|Year : 2020 | Volume
| Issue : 2 | Page : 93-99
Pattern of tracheostomy-related complications and its determinants in Kano: a ten-year single institution experience
Department of Otorhinolaryngology, Faculty of Clinical Sciences, College of Health Sciences, Bayero University, Kano, Nigeria
|Date of Submission||09-Dec-2019|
|Date of Decision||29-Apr-2020|
|Date of Acceptance||14-May-2020|
|Date of Web Publication||11-Sep-2020|
Dr. Abdulrazak Ajiya
Department of Otorhinolaryngology, Faculty of Clinical Sciences, College of Health Sciences, Bayero University, Kano
Source of Support: None, Conflict of Interest: None
Background: Tracheostomy is the surgical creation of an opening into the trachea. Reported complication rates of tracheostomy are varied and depends on the study design, study population, patients’ follow-up and the definition of the different complications. We reviewed the pattern of tracheostomy-related complications and its determinants. Methods: This study was a 10-year retrospective review of patients who had tracheostomy in the study area between January 2008 to December 2017. Case files of the patients were retrieved, reviewed, and information extracted. Results: Of the 149 patients, the male: female ratio was 3.8:1 with age range of 6 months to 86 years. The peak age group was 1−10 years. Foreign body aspiration and head and neck neoplasia were the two most common admitting diagnoses; 56 (37.6%) and 55 (36.8%) respectively. The most common indication was upper airway obstruction (129, 86.6%). Emergency tracheostomy was most commonly done (126, 84.6%) and majority of the tracheostomies were done under general anaesthesia (101, 67.8%). Trainee ENT surgeons performed the most tracheostomies (108, 72.5%). Surgical decanulation was done for 5 (3.4%) of the patients. The complication and mortality rates were 42.3% and 2.6% respectively. The most common period of complication was early postoperative period (46, 73.0%), and the most common complications were tube blockage and tube displacement (26, 41.3% and 11, 17.5%) respectively. The analyzed variables were not statistically significant determinants of tracheostomy-related complications among the patients. Conclusion: Tracheostomy-related complications are common, usually in the early postoperative period and usually involve blockage or displacement of the tube.
Keywords: Adult, complications, determinants, paediatric, tracheostomy
|How to cite this article:|
Ajiya A. Pattern of tracheostomy-related complications and its determinants in Kano: a ten-year single institution experience. J Med Trop 2020;22:93-9
|How to cite this URL:|
Ajiya A. Pattern of tracheostomy-related complications and its determinants in Kano: a ten-year single institution experience. J Med Trop [serial online] 2020 [cited 2020 Sep 22];22:93-9. Available from: http://www.jmedtropics.org/text.asp?2020/22/2/93/294819
| Introduction|| |
Tracheostomy is the surgical creation of an opening into the trachea which is maintained with a tube, aimed at creating an alternative airway in critically ill patients or patients with other indications. Tracheostomy is one of the oldest surgical procedures on record, dating back as far as 3600 B.C.E in Egypt. Tracheostomy today is one of the most frequently performed procedures in critically ill patients, and is one of the cornerstones (in addition to surgically placed enteral feeding tubes) that help improve the lives of patients who are ventilator-dependent or have lost their native airway (e.g., post-laryngectomy patients).
In previous reviews, the overall complication rate of tracheostomy ranged from 6.7-48% with a mortality of 1.6%., The tracheostomy complication rate in the present era is comparably lower, and most complications are minor, however, there remains the potential for life-threatening events. Complications of tracheostomy can occur intraoperatively, in the early postoperative period or the late postoperative period.,, Early complications include bleeding from the operative site, injury to the larynx or tracheal mucosa, forced insertion of tracheostomy cannula resulting in pneumomediastinum, pneumothorax, hemorrhage, wound complications and misplacement of cannula, while tracheal stenosis, laryngeal stenosis, and failed re-insertion of cannula are some of the late complications.
Despite the possible complications that could follow the procedure of tracheostomy, the decision to place a tracheostomy is made in consideration of the benefits versus the risks of the procedure.
Several studies have reported morbid obesity, emergency tracheostomy as opposed to elective, pediatric tracheostomy as opposed to adult, and the surgeon experience as some of the factors associated with increased rate of complications following tracheostomy.,,,,, In addition, tracheostomy complications vary according to the method of tracheostomy, intra- and postoperative care, duration of intubation, and medical conditions of the patient. Alternative procedures for airway maintenance include endotracheal intubation, cricothyrotomy, and percutaneous dilational tracheostomy.,,
There is paucity of information on tracheostomy-related complications despite it been a common life-saving procedure in the study area. This study aimed to bring to light our experience on the subject of tracheostomy, the complications, determinants of the complications, and the outcome of the procedure.
| Materials and methods|| |
This was a retrospective review of patients who had tracheostomies performed at the Department of Otorhinolaryngology, Aminu Kano Teaching Hospital, Kano, Nigeria over a 10-year period between January 2008 and December 2017.
