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COMPLICATIONS OF TRACHEOSTOMY AT TERTIARY CARE HOSPITAL.

Byline: SALMAN SHAFIQUE ARSALAN AHMED SHAIKH and SUNEEL KUMAR PUNJABI

ABSTRACT

Tracheostomy is a very common emergency procedure and it is most widely used in patients suffering from airway obstruction either as emergency or electively. This Descriptive study was conduct- ed to evaluate complications of tracheostomy from January 2008 to December 2009 at Department of oral and Maxillofacial Surgery and otorhinolaryngology Civil Hospital Karachi. This study included 175 patients who underwent tracheostomy were evaluated for occurrence of various types of complications and also their frequencies. Out of 175 patients age ranged from 10 years to 82 years (Std Deviation 15.06). 75.4% of patients were male and 24.6% of patients were female and male to female ratio was .1:1. The overall complications were 47.4%. Among them 28.9% suffered early complications while 40.9% and 0.2% had intermediate and late complication respectively. Obstruction of tube was seen in 21.7% as the most frequent intermediate complication whereas primary hemorrhage was the most frequent early complication that accounts for 19.%. However Supra stomal granulation tissue was reported 14.5% as late complication.

Key Words: Complication Tracheostomy Tube Obstruction Hemorrhage.

INTRODUCTION

Tracheostomy is a very common procedure per- formed by head and neck surgeons and maxillofacial surgeons and it is most widely used in patients suffering from airway obstruction either as emergency or elec- tively. Tracheostomy is not psychosocially acceptable to patients because of the difficulty with phonation and the stigma associated with it by some uninformed people. Asclepiades of Persia was first who performed the tracheostomies but Jackson in nineteen century codified the modern technique for tracheostomy.1 Tra- cheostomy is the procedure which deals with airway so the operation theatre is considered as the ideal place.2

Tracheostomy can substantially reduce the mechan- ical workload of ventilator- dependent patients. The indications of tracheostomy are respiratory obstruction respiratory failure and respiratory paralysis removal of retained secretions and reduction of dead space.

The aggravation of dysphasia is an important index in judging the indication of tracheostomy.4 Standard surgical tracheostomy is an irreplaceable procedure in-patient with complex anatomic condition or in high- risk patient.5 There are complications associated with tracheostomy some of these include bleeding injury to cricothyroid complex injury in the posterior laryngeal wall pneuomothorax subcutaneous emphysema.6

The high mortality may be due to the primary medical problems rather than the complications of tracheostomy alone.7 Complications of tracheostomy quoted as 6 to 66% in medical literature and complications could be either early or late. Mortality of the tracheostomy is reported as less than 2%.8

The purpose of this study was to find out various types and frequencies of complications of tracheostomy at tertiary care hospital.

METHODOLOGY

This descriptive prospective study was carried out in the Department of Maxillo-facial Surgery and otorhinolaryngology at Dow University of Health Sci- ences and Civil Hospital Karachi from January 2008 to December 2009.

This study included 175 patients who underwent tracheostomy under local anesthesia either as emergen- cy procedure or electively from all age groups and both genders and socio-economical class. Those patients who underwent another procedure like total laryngectomy or tracheostomy tube was removed within 24 hours after the procedure like temporo-mandibular joint arthoplasty or who were shifted to other health care facilities were excluded from this study. Frequencies and various types of complications of tracheostomy were recorded in purposely designed proforma.

Data were analyzed by using SPSS version 16. Frequency and percentage were computed for presen- tation of all variables including age gender and various complications of tracheostomy. No inferential test was applicable for this descriptive study.

RESULTS

Out of 175 patients 12 (75.4%) were male and 4 (24.6%) were female and male to female ratio was approximately .1:1 (Fig 1). Patient's age ranged from 10 years to 82 years with mean as 40.5 years and Std Deviation of 15.06 (Fig 2).

Approximately 47.4% patients encountered com- plication where as 52.6% recovered with any compli- cation of the tracheostomy (Fig ). Among them 28.9% suffered early complications while 40.9% and 0.2% had intermediate and late complication respectively (Table 1).

