- Email: [email protected]
Analysis of Risk Factors for Pneumonia in 482 Patients Undergoing Oral Cancer Surgery With Tracheotomy
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56
SURGICAL ONCOLOGY AND RECONSTRUCTION
Analysis of Risk Factors for Pneumonia in 482 Patients Undergoing Oral Cancer Surgery With Tracheotomy Li Li, PhD,* Weijun Yuan, MSc,y Shilei Zhang, PhD,z Kewei Wang, PhD,x and Hong Ruan, MSck
Q11
Purpose:
Elective tracheostomy is a common procedure used in patients with oral cancer. However, secondary tracheotomy-associated pneumonia (TAP) is an important complication after surgery. This study investigated the risk factors related to postoperative TAP complications in patients with oral cancer.
Materials and Methods:
Q3
A retrospective study was performed from January 2012 to October 2013. Data on patients who had oral cancer and underwent neck dissection or reconstructive surgery with tracheotomy were collected from the Hospital Information System. The predictive variables were age, gender, alcohol history, smoking history, basic disease (including diabetes, hypertension, and cardiovascular disease), tumor location, and duration of tracheotomy, which were extracted from electronic medical records. The outcome variable was TAP. Descriptive single factors and bivariable statistics were computed and the P value was set at .05.
Results: Q4
Q5
Four hundred eighty-two patients who received tracheotomy after oral cancer surgery were included in this study and 95 (19.7%) developed TAP. Univariate analysis showed that male gender (odds ratio [OR] = 1.853; 95% confidence interval [CI], 1.083-3.17; P = .024 to <.05), long duration of tracheotomy (OR = 1.673; 95% CI, 1.343-2.083; P < .0001), and smoking (OR = 1.656; 95% CI, 1.053-2.604; P = .029 to <.05) were risk factors for TAP. Then, 2 variables independently related to an increased risk of postoperative TAP were found by multivariate regression analysis, which were male gender (OR = 1.945; P = .018) and long duration of tracheotomy (OR = 1.694; P = .0001).
Conclusions: The present findings indicate that male gender and tracheotomy duration are important risk factors for TAP in patients undergoing major oral cancer surgery. Ó 2015 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1-5, 2015
The risk of complications is increased during the postoperative period; in surgical procedures, the respiratory system is frequently affected. In a large meta-analysis, the incidence of postoperative pulmonary complications (PPCs) reported in patients un-
dergoing non-thoracic surgery varied widely from 2 to 19%.1 Major head and neck surgery most often results in upper airway obstruction, which in turn causes edema of the larynx, pharynx, and posterior tongue and requires the use of bulky reconstructive
*Department Head, Department of Oral and Maxillofacial Surgery,
Dr Li and Mr Yuan contributed equally to this work. Address correspondence and reprint requests to Prof Ruan:
Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University
Department of Nursing, Ninth People’s Hospital affiliated to
School of Medicine, Shanghai, China. yDepartment Head, Department of Oral and Maxillofacial Surgery,
Shanghai Jiaotong University, 639 Zhizao Ju Road, Huangpu District,
Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University
Shanghai, 200011, People’s Republic of China; e-mail: sunbook_
School of Medicine, Shanghai, China.
[email protected]
zProfessor, Department of Oral and Maxillofacial Surgery,
Received May 29 2015 Accepted August 24 2015
Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
Ó 2015 American Association of Oral and Maxillofacial Surgeons
xResident, Jiangnan University School of Medicine, Wuxi, Jiangsu,
0278-2391/15/01263-X
China.
