Outcome and survival following tracheostomy in patients ≥ 85 years old

PURPOSE

To evaluate percutaneous dilatational tracheostomy in patients ≥ 85 years old: its complication rate and possible risk factors. In addition, to assess prognostic factors for short, intermediate and long term survival following the procedure.

METHODS

A retrospective case-control study of 72 patients ≥ 85 years who received percutaneous dilatation tracheotomy (PTD), compared to a control group of younger patients (n = 182). Demographics, clinical and laboratory data were collected. Survival and risk for complications were analyzed.

RESULTS

The study group's mean age was 89 ± 4. Twelve patients had complications, three (4.2%) were major. No significant difference was found in overall complication rates between the groups. Cerebrovascular disease with neurologic deficits and pre-procedure albumin levels were significantly associated with complications. Survival rates did not differ in 1 week and 1 month following procedure between study and control group. There was a significant difference in the 1-year survival rates between the patients ≥ 85 years and the control groups (18.1% vs. 34.4%, p = 0.01, respectively). Congestive heart failure, a frailty score > 0.27 and failure to wean from a cannula were associated with reduced 1-year survival.

CONCLUSION

PTD is safe for patients ≥ 85 years. Complication risk factors and reduced survival should be discussed with patients and families before conducting tracheostomies.

LEVEL OF EVIDENCE

3b.

Tracheotomy-Related Deaths

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.

[Survival analysis for patients with severe motor and intellectual disabilities following tracheotomy]

To investigate the survival rate and causes of death in patients with severe motor and intellectual disabilities (SMIDs) that necessitated tracheotomy, we retrospectively analyzed 90 patients who underwent tracheotomy between 1990 and 2009. Indications for tracheotomy in these patients were upper airway obstruction (44 patients), recurrent aspiration pneumonia (28 patients), retained secretions (23 patients), prolonged mechanical ventilation (18 patients), chronic respiratory failure (9 patients), central respiratory failure (5 patients), and gastroesophageal reflux (8 patients). Most of the patients underwent tracheotomy at the age of 0-5 years or 10-19 years. As of April 1, 2010, 28 patients had died. The survival rate was 0.91 at 1 year, 0.74 at 5 years, 0.59 at 10 years, 0.54 at 15 years, and 0.40 at 19 years after tracheotomy. Massive tracheal bleeding due to development of tracheo-innominate artery fistulas occurred in 5 patients, and 4 of them died. They were thirteen years of age or older when they underwent tracheotomy, and developed fistulas after 2 weeks or later. In contrast, 7 patients at high risk for fistula formation, including those that had developed severe tracheomalacia associated with granulation or warning hemorrhages, underwent preventive resection of the innominate artery, and all of them had survived. It is important to regularly evaluate patients with SMIDs who have undergone tracheotomy by using bronchofiberscopy to identify risk factors for tracheoinnominate artery fistulas, a preventable cause of death.

Percutaneous dilatational tracheotomy in intensive care unit patients with increased bleeding risk or obesity. A prospective analysis of 1000 procedures

BACKGROUND

Percutaneous dilatational tracheotomy (PT) is safe and cost effective, and has become a routine method in intensive care units (ICU), but safety concerns persist for obese patients and for patients with a high risk of bleeding. In this prospective study of 1000 PTs, we have investigated whether such patient characteristics were associated with an increased procedural risk.

METHODS

We prospectively recorded all PTs performed in our ICU from 2001 to 2009. Data on blood transfusion were entered from a central database. The association of risk factors with bleeding and other complications was analysed with logistic regression.

RESULTS

The total number of PTs and surgical tracheotomies was 1.454. The median number of days on a ventilator until PT was 6 in 2001, decreasing to 3 in 2009. A procedure-related complication was reported in 17.5%. There was no PT-related mortality. The rate of potentially life-threatening complications was 1.2%. Three patients developed pneumothorax and one of these had circulatory arrest and was successfully resuscitated. Three hundred and twelve patients had one or more units of blood transfused, but only 19 (1.9%) were PT related. Increased INR was the most important risk factor for bleeding [odds ratio (OR) 2.99], followed by low platelets (OR 1.99). The rate of complications in patients with high body mass index was not increased.

