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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 3  |  Issue : 3  |  Page : 730-734

Incidence of tracheostomy in prolonged mechanically ventilated patient in the respiratory intensive care unit


1 Department of Chest Diseases, Faculty of Medicine, Al-Azhar University, Egypt
2 Department of Otorhinolryngology, Faculty of Medicine, Al-Azhar University, Egypt
3 Department of Public Health and Community Medicine, Al-Azhar University, Damietta; Department of Health Education and Promotion, Faculty of Public Health and Health Informatics, Umm Al-Qura University, Makkah, Saudi Arabia, Egypt

Date of Submission31-Oct-2019
Date of Decision31-Oct-2019
Date of Acceptance18-Nov-2019
Date of Web Publication10-Feb-2020

Correspondence Address:
MD Chest Degree Farid S Basiony
Department of Chest Diseases, Al-Azhar University, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjamf.sjamf_92_19

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  Abstract 


Background Tracheostomy is considered for ill patients with respiratory failure with expected prolonged mechanical ventilation not only to facilitate pulmonary toilet, ventilator weaning but also decrease the direct laryngeal injury of endotracheal intubation.
Aim The aim was to assess the incidence, indications, complications, and outcome of tracheostomy for patients with prolonged mechanical ventilation.
Patients and methods A retrospective study was carried out over 10 years from January 2009 to December 2018 at the Respiratory Intensive Care Unit, El-Hussein University Hospital. This study included 120 patients who underwent open tracheostomy in the operation theater carried out by otorhinolaryngology surgeons. Complications of tracheostomy were documented.
Results The age of the study group ranged from 45 to 82 years. The complications were two cases of bleeding, one case of cardiac arrest, two cases of Pneumothorax, three cases of stomal sepsis, and four cases of surgical emphysema. Laryngotracheal stenosis was observed in five patients and tubal obstruction in three patients.
Conclusion Prolonged endotracheal intubation is the first main indication of tracheostomy in the respiratory ICU, although there were minimal complications from this procedure.
Recommendation Early tracheostomy is recommended for patients who are expected to have prolonged tracheal intubation.

Keywords: intensive care unit, mechanical ventilation, prolonged tracheal intubation, respiratory failure, tracheostomy


How to cite this article:
Wahba AH, Basiony FS, Elsamanody AN, Nour MO. Incidence of tracheostomy in prolonged mechanically ventilated patient in the respiratory intensive care unit. Sci J Al-Azhar Med Fac Girls 2019;3:730-4

How to cite this URL:
Wahba AH, Basiony FS, Elsamanody AN, Nour MO. Incidence of tracheostomy in prolonged mechanically ventilated patient in the respiratory intensive care unit. Sci J Al-Azhar Med Fac Girls [serial online] 2019 [cited 2020 Feb 29];3:730-4. Available from: http://www.sjamf.eg.net/text.asp?2019/3/3/730/278055




  Introduction Top


More than 25% of intensive care admissions require invasive mechanical ventilation (MV) annually. Use of MV has increased over time, especially with aging and comorbidity [1].

Respiratory failure that requires prolonged MV is predicted to increase, particularly in chronic obstructive pulmonary disease (COPD), lung cancer, and sepsis [2].

The outcome and prognosis of patients with prolonged MV are important for physician and patients; thus, good communication on the care plan should be followed [3].

Patients using PMV have end-stage disease, and they are likely to be near the end of life. Palliative care to preserve quality of life is very important [4].

This choice of tracheostomy has some implications for cost, resource use, and outcomes during acute hospitalization and following hospital discharge [5].

Tracheostomy is the most important surgical procedure in respiratory intensive care units (RICU) to allow gradual waning of ventilatory support and for airway protection, especially in unconscious patients [6].

Tracheostomy has important benefits such as decreased laryngeal injury of intubation and decreased sedation requirements, and facilitates transfer to the ward and improves patient comfort [7].


  Aim Top


The aim was to report the incidence, indications, and complications of tracheostomy for patients with prolonged MV.


  Patients and methods Top


A retrospective study was carried out over ten years from January 2009 to December 2018 in the Respiratory Intensive Care Unit, El-Hussein University Hospital. Ethical consideration the study was approved by ethics committee of faculty of medicine, al-Azhar University. Privacy was maintained throughout the study process using a unique code number for each case file. This study included 950 patients admitted to RICU. Only 120 patients underwent open tracheostomy in the operation theater.