This study included all patients who underwent tracheostomy at the hospital during the period under study. Patients who had incomplete or missing information were excluded from the study.
Data were retrieved from the patients’ case files collected from the medical records department. The information was entered into a preformed questionnaire. The data included: demographic profile (age, sex), main presenting complaint, duration of presenting complaint, primary diagnosis, indication, venue of tracheostomy, duration of the procedure (between skin incision and placement of T-tube), type of tracheostomy, timing of tracheostomy, surgeon’s rank, anaesthetic technique, timing of first tracheostomy tube change, technique of decanulation, additional procedure performed, timing of complication, and type of complication.
The primary diagnosis was categorized based on aetiology into trauma, infection/inflammation, neoplasm, congenital airway disease, foreign body aspiration and others. The indication for tracheostomy was divided into upper airway obstruction, respiratory insufficiency, bronchial toileting, and as adjunct to head and neck surgeries. Complications related to tracheostomy was classified as: intraoperative, immediate postoperative (within the first 24hours after surgery), early postoperative (within the first 2 weeks after surgery), and late postoperative (beyond 2 weeks).
All tracheostomies were done open under local or general anesthesia as indicated, via a transverse incision done by ENT surgeons and trainee ENT surgeons while trained nurses carried out postoperative tracheostomy care. An electric suction machine was provided at bedside for suction as needed. Tracheostomy decannulation was carried out when the indication had been resolved with satisfactory maintenance of the airway. All decannulation were performed in the ward and/or clinic as required. Patients were then kept under observation for 24 hours after decanulation before discharge. Air sealed dressing was kept over the stoma allowing for healing by secondary intention. Patients and caregivers were counseled to present at the hospital immediately should respiratory distress occur. First follow-up was done after 2 weeks.
Ethical approval obtained from the institutional ethical review committee of the hospital.
The statistical analysis was done using statistical product and service solution (SPSS) version 23.0 (SPSS, Chicago IL, USA). The median, interquartile range and age range were calculated for continuous variables whereas proportions and frequency tables were used to summarize categorical variables. Chi-squared test was used to compare proportions with statistical significance set at a P value of < 0.05. Multivariate logistic regression analysis was used to determine predictor variables that predicted occurrence of complications.
| Results|| |
Over a ten-year period between January of 2008 to December of 2017, a total number of 192 patients had tracheostomy at the department of otorhinolaryngology, Aminu Kano Teaching Hospital (AKTH), Kano, Nigeria. Only 149 patients satisfied the inclusion criteria and were included in the study.
Among the 149 patients reviewed, 118 (79.2%) were males and 31(20.8%) were females with a male: female of 3.8:1. The age of the patients ranged from 6 months to 86years with a median age of 8 years and an interquartile range of 39.0. The peak age was in the age group 1–10 years [Table 1].
Those that presented to the hospital within 24 hours of commencement of symptoms were in the majority, 42 (28.2%), while foreign body aspiration and head and neck neoplasm were the two most common diagnoses among the patients that had tracheostomy: 56 (37.6%) and 55(36.8%), respectively. The most common indication for tracheostomy among the patients was upper airway obstruction, 129 (86.6%) [Table 1].
The majority of the tracheostomies were done as emergency: 126 (84.6%), temporary tracheostomies: 130 (87.2%), and were done under general anaesthesia: 101 (67.8%). Predominantly the patients had foreign body removal from the airway and direct laryngoscopy with biopsy for aerodigestive tract masses as additional procedures done alongside the tracheostomy; 52 (34.9%) and 44 (29.5%) respectively. The procedure of tracheostomy lasted between 30 minutes to 1hour in most cases; 131(87.9%) and was carried out mostly during the day; 80 (53.7%). Trainee ENT surgeons performed the most procedures; 108(72.5%), with the theatre been the venue in 144 cases (96.6%) [Table 1].
The first tube change among the patients was commonly carried out after the first 72 hours post-operatively, 99 (66.4%). Most of the patients were decanulated using normal serial tube blockage, 85 (57.0%) [Table 1].
The complication rate among our patients was 42.3% with mortality of 2.6%. The most common complications seen among our patients were tube blockage and tube dislodgement, 26 (41.3%) and 11 (17.5%), respectively [Table 1].