CONCLUSION

PT is a safe procedure that can be performed with a low complication rate in patients with increased risk of bleeding as well as in obese patients.

Tracheotomy in a Canadian urban centre

Sixty-two patients requiring tracheotomy from 1998 to 2002 were followed for a mean length of 223.3 days. Outcomes were measured based on indications for ventilatory support, age, sex, length of intensive care unit (ICU) and hospital stay, and overall status at discharge. The overall mortality was 50%. Those who survived required a tracheotomy for an average of 41.6 days before decannulation; 41.2% of patients were discharged home. Information should assist families, intensivists, and physicians involved in the care of such critically ill patients. Ethical questions that arise in the care of these patients are addressed.

[Percutaneous tracheotomy with the Ciaglia Blue Rhino technique: a critical analysis after 1 year]

OBJECTIVES

To report our experience during a learning period with the Ciaglia Blue Rhino (William Cook Europe) kit for percutaneous tracheotomy.

PATIENTS AND METHODS

This prospective, observational study included 38 adult patients who underwent elective placement of a percutaneous tracheostomy tube with the Ciaglia Blue Rhino introducer kit. The study was carried out from April 2002 to May 2003. The main variables analyzed were duration of the procedure, level of difficulty (easy, moderately difficult, difficult), and complications while the procedure was being performed.

RESULTS

The mean time of orotracheal intubation was 13.5 days (range, 2-28 days). The mean duration of the procedure was 12 minutes 36 seconds (range, 4 minutes 30 seconds-29 minutes; 95% confidence interval, 10 minutes 30 seconds-14 minutes 36 seconds). The procedure was rated easy in 60.5% of the cases, moderately difficult in 31.6%, and difficult in 7.9%. Some form of complication occurred in 28 patients (73.6%), the most common being puncture of the orotracheal tube (28.9%) and slight bleeding (26.3%). Two patients (5.2%) died, from massive hemorrhage in 1 case and pneumothorax in the other.

CONCLUSIONS

The Ciaglia Blue Rhino technique for percutaneous tracheotomy is useful, rapid, and easy but not free of risk. There is a learning curve that calls for caution and an experienced physician to perform the maneuvers, given that potentially fatal complications can occur.

Tracheotomy in pediatric patients: a national perspective

BACKGROUND

During the past 50 years, changes in the epidemiology of infectious diseases and the capabilities of medical technology have altered the indications for, and implications of, tracheotomy in children. Given the complexity of health care that these patients subsequently require, monitoring the performance of this procedure and patient outcomes across the diverse US health care system is warranted.

OBJECTIVES

To characterize children who received tracheotomies in 1997 and to determine whether disposition and mortality vary by region or health care system attributes.

DESIGN

A nationally representative retrospective cohort drawn from an 80% sample of administrative hospital discharge records from all pediatric admissions in 22 states during 1997.

PARTICIPANTS

Patients aged 0 to 18 years who underwent tracheotomy.

METHODS

The sampling scheme of the discharge records enabled the calculation of regional and national estimates and of age-stratified population-based rates of tracheotomies. Weighted descriptive statistical and Poisson analyses were performed.

RESULTS

The 2065 tracheotomy procedures recorded in the Kids' Inpatient Database yielded a national estimate of 4861 tracheotomies performed in 1997. The mean length of hospital stay was 50 days, with a mean total facilities charge exceeding $200,000. The rate of tracheotomy was highest among infants and varied significantly across regions of the United States. Adjusting for other patient and health care system attributes, patients who received their tracheotomy in a children's hospital had half the risk of dying during the admission compared with patients who were cared for in a non-children's hospital. Hospitals that performed more pediatric tracheotomies had significantly lower mortality rates than hospitals with lesser case volume. Among patients who survived to discharge, those cared for in the Northeast were discharged to long-term care facilities at twice the rate of patients in the West. Children cared for in children's hospitals or in teaching hospitals were significantly less likely to be discharged to a long-term care facility.