TABLE 1: TYPE OF COMPLICATIONS (n=175)

S. No.###Types###Number###Percentage

###1.###Early###24###28.9

###2.###Intermediate###34###40.9

###3.###Late###25###30.2

TABLE 2: DISTRIBUTION OF COMPLICATIONS

Complication###Number###Percentage

Early

Primary haemorrhage###16###19.3

Apnea###04###4.8

Damage to local structure###04###4.8

Intermediate###

Tube obstruction###18###21.7

Scabs and crusis formation###06###7.2

Superficial emphysema###04###4.8

Stomal infection###06###7.2

Late###

Disfiguring scar###10###12.1

Tracheal stenosis###02###2.4

Tracheocutenous fistula###01###1.2

Supra-stomal Granula-###12###14.5

Haemorrhage was the most frequent early com- plication that accounts for 19.% followed by apnoea and damaged to local structure as 4.8% respectively (Table 2).

Whereas obstruction of tube was seen in 21.7% as the most frequent intermediate complication while stomal infection and scabs formation were second most commonly encountered complication as 7.2% respec- tively in intermediate complication group. Surgical emphysema was seen only in 4.8% and recorded as an intermediate complication (Table 2). Supra-stomal granulation tissue was most com- monly encountered late complication an accounts for 14.5%. Whereas disfiguring scar tracheal steno- sis and tracheocutenous fistula were less common and comprised 12.1% 2.4% and 1.2% respectively (Table 2).

DISCUSSION

Tracheostomy is an ancient surgical procedure indicated for management of upper airway obstruction. It is the procedure that creates surgical opening into the trachea and exteriorizing it into anterior cervical region. Historical description of tracheostomy was found even 2000 years ago. Tracheostomy can be either as an elective surgical procedure or as an emergency proce- dure. It is most commonly performed in patients who have had difficulty weaning off a ventilator followed by those who have suffered trauma or some catastrophic neurologic insult. Infectious and neoplastic processes are less common in diseases that require a surgical airway. Indications of tracheostomy have been evolved during a couple of decades.10-11

This study was directed to evaluate frequency and types of complications of tracheostomy in two depart- ments of tertiary care setting. Mean age of the patient was noticed as 40.5 years which in fact is slightly higher from an international study.12 Even another local study also reported younger mean age.1 Male to female ra- tio was identical to Santosh and colleagues although sample size in their study was small.14 Another local study also reported closer findings with 2.9:1 ratio and even lower stated by imran munir and his colleagues probably because of difference in number of the patients received at private and public sector hospital.15

Final outcome of tracheostomy patient is signifi- cantly influenced by post operative complications. Complication rate of tracheostomy have been quoted between 6-66%1617 while the overall complication rate in this study was 47.4% however abdul aziz Hamid18 reported higher incidence of overall complication in his research. In contrast significantly lower incidence of complications was observed in international literature.10

This variation in incidence of complication reflects the difference in quality and standard of operating circum- stances and post operative care.

In present study intermediate complications were more frequently encountered then early and delayed. However lower intermediate complication reported by Munir et al.15 In other study early complications were more frequently observed.19 Another local study reported higher incidence of intermediate complications as compare to the early and late complications.20 How- ever their rate of intermediate complications was still lower than that of ours because their study comprised of patients in intensive care unit where better nursing care was provided to the patients.

Primary hemorrhage was the most frequent one among the complications in early phase. Significantly lower rate reported in local research.15 Comparable observation was documented by other local and in- ternational studies.1921 Tube obstruction was most common intermediate complication and in fact was the most common complications among the all groups. Almost similar incidence reported in the local study.22

In contrast to our study harriet J et al reported tube obstruction in 14% cases of his series.2

Among late complication in this study supra sto- mal granulation tissue was the most common one. In comparison to the local literature munir et al15 reported decannulation as most common late complication and similar finding documented by Chistoper KL24. In another international study stomal granulation was observed as most frequent late complication in consis- tence on our observation.25

Occurrence of early complications can be attributed to surgical expertise operative circumstances and indi- cation of procedure whereas intermediate complications are related to quality of post operative nursing. Delayed complications are usually related to late hospital and homecare time of decanulation disease process and further management of underlying problem.

CONCLUSION

It is concluded from this study that complication of tracheostomy is not something uncommon and in- termediate complication are most frequent event and among them tube obstruction was most commonly en- countered complication. However improved and vigilant nursing care may result in minimizing the incidence of intermediate complications. Proper training of hospital staff including resident house surgeons and nursing staff about tracheostomy care may help in improving outcome of the procedure.

Tracheostomy is a life saving procedure can be considered as a mandatory surgical skill. However of adherence to surgical principles and understanding of complications can be improved the ultimate outcome of this procedure.

REFERENCES

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Publication:Pakistan Oral and Dental Journal
Article Type:Report
Geographic Code:9PAKI
Date:Dec 31, 2014
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