Inclusion criteria

We included patients admitted to RICU and required MV for more than 3 weeks.

Exclusion criteria

The following patients were excluded from the study:
  1. Children and adolescents.
  2. Urgent airway patency.
  3. Thyroid goiter.
  4. Failure to palpate cricoid cartilage.
  5. Short neck secondary to obesity.
  6. Spinal cord injury.
  7. Previous tracheostomy operation.
  8. Severe thrombocytopenia and uncorrectable coagulopathy.
  9. Inexperienced practitioner.
  10. Percutaneous tracheostomy


Tracheostomy procedure

The patients who needed tracheostomy were transferred to the operation theater from RICU within the same hospital. During the transfer, all patients were assisted by a portable MV. Then, noninvasive blood pressure measurement, ECG, pulse oximetry, and capnogram were performed for patients. Anesthesia was induced with sedatives, analgesics, and neuromuscular blockers and maintained by MV with inhalation anesthetic. Otolaryngology surgeons performed all the tracheotomies. The selected tracheostomy tube should be available in the operation theater and checked for any cuff leaks. After positioning, the symmetrical level of shoulders was assessed; thus, the midline neck structures are not skewed to one side. A 3 cm transverse incision through the skin is made halfway between the lower border of the cricoid and the suprasternal notch. Once skin has been incised, dissection through subcutaneous tissues is performed. Strap muscles are identified and divided vertically in the midline. Hemostasis and dissection of thyroid isthmus are performed. Exposure of the trachea is performed by blunt dissection. The tracheotomy is usually carried out in the third or fourth tracheal rings. The anesthetist is informed about tracheostomy procedure. When the tip is immediately above the tracheotomy, the withdrawal is stopped and the tracheostomy tube is inserted. The tracheostomy cuff is then inflated and bilateral chest expansion and carbon dioxide trace uptake on the anesthetic machine is confirmed. The incision is closed loosely and the tracheostomy tube is secured in position. Tracheostomy dressing is finally applied; then, the patients are returned to the RICU, assisted by a MV, and they receive good care, along with management of any post-operative complications.

Statistical analysis

Statistical analysis was carried out using the SPSS computer package version 21.0 (SPSS Inc., Chicago, Illinois, USA). For descriptive statistics, the mean±SD were used for quantitative variables, whereas the number and percentage were used for qualitative variables. Fischer’s exact test was used to assess the differences in the frequency of qualitative variables, whereas the Mann–Whitney U-test was applied to assess the differences in the means of quantitative variables. The statistical methods were verified, assuming a significance level of P less than 0.05 and a highly significant level of P less than 0.001.


  Results Top


The study included 950 patients admitted to the RICU over a 10-year period from January 2009 to December 2018. Tracheostomy was performed for 120 (12.6%) patients. The number of tracheostomies performed each year decreased gradually from 20 patients in 2009 to five patients in 2018. One hundred (83.3%) patients were male and 20 (16.7%) were female, mean age 55±13.6 years, range 30–80 years. Cigarette smokers accounted for 90 (75%) patients and 88 (73.3%) patients were living in urban areas as shown in [Table 1].
Table 1 General characteristics of the studied patients

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The most common causes for performing tracheostomy were COPD in 60 (50.0%) patients; pneumonia and sepsis in 10 (8.3%) patients; Interstitial lung disease (ILD), bronchogenic carcinoma, and Kyphoscoliosis in eight (6.7%) patients; obesity hypoventilation syndrome in six (5.0%) patients; and bronchiectasis and brain disorders in five (4.2%) patients ([Table 2]).
Table 2 Diagnosis at admission of studied patients

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The tracheostomy was performed for prolonged intubation and weaning failure in 92 (76.7%) patients, removal of bronchial secretions in 16 (13.3%) patients, diaphragmatic paralysis in four (3.3%) patients, and airway patency for upper airway obstruction in eight (6.7%) patients, as summarized in [Table 3].
Table 3 Main indications for tracheostomy in studied patients

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A total of 20 (16.7%) cases reported complications during tracheostomy. Laryngotracheal stenosis is the most common complication that occurred in five (4.2%) cases, followed by surgical emphysema in four (3.3%) cases. Infection at stoma and tubal obstruction occurred in three (2.5%) cases, hemorrhage and Pneumothorax occurred in two (1.7%) cases, and one (0.85) case developed cardiac arrest as shown in [Table 4].
Table 4 Complications of tracheostomy in studied patients

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Tracheostomy was performed within 16–28 days after intubation, with a mean duration of 18.4±2.7 days.