CONCLUSIONS

Pediatric tracheotomy is associated with significant variation in rates and outcomes across the United States and across different hospital types. Further research to clarify the reasons for these associations is warranted.

Indications for tracheotomy in the pediatric intensive care unit population: a pilot study

OBJECTIVE

To define the indications for tracheotomy in patients requiring prolonged intubation (>1 week) in the pediatric intensive care unit (PICU).

DESIGN

Retrospective chart review and follow-up telephone survey.

SETTING

A tertiary care center PICU.

OUTCOME MEASURE

Tracheotomy or extubation.

PATIENTS

All patients older than 30 days in the PICU intubated for longer than 1 week between 1997 and 1999.

RESULTS

During the study, 63 total admissions required intubation for longer than 1 week. A tracheotomy was necessary in 14% of admissions (n = 9). The mean length of intubation before the tracheotomy was 424 hours, whereas the mean length of intubation without the need for tracheotomy was 386 hours. Length of intubation, age, and number of intubations did not increase the probability of having a tracheotomy. Of those requiring a tracheotomy, 2 had tracheomalacia, 1 had subglottic edema, 1 had plastic bronchitis, 1 had Down syndrome with apnea resulting in right heart failure, 3 required long-term ventilation after cardiopulmonary collapse, and 1 had mitochondrial cytopathy. Of these 9 children, 7 were successfully decannulated, 1 patient died of underlying disease, and 1 patient remained cannulated secondary to the mitochondrial cytopathy. Twenty families of the patients who did not undergo a tracheotomy were reached by telephone after discharge. Most of the families reported that their children were free of stridor and hoarseness after extubation.

CONCLUSIONS

Children tolerate prolonged intubation without laryngeal complications. The consideration for tracheotomy in the PICU setting must be highly individualized for each child.

Tracheotomy: changing indications and a review of 1,130 cases

BACKGROUND

Tracheotomy is one of the oldest known operations, dating back to ancient Egypt and India some 3000 years ago. The indications for tracheotomy have changed and expanded during the twentieth century. Today, owing to advancements in intensive care and the widespread use of mechanical ventilation, tracheotomy is one of the most commonly performed surgical procedures and is encountered on a regular basis by hospital physicians in all fields. We present one of the largest series of consecutive tracheotomies spanning one decade. We review and discuss the modern indications for tracheotomy and emphasize the changes in these indications over the past century.

METHODS

A retrospective study of 1,130 consecutive tracheotomies performed over one decade is presented. We studied the indications for surgery, the complications and mortality rate, and the various hospital departments requiring tracheotomies.

RESULTS

A total of 1,130 tracheotomies were performed: 859 to assist in mechanical ventilation, 124 as an adjunct to head and neck or chest surgery, and 68 to relieve upper airway obstruction. Major complications occurred in 49 of the cases, and there were 8 deaths directly attributed to the tracheotomies. The most common complication was tracheal stenosis, occurring in 21 cases. Hemorrhage was the second most common complication, occurring in 9 cases.

CONCLUSION

Tracheotomy, once used almost exclusively to bypass upper airway obstruction, is now a very common elective therapeutic procedure used mostly to facilitate prolonged intubation and ventilation of the critically ill. Today tracheotomy is not and should not be an emergency procedure owing to the huge complication and mortality rate of emergency tracheotomy and the existence of alternative routes to obtain immediate airway control in the acutely obstructed upper airway.

Emergency cricothyrotomy: long-term results

In 1996 we reviewed the literature and reported on our own series of emergency cricothyrotomy (EC) patients. The success rate in obtaining an airway was very good. The survival rate was also acceptable. However, there have been no reports of long-term results of EC. We retrospectively reviewed the long-term results in 27 survivors of 65 original EC patients. The average length of follow-up was 37 months (1-77 months). In 13 patients no airway problems were found. The remaining 14 patients had only minor problems such as hoarse voice and mild untreated stenosis. Of these 27 patients, however, only seven were doing well. Five patients had relatively minor problems such as the need for a gastrostomy tube, minor shortness of breath, or minor neurological problems. Fifteen patients had major problems: cervical spine injuries, changes in mental status, need for permanent nursing home care, seizure disorders, or injuries that precluded their working. In most cases these problems were due to the underlying disease process. EC is effective in obtaining an airway with a low incidence of later severe airway problems. However, many of these patients do poorly overall.