http://dx.doi.org/10.1016/j.joms.2015.08.018
kProfessor, Department of Nursing, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
1 FLA 5.4.0 DTD YJOMS56953_proof 22 September 2015 12:10 am CE AH
Q2
57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112
113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168
2
RISK FACTORS FOR PNEUMONIA DURING TRACHEOTOMY
flaps. Bilateral neck dissection surgery or removal of the mandible, tongue, and floor of the mouth is even more risky.2 The incidence of PPC has been shown to vary among patients after head and neck surgery, which was considered intermediate in a large meta-analysis.3 Although elective tracheostomy is performed as part of this surgical procedure, patients easily develop PPCs.4 Therefore, the incidence of PPC in patients after head and neck surgery is 15 to 46%.5 For instance, pneumonia has been reported at an overall postoperative rate of at least 20%.6 Ong et al6 suggested that 73 patients treated with major head and neck surgery were sufficient for analysis: 37 patients (47%) had pulmonary complications that progressed to pneumonia in 29 (40%). Petrar et al4 found that major head and neck surgery results in increased risk for PPCs, with advanced age and hypertension strongly related to PPCs. Decreased lung function and postsurgical atelectasis have emerged as important risk factors for pneumonia.6 Previous meta-analyses have reported that cigarette smoking is an independent predictor of PPCs.3,7 Tracheostomy and anesthesia lasting longer than 4 hours are other known risk factors for pneumonia in head and neck surgery.8 An increased incidence of pulmonary complications delays recovery, demands greater intensive care, increases hospital stay, and obviously leads to higher health care costs. In this study, all patients underwent oral oncology resection, free flap transplantation, and tracheostomy after surgery. The authors assessed other risk factors for their roles in the occurrence of pneumonia.
Materials and Methods This retrospective study was approved by the institutional research ethics board to review data of patients after oral cancer surgery at a tertiary care center in Shanghai, China. Data recorded from admission and anesthesia records included age, gender, basic diseases (including diabetes, hypertension, and cardiovascular disease), preoperative smoking, and alcohol use. Patients were considered smokers when currently smoking or had a smoking history of 10 pack-years during their lifetime. Patients with unrecorded current smoking status or history of cigarette use were counted as nonsmokers. Preoperative comorbidities were obtained from hospitalization documents. Duration of tracheostomy and tumor site were determined from hospital charts. Inclusion criteria were an age older than 18 years, anesthesia time longer than 3 hours, procedure requiring tracheotomy, and free tissue transfer repair without postoperative mechanical ventilation. Patients with pre-existing pulmonary disease were excluded.
The practices of the authors’ clinic are similar to those found in other major head and neck cancer centers, as described in contemporary reports in the field (elective tracheostomy is a common procedure in patients after head and neck surgery). A gastric feeding tube was implanted before transfer to the intensive care unit (ICU) in a fully awake state, where oxygen was provided through a tracheotomy. After the operation, all patients were routinely treated with antibiotics. PRIMARY OUTCOME VARIABLE
The primary outcome was tracheotomy-associated pneumonia (TAP). Diagnosis of pneumonia was contingent on at least 2 of the following criteria: persistent (ie, $24 hours) fever (>37.5 C), purulent sputum volume increase (20%), new shadowing on chest radiograph, or persistent (ie, $2 days) localized signs at chest examination (crackles, bronchial breathing, wheeze, or pleural rub).6 Chest radiographs were assessed by a respiratory physician (J.K.) who was blinded to patients’ postoperative therapy. DATA COLLECTION
Data were obtained retrospectively on patients undergoing oral oncology surgery with tracheostomy from January 2012 to December 2013 in the authors’ hospital unit. Data regarding overall outcomes were collected for 523 cases, although comprehensive operation details were available for 482 patients. All procedures included neck dissection with or without reconstructive surgery. Tracheotomies were carried out by the surgical team. STATISTICAL ANALYSIS
Data analysis was performed using SPSS 16 (SPSS, Inc, Chicago, IL). Univariate analyses were carried out by c2 test; logistic regression analysis was conducted using statistically relevant factors to identify independent risk factors for TAP; data are presented as unadjusted odds ratios (ORs) and 95% confidence intervals (CIs). A P value less than .05 was considered statistically significant.