Failed decanulation was most commonly encountered among the paediatric age group [6 (17.1%)] compared to adults [1 (3.6%)] [Figure 1]. Early postoperative complications were the predominant among the patients as seen in 46 (73.0%) patients. Intraoperative and late complications were seen in [3 (5%)] and [14 (22%)] of the patients respectively.
|Figure 1: Comparison of tracheostomy-related complications in adults and children|
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There were more complications among children, female patients, those with upper airway obstruction, tracheostomy done in ICU, emergency tracheostomy, procedures done by consultants, those done under local anaesthesia and those done in the evenings. However, none were significant predictors of complications among the patients (P-values of 0.842, 0.421, 0.079, 0.729, 0.168, 0.270, 0.651, and 0.655 respectively as seen in [Table 2]).
| Discussion|| |
Tracheostomy is a common surgical procedure and is often associated with complications, usually minor but occasionally life threatening. In this study, the median age of our patients was similar to other reviews.,,,, However, other studies reported relatively higher median age among their patients., Patients in their first decade of life were the predominant in this study comparable to what was reported by similar studies in Nigeria., In other parts of Africa and Asia, studies revealed higher peak ages.,,,, Most series worldwide in agreement with the findings in this study show a male preponderance among tracheostomized patients.,,,,,
Some authors in Nigeria reported foreign body aspiration and head & neck neoplasia as the two most common admitting diagnoses amongst their tracheostomized patients comparable to the findings of this study., However, foreign body aspiration is relatively uncommon among tracheostomized patients in Asia., Moreover, Adoga et al. in Jos and Onotai et al. in Portharcout, both in Nigeria, reviewed paediatric tracheostomies and reported laryngeal papilloma and foreign body aspiration as the most common diagnoses in their series.
Upper airway obstruction has been reported worldwide as the most common indication for tracheostomy.,,,, The finding of this study is not different. However, several other authors reported prolonged intubation as their most common indication for tracheostomy in contrast to this study.,,,, This could be due to differences in study population or study design.
Tracheostomy was most commonly done as an emergency in this study similar to what some authors reported.,,,,, Contrary to this, elective tracheostomy was the predominant in other series.,,,,, Similarly, differences in study population and design could explain that. Gilyoma et al. in Northwestern Tanzania reported temporary tracheostomy as the common type of tracheostomy among their cohort, similar to what was found in the present study.
Tracheostomy was most commonly done under general anesthesia among the patients in this study. Gilyoma et al. in Tanzania similarly reported same. However, other authors reported local anesthesia as most commonly employed in their series.,, The larger proportion of pediatric patients in our study could explain this. Similar to this study, Cordes et al. in the United States reported direct laryngoscopy and biopsy as the most common additional procedure done alongside tracheostomy in their series.
Majority of our patients were successfully decanulated as was also reported in Southwestern Nigeria by Adetinuola et al. However, in other studies, the number of patients successfully decanulated is much lower.,
The complication rate in this study is relatively higher than in other related studies worldwide.,,,, However, some reported similar high rates in their series., Differences in the definition of the complications and predominance of emergency and/or pediatric tracheostomies in this study could be explanations behind these differences.
Absent tracheostomy-related mortality was severally reported by authors in contrast to the findings of the current study.,,, However, in agreement with this study, mortality rates ranging from 0.6% to 3.1% were reported by other authors.,,, In addition, Sakai et al., in the United States, reported a much higher mortality rate of 8% in their series.
Tube blockage and tube displacement were the most common tracheostomy-related complications in this series. Comparable to other similar studies in South Korea, Brazil, and United States.,, Other studies, however variously reported bleeding, surgical emphysema, and stoma infection as the most common complication of tracheostomy.,,, Failed decanulation, a late complication of tracheostomy, was common among the pediatric age group in this series. Onotai et al. similarly reported this in Port Harcourt, Nigeria.
Early postoperative tracheostomy-related complications were the most common finding in this study, in agreement to findings by other authors.,, However, many other similar studies reported late complications as most common.,,, The relatively short follow-up period and incomplete documentation during follow-ups might explain the differences.
Though several studies documented significant statistical correlation between tracheostomy-related complications and some variables such as emergency tracheostomy, children, obesity, type of tube, and smoking status.,,, The current study, however, in contrast showed none of the analyzed variables to be determinants of complications among the patients. In agreement to this finding, several authors reported similar findings.,,,,,
The retrospective nature of this review, inconsistent follow up periods for the patients in addition to the large number of patients excluded due to incomplete records are limitations to the study.
Pediatric tracheostomy is quite common and foreign body aspiration is a common admitting diagnosis among the children. Early postoperative complications are predominant, and the most common complications were tube blockage and tube dislodgement. Though complications were more common among children, female, those who had emergency tracheostomy, and other analyzed variables; none of these were statistically significant determinants of occurrence of complications.
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Conflicts of interest
There are no conflicts of interest.
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