Tracheotomy complications: a retrospective study of 1130 cases

BACKGROUND

Tracheotomy is one of the most frequently performed surgical procedures in the critically ill patient. It is frequently performed as an elective therapeutic procedure and only rarely as an emergency procedure. Complications occur in 5% to 40% of tracheotomies depending on study design, patient follow-up, and the definition of the different complications. The mortality rate of tracheotomy is less than 2%. Numerous studies demonstrate a greater complication and mortality rate in emergency situations, in severely ill patients, and in small children.

METHODS

A retrospective study of 1130 consecutive tracheotomies performed during 1 decade (January 1987 through December 1996) is presented. We studied the indications for surgery, the major complications of tracheotomy, and their treatment and outcome. We also noted the overall mortality rate and the specific complications that led to these deaths.

RESULTS

In total, 1130 tracheotomies were performed. Major complications occurred in 49 of the cases, and 8 deaths were directly attributed to the tracheotomy. The most common complication was tracheal stenosis, which occurred in 21 cases. Hemorrhage was the second most common complication, which occurred in 9 cases.

CONCLUSION

This is one of the largest series of consecutive tracheotomies compiled. We found a relatively low overall complication and mortality rate compared with other large series. Tracheal stenosis was the most common complication in contrast to other series. Our opinion is that this may reflect tracheal damage originally caused by prolonged intubation before the tracheotomy. We believe that all other complications of tracheotomy may be prevented or minimized by careful surgical technique and postoperative tracheotomy care.

Percutaneous or surgical tracheostomy: a meta-analysis

OBJECTIVE

To compare percutaneous with surgical tracheostomy using a meta-analysis of studies published from 1960 to 1996.

DATA SOURCES

Publications obtained through a MEDLINE database search with a Boolean combination (tracheostomy or tracheotomy) and complications, with constraints for human studies and English language.

STUDY SELECTION

Publications addressing all peri- and postoperative complications. Studies limited to specific tracheostomy complications or containing insufficient details were excluded. Two authors independently selected the publications.

DATA EXTRACTION

A list of relevant surgical variables and complications was compiled. Complications were divided into peri- and postoperative groups and further subclassified into severe, intermediate, and minor groups. Because most studies of percutaneous tracheostomy were published after 1985, surgical tracheostomy studies were divided into two periods: 1960 to 1984 and 1985 to 1996. The articles were analyzed independently by three investigators, and rare discrepancies were resolved through discussion and data reexamination.

DATA SYNTHESIS

Earlier surgical tracheostomy studies (n = 17; patients, 4185) have the highest rates of both peri- (8.5%) and postoperative (33%) complications. Comparison of recent surgical (n = 21; patients, 3512) and percutaneous (n = 27; patients, 1817) tracheostomy trials shows that perioperative complications are more frequent with the percutaneous technique (10% vs. 3%), whereas postoperative complications occur more often with surgical tracheotomy (10% vs. 7%). The bulk of the differences is in minor complications, except perioperative death (0.44% vs. 0.03%) and serious cardiorespiratory events (0.33% vs. 0.06%), which were higher with the percutaneous technique. Heterogeneity analysis of complication rates shows higher heterogeneity in older and surgical trials.

CONCLUSIONS

Percutaneous tracheostomy is associated with a higher prevalence of perioperative complications and, especially, perioperative deaths and cardiorespiratory arrests. Postoperative complication rates are higher with surgical tracheostomy.