Results PATIENT DATA
The present study included 482 patients (334 men and 148 women; 20 to 88 yr old; 58.28 13 yr). There were 197 (40.87%) cases of tongue carcinoma, 61 (12.66%) cases of cancer of the floor of the mouth, 54 (11.2%) cases of buccal mucosa carcinoma, 64 (13.28%) cases of jaw malignant neoplasm, 15 (3.11%) cases of palate carcinoma, 70 (14.52%) cases of gingiva carcinoma, and 21 (4.4%) cases of
FLA 5.4.0 DTD YJOMS56953_proof 22 September 2015 12:10 am CE AH
Q1
169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224
3
LI ET AL
225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280
Table 1. SINGLE-FACTOR ANALYSIS OF RISK FACTORS FOR PULMONARY INFECTION
Pulmonary Infection, n (%) Q8
Gender Men Women Age (yr) <50 50-59 $60 Smoking history Yes No Alcohol history Yes No Basic disease Yes No Oral tumor site Tongue Floor of mouth Buccal mucosa Jaw Palate Gingiva Oropharynx Duration of tracheostomy (days) 7-10 11-15 16-20 >20
Affected (n = 95)
Unaffected (n = 387)
75 (78.9) 20 (21.1)
259 (66.9) 128 (33.1)
29 (30.5) 19 (20) 47 (49.5)
83 (21.4) 118 (30.5) 186 (48.1)
46 (48.4) 49 (51.6)
140 (36.2) 247 (63.8)
31 (32.6) 64 (67.4)
99 (25.6) 288 (74.4)
55 (57.9) 40 (42.1)
142 (36.7) 245 (63.3)
36 (37.9) 11 (11.6) 14 (14.7) 14 (14.7) 4 (4.2) 9 (9.5) 7 (7.4)
161 (41.6) 50 (12.9) 40 (10.3) 50 (12.9) 11 (2.8) 61 (15.8) 14 (3.6)
29 (30.5) 32 (33.7) 16 (16.8) 18 (18.9)
Value
P Value
5.075
.024
5.691
.058
4.773
.029
1.914
1.167
0.949
.33
2.962
.085
21.148
.0001
196 (50.6) 132 (34.1) 30 (7.8) 29 (7.5)
Li et al. Risk Factors for Pneumonia During Tracheotomy. J Oral Maxillofac Surg 2015.
TRACHEOTOMY-ASSOCIATED PNEUMONIA
oropharyngeal cancer. These patients underwent cancer resection with tracheotomy, free tissue transfer reconstruction, postoperative oxygen, and dynamic observation in the ICU without postoperative mechanical ventilation.
Q9
Analysis showed that 95 of 482 patients (19.71%) met the criteria for TAP. The patients who developed TAP (median age standard deviation, 59 12 yr) showed no statistical differences from those who did not
Table 2. LOGISTIC REGRESSION ANALYSIS OF INDEPENDENT RISK FACTORS AFFECTING PULMONARY INFECTION POSTOPERATIVELY
95.0% CI for Exp (B)
Gender Duration of tracheostomy
0.665 0.527
B
Wald
Sig
Exp (B)
Lower
Upper
0.281 0.113
5.612 21.659
0.018 0.0001
1.945 1.694
1.122 1.357
3.373 2.115
Abbreviation: CI, confidence interval. Li et al. Risk Factors for Pneumonia During Tracheotomy. J Oral Maxillofac Surg 2015.
FLA 5.4.0 DTD YJOMS56953_proof 22 September 2015 12:10 am CE AH
281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336
337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392
4
RISK FACTORS FOR PNEUMONIA DURING TRACHEOTOMY
develop TAP (59 14 yr; P > .05). Patients with TAP who underwent tracheotomy (15.45 8.48 days) were statistically different from those who did not develop TAP (12.02 5.23 days; P < .0001). ANESTHESIA AND SURGICAL PROCEDURE
All patients underwent tumor resection and neck dissection with or without a reconstructive procedure under intravenous anesthesia and tracheal intubation with mechanical ventilation. Operations were carried out by at least 3 surgeons, and the patients were transferred to the oral and maxillofacial surgical ward after the operation. The surgical procedure lasted an average of 8.85 hours (range, 4 to 14.5 hours). LOGISTIC REGRESSION ANALYSIS FOR DETERMINATION OF SINGLE RISK FACTORS
An association was found between TAP and smoking status, alcohol history, gender, age, duration of tracheotomy, and in combination with other diseases (eg, hypertension, diabetes, and coronary heart disease). Univariate analysis showed that male gender (OR = 1.853; 95% CI, 1.083-3.17; P = .024 to <.05), longer duration of tracheotomy (OR = 1.673; 95% CI, 1.343-2.083; P < .0001), and smoking (OR = 1.656; 95% CI, 1.053-2.604; P = .029 to <.05) were risk factors for TAP (Table 1). Multivariate regression analysis showed that male gender (OR = 1.945; P = .018) and duration of tracheotomy (OR = 1.694; P = .00012) were independently related to an increased risk for postoperative TAP (Table 2).
