 1993;27:47-54.

Waldron J, Padgham ND, Hurley SE. Complications of emergency and elective tracheostomy: a retrospective study of 150 consecutive cases. Ann R Coll Surg Engl 1990;72:218-220.

Wang RC, Perlman PW, Parnes SM. Near-fatal complications of tracheotomy infections and their preventions. Head Neck 1989;11:528-533.

Weymuller EA, Bishop MJ, Fink BR, Hibbard AW, Spelman FA. Quantification of intralaryngeal pressure exerted by endotracheal tubes. Ann Otol Rhinol Laryngol 1983;92:444-447.

Whited RE. A study of endotracheal tube injury to the subglottis. Laryngoscope 1985;95:1216-1219.

Wood DE, Mathisen DJ. Late complications of tracheotomy. Clin Chest Med 1991;12:597-609.

Zeitouni AG, Kost KM. Tracheostomy: a retrospective review of 281 cases. J Otolaryngol 1994;23:61-66.

Zeitouni A, Manoukian J. Tracheotomy in the first year of life. J Otolaryngol 1993;22:431-434.

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Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery
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