[Tracheotomy in the child with a foreign body in the lower respiratory passages]

In 15 years period, 137 children with foreign bodies of inferior respiratory tracts were admitted in the otorhinolaryngology and head and neck department of the University of Dakar. For 48 of them, generally late admitted, a tracheostomy was performed. Male children were most affected. About 81% of the removed foreign bodies were organic, dominated by peanuts. 76% of the foreign bodies were found in the larynx. Tracheostomy had been realized before extraction of foreign body for 90% of the cases and after extraction for the others 10%. One case of death was to be deplored. This critical place of tracheostomy increases the morbidity and the mortality in relation with the inhalation of foreign body. This unusual practice of tracheostomy illustrates the arduousness of our working conditions.

Slide tracheoplasty in the management of congenital tracheal stenosis

Long-segment congenital tracheal stenosis (LSCTS) is a rare condition. Originally, it was felt to be uniformly fatal; however, advances in technique have made surgical repair and survival possible. Our objective is to report results and technique of slide tracheoplasty for the treatment of LSCTS in the context of the overall experience at the Children's Memorial Hospital in Chicago. We reviewed 37 cases of infants and children with LSCTS. Thirty of the 37 infants underwent surgical intervention. Slide tracheoplasty resulted in survival in 1 of 2 infants, and pericardial patch tracheoplasty resulted in survival in 21 of 28 (75%). Of the 30 patients who had surgical repair, 7 (23%) have died, and 1 has been lost to follow-up (3%). Follow-up has ranged from 6 months to 13 years. Slide tracheoplasty is a satisfactory adjunct to existing techniques. With early diagnosis and appropriate management of LSCTS, survival is possible in a majority of patients.

[Fatal complications in tracheotomized children]

BACKGROUND

Tracheotomy in the pediatric patient has become a routine procedure since the late 19th century, when it was used in treating diphtheria. Although underlying diseases have changed, the child with an artificial airway still faces numerous risks. This study investigates fatal complications in 280 patients with tracheostomy who were seen in the Dr. von Haunersches Kinderspital for laryngo-tracheo-bronchoscopy.

METHOD

Data was acquired from patients' records of the Dr. von Haunersches Kinderspital and communications with other institutions.

RESULTS

Nineteen deaths were investigated. Three patients died of acute cannula obstruction although hospitalized in different institutions. Two patients who died at home may also have suffered cannula obstruction, although this could not be verified. The majority of patients succumbed to the underlying disease.

CONCLUSIONS

Permanent close supervision or monitoring at all times is critical to prevent cannular related deaths. Our results are compared with major series in other studies. In addition, we propose a booklet for the pediatric tracheotomy patient to document patient data and examination findings, e. g. type and size of cannula, duration of cannulation, laryngotracheometry, and complications. Its purpose will be to support communication between patients, parents, pediatricians, pediatric surgeons, and otolaryngologists. Furthermore, this booklet will help in evaluating risks, which may encounter pediatric tracheostomy patients, thereby enabling future studies.

Mortality in the pediatric patient with tracheotomy

BACKGROUND

The mortality rate of children with tracheotomies is estimated to be between 11% and 40%, although the incidence of tracheotomy-related deaths is only between 0% and 3.4%. The purpose of this report was to analyze the mortality rate in children with tracheotomies.

METHODS

A review of the medical records of children at the University of Iowa Hospitals and Clinics who underwent tracheotomy over a 15-year period ending in 1989 was performed. Data were analyzed in 5-year time blocks (Block 1, 1975 to 1979; Block 2, 1980 to 1984; and Block 3, 1985 to 1989).

RESULTS

Fifty-two patients died with tracheotomy tubes in place. In 4 patients, the cause of death was tracheotomy related. Three of these patients were under 5 years of age and died secondary to tracheotomy tube displacement or obstruction; one patient, an 18-year-old, developed a fatal tracheotomy-related vascular hemorrhage. The average age of patients who died with tracheotomies decreased significantly from Block 1 to Block 3; in Block 3, mean age at the time of tracheotomy was significantly lower in patients who died than in patients who survived. A comorbidity score (CS) based on the number of airway diagnoses showed that higher CSs were associated with a poorer prognosis.

CONCLUSIONS

Mortality does not seem to be strongly related to the presence of the tracheotomy tube. Overall, two diagnostic groups were found to be independently associated with a poorer prognosis, ie, mechanical ventilation and pulmonary disease. Tracheotomies performed to provide airway access during other surgical procedures were associated with a better prognosis.