Discussion In a tertiary general hospital in Shanghai, the incidence of TAP in patients who underwent oral tumor resection with tracheotomy was 19.71%. The results support previous data on pneumonia in patients treated with head and neck surgery. Of 105 patients enrolled in a retrospective cohort study, 47 (44.8%) sustained at least 1 PPC after head and neck cancer resection with tracheostomy and 14 (13.3%) of these patients developed pneumonia.3 Rao et al9 found that 46% of patients who underwent head and neck surgeries of varying complexity developed PPCs, with only 37 of 73 patients requiring tracheostomy. Ong et al6 found that prolonged antibiotic use did not prevent postoperative pneumonia in patients after major head and neck surgery with tracheostomy. Rao et al9 also indicated that advanced age, longer smoking history, tracheostomy, and prolonged anesthesia considerably increased the risk for pulmonary complications. As shown in the present study, age, baseline diseases (diabetes, hypertension, and cardiovascular
disease), and alcohol history did not statistically differ between patients with and those without TAP. Univariate analysis showed that advanced age could be a potential risk factor for TAP (P = .058). However, this finding might have been affected by sample size differences or other parameters. Single-variable analysis showed that the occurrence of TAP was statistically correlated with smoking history, male gender, and duration of tracheotomy. However, when they were placed in the model, the variable with the strongest correlation diluted the independent strength of the related parameters, which then gradually lost their relevant associations. Logistic regression analysis of individual variables yielded valuable information; these variables did not maintain independent importance in the multivariable model. Logistic regression analysis provided a regression coefficient that was used to derive the relative risk. Multivariable analysis showed that only male gender and duration of tracheotomy were independent risk factors for TAP. It is widely known that a history of smoking is an independent risk factor for PPCs after lung, abdominal, and cardiac surgery and craniocerebral-associated surgical procedures.10-12 In patients with head and neck cancer, Weber et al13 and Jensen et al14 suggested that a patient’s smoking history is the factor most strongly associated with postoperative pneumonia. Accordingly, exposure to cigarette smoke results in increased susceptibility to infections and major changes in cellular immune responses, promoting chronic inflammation and immune dysfunction.15-17 Because this study used a retrospective design, data on smoking history were collected from medical records. Therefore, there might be a retrospective deviation in the results. Patients who developed postoperative pneumonia had a longer duration of tracheotomy (OR = 1.694; P = .0001). Patients enrolled in the present study were generally in good condition, indicating uniformity of the population. Patients who undergo major head and neck surgery involving a tracheostomy often display pulmonary complications, with pneumonia more frequent after tracheostomy.18 Tracheostomyrelated complications can be alarming, because they can be life-threatening and prolong recovery, extend rehabilitation, and delay discharge from the hospital. Results of binary logistic analysis showed that gender is a risk factor. Of patients with tracheotomy, men were more prone to pneumonia after oral tumor resection. In this study, the authors established that male patients undergoing major oral cancer surgery and tracheotomy are more prone to pneumonia. Infection usually supervened the duration of the tracheotomy. The results also implied that shortening the duration of tracheotomy might lower the rate of TAP. Smoking history
FLA 5.4.0 DTD YJOMS56953_proof 22 September 2015 12:10 am CE AH
Q6
393 394 395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448
5
LI ET AL
449 450 451 452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504
Q7
emerged as risk factor in univariate analysis. Eid et al19 found that decreasing TAP is a continuous multidisciplinary process involving the assessment of multiple performance metrics; in future research, these metrics will be used to investigate the outcomes of patients undergoing major oral cancer surgery and tracheotomy. Acknowledgments The authors are indebted to the staff of the hospital infection control department and medical record archives department and to Dr Jiajie Zang for helpful statistical advice.
