The role of tracheostomy in otolaryngological practice in a developing country

An analysis of 155 tracheostomies performed over a period of six years in a teaching hospital in a developing country is presented in this paper. It is a follow-up of an earlier analysis of such procedures performed in the same hospital. Tetanus has established itself as the main indication for tracheostomy while other conditions such as laryngotracheobronchitis, which was the leading indication a decade ago, have been treated more successfully as a result of other better and non-invasive management. A continuing analysis of the indication for and mortality attending tracheostomy is considered important as it gives an indication of the quality of health care delivery in developing countries.

Pediatric tracheostomy. Experience during the past decade

A retrospective review of a decade of experience with pediatric tracheostomy encompassed 420 children. Analysis was performed with respect to primary diagnosis, age, duration of tracheostomy and hospitalization, early and late complications and mortality. While the incidence of tracheostomy per hospital admission decreased over the period of review, there was substantial increase in duration of tracheotomy. Approximately half of the patients sustained complications. While overall mortality approached 28%, tracheostomy-related deaths occurred in only eight patients (2%). Almost one fifth of children with tracheostomies were discharged to home care, and 3% were involved in our home ventilator program.

Home care of the pediatric patient with a tracheotomy

Forty-seven infants and children with tracheotomies were cared for at home for a follow-up period of 1,581 months. There were two relevant fatalities which gave a death rate of 0.13 deaths per 100 months. The average age at the time of tracheotomy was 13 months and the tracheotomy was in place for an average of 33 months per patient. The ability to care for these children was provided through coordinated, intensive training and a home-care program in which the inpatient nurse, nurse practitioner, social worker, pediatrician, and otorhinolaryngologist worked as a team.

Complications of airway intrusion in 100 consecutive cases in a pediatric ICU

One-hundred consecutive patients who underwent orotracheal intubation (OT), nasotracheal intubation (NT), or tracheostomy in the pediatric ICU were evaluated for complications of these airway invasions. Twelve patients had major complications as a result of airway intervention. The mortality for patients requiring mechanical ventilation was 17% as compared with a total overall mortality of 8.3% for patients in the pediatric ICU. Major complications occurred in 10% of patients who had orotracheal intubation, in 11% of patients who had nasotracheal intubations, and in 26% of patients subjected to tracheostomy. Laryngotracheobronchitis (croup) was the primary diagnosis associated with the highest rate of complications. An association was found between the occurrence of seizures or hypoperfusion state (shock) while intubated and the occurrence of major complications of airway intrusion. Acquired infections of the respiratory tract with Hemophilus influenzae, Pseudomonas, Klebsiella, and Candida albicans were also associated with a high rate of complications.

Massive hemorrhage from perforated thyroid complicating tracheostomy. Report of two cases

Two cases of unusual hemorrhagic complication of tracheostomy involved perforation of the thyroid gland as the cause of hemorrhagic episodes. In one case, massive hemorrhage complicated the postoperative course of a 62-year-old man with dissecting aortic aneurysm. In the other, fatal hemorrhage occurred after tracheostomy through the thyroid gland in a 6-month-old boy. A major branch of the thyroid artery was ruptured adjacent to the tracheostomy wound. This is the sixth reported case of fatal hemorrhage from perforation of thyroid artery after tracheostomy, to our knowledge.

Tracheostomy in the first year of life

Three series totaling 301 infants under 1 year of age who had tracheotomies during three successive decades are reviewed. The first series (62 infants) was seen prior to 1953, the second (86 infants) was seen between 1954 and 1963, while the latest series (153 infants) was seen between 1964 and 1973. A comparison of the three series with reference to etiology, incidence, indications, management, and mortality leads to significant conclusions. (1) The incidence of tracheotomy is increasing. More aggressive approach to many problems, previously considered inoperable, resulted in an increased number of infants undergoing tracheotomy for postintubation problems and ventilatory support. (2) The incidence of congenital malformations of the airway necessitating tracheostomy has remained constant, while the downward trend in the incidence of inflammatory conditions was reversed. (3) Infants in the latest series underwent tracheotomy, on the average, at a later age than the 1954 to 1963 series, largely as a result of the increased number of patients with cardiac anomalies undergoing corrective cardiovascular surgery and subsequent tracheotomy at a later age. (4) A review of the 77 deaths in the latest series again shows the death rate to be dependent on the underlying systemic condition which necessitated tracheotomy, rather than the tracheostomy itself. (5) The importance of temporary intubation to relieve respiratory obstruction in infants is stressed, while the significant laryngeal damage following prolonged intubation and delayed tracheotomy is apparent.

Fatal complications of tracheotomy

Thirty-six of 403 deaths after tracheotomy were direct complications of that procedure. Arterial hemorrhage caused three deaths, venous bleeding, seven. Airway obstruction resulted in six fatalities. Tracheoesophageal fistula caused five deaths. Eight deaths were due to infection and sepsis. Tension pneumothorax developed in one patient and the remaining six deaths were due to cardiopulmonary collapse. Many of the complications of tracheotomy can be avoided with accurate knowledge of anatomic variations, ideal operating conditions, proper technic, careful arterial and venous hemostasis, routine postoperative chest x-ray films, sterile suction technic, proper use of soft cuffed tracheotomy tubes, adequate humidification, and careful postoperative blood gas monitoring.

Tracheostomy in children

Tracheostomies were performed on 47 children, using the flap technique. Thirteen patients (28%) died of their basic disease and two (4%) died of complications resulting from the tracheostomy. Decannulation was difficult in four patients, and there was one case each of bleeding, infection, and tracheocutaneous fistula. Thus, the primary complication rate was 19%, including the two deaths. Clinical reexamination with tracheography was made on 20 patients after a follow-up period varying from four to ten years (average, eight years). One small stenotic ring in the area of the distal end of the cannula site and two slight depressions in the tracheal forewall were found. According to these results, the flap technique, if properly performed, is safe also in children.

Tracheostomy

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