Tracheoplasty for congenital complete tracheal rings

OBJECTIVE

To better appreciate the complex nature of the pediatric patient with tracheal stenosis due to congenital complete tracheal rings, we evaluated clinical presentation, methods of evaluation, necessity for surgical repair, associated anomalies, and outcome.

DESIGN

Retrospective study.

PATIENTS

Eighteen patients with long-segment tracheal stenosis due to congenital complete tracheal rings were evaluated at Cincinnati (Ohio) Children's Hospital Medical Center between 1985 and 1991. Three patients did not require surgical intervention. Fifteen patients underwent tracheoplasty with cardiopulmonary bypass through a midline sternotomy.

RESULTS

The patients with congenital complete tracheal rings usually present with respiratory compromise in the first year of life. In the majority of patients, a diagnosis was made based on the symptoms and findings of an endoscopic examination with the aid of plain film roentgenography. In selected patients, computed tomography or magnetic resonance imaging was used. We evaluated symptoms, length of stenosis, type of repair, duration of intubation, and complications, as well as the mortality associated with this procedure.

CONCLUSIONS

The technique of tracheoplasty has evolved at our institution, including the use of a posterior tracheal division, anterior castellated division, autologous pericardial patch grafting, and cricoid split with intubation for 7 to 21 days. We found the mortality associated with this procedure quite high at 47%, compared with previously published reports with mortality figures between zero and 77%.

Tracheotomy in the first year of life

Tracheotomy in infants is considered to be associated with a high complication rate. This study was conducted to establish the indications and complications associated with tracheotomy in patients less than one year old. The charts of 44 consecutive infants operated on between 1982 and 1991 at the Montreal Children's Hospital were reviewed. The intra-operative complication rate was 9%; the postoperative was 18%. Home care was associated with a very low morbidity. The mortality attributable to tracheotomy was 5%. Significant complications were associated with the lack of availability of the correct size tracheotomy cannula. This study finds a significant rate of complications in the infant age group, but differs from other studies in finding that very premature neonates do not experience a higher rate of complications.

Tracheotomy in the first year of life

Much has been written concerning complications of pediatric tracheotomies, but few studies have reviewed the complication rates of tracheotomies performed in the first 12 months of life. We reviewed the records of 60 patients who underwent tracheotomy in the first year of life between 1976 and 1988. This study includes 30 full-term infants and 30 premature infants, 16 of whom were very low birth weight preterm infants (less than or equal to 32 weeks' gestation and less than 1,500 g birth weight). Overall complication rates were 3% intraoperative, 13% early postoperative, and 38% late postoperative. The early postoperative complication rate in preterm infants was nearly double that of full-term infants. The late postoperative complication rate of patients undergoing tracheotomy for airway obstruction was more than double that of patients requiring tracheotomy for pulmonary indications. Duration of tracheotomy, however, was felt to be the most important factor in the development of a late postoperative complication.

Tracheotomy in infants and young children: the changing perspective 1970-1985

One hundred fifty-three children 3 years of age or younger who had tracheotomies performed during the past 15 years are reviewed. During this time, short-term endotracheal intubation for airway obstruction from acute infections and long-term intubation for patients on ventilators have replaced early tracheotomy for these conditions. The number of tracheotomies decreased during each of three 5-year periods, from 73 to 55 to 25, respectively. Improvements in medical management resulted in prolonged survival of children with multiple abnormalities and resulted in more prolonged tracheotomies. Early complications occurred in 12% of patients and late complications occurred in 26%. In spite of changes in the indications, basic fundamentals of pediatric tracheotomy management remain unchanged.

Experimental reconstruction of the trachea with autogenous materials

Composite intercostal muscle flaps were experimentally used to repair major intrathoracic tracheal defects in the mongrel dog. These composite flaps provided an adequate tracheal lumen with both sufficient mobility and structural stability. Stenosis of the reconstructed trachea was an uncommon finding, but the incidence of early postoperative mortality was high.

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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