A total of 100 (83.3%) patients were discharged free after receiving tracheostomy, 12 (10.0%) patients required long-term acute care at hospital, and eight (6.7%) patients died ([Figure 1]).
Figure 1 Outcome of patients receiving tracheostomy.

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MV was required in 620/950 (64.2%) of the studied patients and all tracheostomized ICU patients were mechanically ventilated compared with 60.2% of other ICU patients, with a significant difference (P<0.001), as shown in [Table 5].
Table 5 Comparison between tracheostomized and nontracheostomized ICU patients

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  Discussion Top


Patients who required PMV had increased risk for complications during ICU stays and higher death rates.

Damuth and colleagues reported worse outcomes of patients requiring PMV in a postacute care hospital [the in-hospital mortality rate was 31% (95% confidence interval, 26–37) vs 18% (95% confidence interval, 14–24), respectively] [8].

Our study included 950 patients admitted to the RICU over ten years with MV.

The aim of this study is to report tracheostomy incidence, indications, and complications in patients with chronic respiratory failure who need prolonged MV.

Tracheostomy is the most important surgical procedure carried out on RICU patients [9].

From our study, it was found that tracheostomy was performed only for 120 (12.6%) prolonged mechanically ventilated patients with chronic respiratory failure.

Combes et al. [10] reported that about 10–11% of critically ill patients require tracheostomy after prolonged MV.

In the study carried out by El-Anwar et al. [11], tracheostomy was performed for 36 patients (29%).

Also, we observed that the benefits of early tracheostomy in prolonged mechanically ventilated patients over an endotracheal tube include shorter hospital stay, a decrease in direct laryngeal injury as well as improved comfort and daily activities of living [12].

In our study, there were 100 (83.3%) males and (16.7%) 20 females ranging in age from 30 to 80 years, mean age 55 years. Cigarette smokers accounted for 90 (75%) of the studied patients. About 88 (73.3%) patients were living in urban areas.

In the study carried out by El-Anwar et al. [11] on 124 ICU patients, there were 108 (87.1%) males and 16 (12.9%) females, ranging in age from 12 to 67 years.

The most common causes for performing tracheostomy were COPD in 60 (50%) patients, pneumonia and sepsis in eight (8.3%) patients, ILD and bronchogenic carcinoma and Kyphoscoliosis in eight (6.7%) patients, obesity hypoventilation syndrome in six (5.1%) patients, and finally, bronchiectasis and brain disorders in five (4.1%) patients.

The tracheostomy was performed for prolonged intubation in 92 (76.7%) patients, diaphragmatic paralysis in four (3.3%) patients, removal of bronchial secretions in 13.3%, and airway patency for upper airway obstruction in eight (6.7%) patients.

In the study carried out by El-Anwar et al. [11], the main indication for tracheostomy was prolonged intubation in 29 (80.5%) patients and diaphragmatic paralysis in seven (19.5%) patients.

In our study, the complications of tracheostomy included laryngotracheal stenosis, which was the most common complication that occurred in five (4.1%) cases, followed by surgical emphysema, which was reported in four (3.3%) cases and resolved spontaneously. However, infection at stoma and tubal obstruction occurred in three (2.5%) cases, and finally hemorrhage and Pneumothorax occurred in two (1.7%) cases.

In the study carried out by El-Anwar et al. [11], the complications of tracheostomy included surgical emphysema in (8.3%) and resolved spontaneously and three most common tracheostomy emergencies (hemorrhage, tube dislodgement, and tube obstruction in (13.9%), two cases of tubal obstruction in that study and treated by changing the tube while tracheal stenosis in one (2.8%) case needed surgery. However, 9 (25%) patients had subglottic stenosis. In our study, tracheostomy was performed within 16–28 days after intubation, with a mean of 18.4±1.07 days.

In the study carried out by El-Anwar et al. [11], tracheostomy for prolonged intubation was performed within 17–26 days after intubation, with a mean of 19.4±2.07 day.

In the study carried out by El-Anwar et al. [11], ICU stay duration ranged between 2 and 100 days, with a mean (SD) of 15.87 (21.4). This duration ranged between 3 and 100 days (mean: 33.5±30.9) for tracheostomized patients and ranged between 2 and 60 days (mean: 8.6±10.1) for intubated patients. Thus, there were significantly longer durations of ICU stay in tracheostomized patients (t=3.4253 and P=0.0019).

In study carried out by Cox et al. [13], patients with prolonged mechanical ventilation constituted a distinct group of patients, who were sicker on admission and exhibited higher mortality, longer hospital stays and higher costs.


  Conclusion Top


Prolonged endotracheal intubation is the first indication of tracheostomy that is performed to decrease length of hospital stay.

Recommendation

Early tracheostomy is highly recommended whenever prolonged tracheal intubation is expected.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wunsch H, Linde-Zwirble WT, Angus DC, Hartman ME, Milbrandt EB, Kahn JM. The epidemiology of mechanical ventilation use in the United States. Crit Care Med 2010; 38:1947–1953.  Back to cited text no. 1
    
2.
MacIntyre NR, Epstein SK, Carson S, Scheinhorn D, Christopher K, Muldoon S. Management of patients requiring prolonged mechanical ventilation − report of a NAMDRC consensus conference. Chest 2005; 128:3937–3954.  Back to cited text no. 2
    
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Carson SS, Bach PB. The epidemiology and costs of chronic critical illness. Crit Care Clin 2002; 18:461–476.  Back to cited text no. 3
    
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Lai C-C et al. The outcomes and prognostic factors of patients requiring prolonged mechanical ventilation. Sci Rep 2016; 6:28034.  Back to cited text no. 4
    
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Mehta AB, Syeda SN, Bajpayee L, Cooke CR, Walkey AJ, Wiener RS. Trends in tracheostomy for mechanically ventilated patients in the United States, 1993–2012. Am J Respir Crit Care Med 2015; 192:446–454.  Back to cited text no. 5
    
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Nelson JE, Cox CE, Hope AA, Carson SS. Chronic critical illness. Am J Respir Crit Care Med 2010; 182:446–454.  Back to cited text no. 6
    
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Koh WY, Lew TW, Chin NM, Wong MF. Tracheostomy in a neuro-intensive care setting: indications and timing. Anaesth Intensive Care 1997; 25:365–368.  Back to cited text no. 7
    
8.
Damuth E, Mitchell JA, Bartock JL, Roberts BW, Trzeciak S. Long-term survival of critically ill patients treated with prolonged mechanical ventilation: a systematic review and meta-analysis. Lancet Respir Med 2015; 3:544–553.  Back to cited text no. 8
    
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Martin CM, Hill AD, Burns K, Chen LM. Characteristics and outcomes for critically ill patients with prolonged intensive care unit stays. Crit Care Med 2005; 33:1922–1927. quiz 1936  Back to cited text no. 9
    
10.
Combes A, Costa MA, Trouillet JL, Baudot J, Mokhtari M, Gibert C et al. Morbidity, mortality, and quality-of-life outcomes of patients requiring >or=14 days of mechanical ventilation. Crit Care Med 2003; 31:1373–1381.  Back to cited text no. 10
    
11.
El-Anwar MW, Nofal AA-F, El Shawadfy MA, Maaty A, Khazbak AO. tracheostomy in the intensive care unit: a university hospital in a developing country study. Int Arch Otorhinolaryngol 2017; 21:33–37.  Back to cited text no. 11
    
12.
Bittner EA, Schmidt UH. The ventilator liberation process: update on technique, timing, and termination of tracheostomy. Respir Care 2012; 57:1626–1634.  Back to cited text no. 12
    
13.
Cox CE, Carson SS, Lindquist JH, Olsen MK, Govert JA, Chelluri L. Quality of Life After Mechanical Ventilation in the Aged (QOL-MV) Investigators. Differences in one-year health outcomes and resource utilization by definition of prolonged mechanical ventilation: a prospective cohort study. Crit Care 2007; 11:R9.  Back to cited text no. 13
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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