References 1. Fisher B, Majumdar S, McAlister F: Predicting pulmonary complications after nonthoracic surgery: A systematic review of blinded studies. Am J Med 112:219, 2002 2. Crosher R, Baldie C, Mitchell R: Selective use of tracheostomy in surgery for head and neck cancer: An audit. Br J Oral Maxillofac Surg 35:43, 1997 3. Smetana GW, Lawrence VA, Cornell JE: Preoperative pulmonary risk stratification for noncardiothoracic surgery: Systematic review for the American College of Physicians. Ann Intern Med 144:581, 2006 4. Petrar S, Bartlett C, Hart RD, et al: Pulmonary complications after major head and neck surgery: A retrospective cohort study. Laryngoscope 122:1057, 2012 5. Joo Y, Sun D, Cho J, et al: Factors that predict postoperative pulmonary complications after supracricoid partial laryngectomy. Arch Otolaryngol Head Neck Surg 135:1154, 2009 6. Ong SK, Morton RP, Kolbe J, et al: Pulmonary complications following major head and neck surgery with tracheostomy: A prospective, randomized, controlled trial of prophylactic antibiotics. Arch Otolaryngol Head Neck Surg 130:1084, 2004
7. Bapoje S, Whitaker J, Schulz T, et al: Preoperative evaluation of the patient with pulmonary disease. Chest 132:1637, 2007 8. Brooks-Brunn JA: Predictors of postoperative pulmonary complications following abdominal surgery. Chest 111:564, 1997 9. Rao MK, Reilley TE, Schuller DE, et al: Analysis of risk factors for postoperative pulmonary complications in head and neck surgery. Laryngoscope 102:45, 1992 10. Nakagawa M, Tanaka H, Tsukuuuma H, et al: Relationship between the duration of the preoperative smoke-free period and the incidence of postoperative pulmonary complications after pulmonary surgery. Chest 120:705, 2001 11. Møller AM, Villebro N, Pedersen T, et al: Effect of preoperative smoking intervention on postoperative complications: A randomized clinical trial. Lancet 359:114, 2002 12. Chu H, Dang BW: Risk factors of postoperative pulmonary complications following elective craniotomy for patients with tumors of the brainstem or adjacent to the brainstem. Oncol Lett 8:1477, 2014 13. Weber RS, Hanking P, Rosenbaum B, et al: Nonwound infections following head and neck oncologic surgery. Laryngoscope 103: 22, 1993 14. Jensen F, Girod DA, Tsue TT, et al: Risk factors for pulmonary complicates in the postoperative head and neck surgery patient. Head Neck 8:372, 1997 15. Mehta H, Nazzal K, Sadikot RT: Cigarette smoking and innate immunity. Inflamm Res 57:497, 2008 16. Feng Y, Kong Y, Barnes PF, et al: Exposure to cigarette smoke inhibits the pulmonary T-cell response to influenza virus and Mycobacterium tuberculosis. Infect Immun 79:229, 2011 17. Hernandez CP, Morrow K, Velasco C, et al: Effects of cigarette smoke extract on primary activated T cells. Cell Immunol 282: 38, 2013 18. Morton RP, Mellow CG, Dorman EB: Chest infection following head and neck surgery: A pilot study. Clin Otolaryngol 15:363, 1990 19. Eid RC, Domingues F, Silva Barreto JK, et al: Successful prevention of tracheostomy associated pneumonia in step-down units. Am J Infect Control 39:500, 2011
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Q10
505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 521 522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560
SURGICAL ONCOLOGY AND RECONSTRUCTION
Analysis of Risk Factors for Pneumonia in 482 Patients Undergoing Oral Cancer Surgery With Tracheotomy Li Li, PhD,* Weijun Yuan, MSc,y Shilei Zhang, PhD,z Kewei Wang, PhD,x and Hong Ruan, MSck
Q11
Purpose:
Elective tracheostomy is a common procedure used in patients with oral cancer. However, secondary tracheotomy-associated pneumonia (TAP) is an important complication after surgery. This study investigated the risk factors related to postoperative TAP complications in patients with oral cancer.
Materials and Methods:
Q3
A retrospective study was performed from January 2012 to October 2013. Data on patients who had oral cancer and underwent neck dissection or reconstructive surgery with tracheotomy were collected from the Hospital Information System. The predictive variables were age, gender, alcohol history, smoking history, basic disease (including diabetes, hypertension, and cardiovascular disease), tumor location, and duration of tracheotomy, which were extracted from electronic medical records. The outcome variable was TAP. Descriptive single factors and bivariable statistics were computed and the P value was set at .05.
Results: Q4
Q5
Four hundred eighty-two patients who received tracheotomy after oral cancer surgery were included in this study and 95 (19.7%) developed TAP. Univariate analysis showed that male gender (odds ratio [OR] = 1.853; 95% confidence interval [CI], 1.083-3.17; P = .024 to <.05), long duration of tracheotomy (OR = 1.673; 95% CI, 1.343-2.083; P < .0001), and smoking (OR = 1.656; 95% CI, 1.053-2.604; P = .029 to <.05) were risk factors for TAP. Then, 2 variables independently related to an increased risk of postoperative TAP were found by multivariate regression analysis, which were male gender (OR = 1.945; P = .018) and long duration of tracheotomy (OR = 1.694; P = .0001).
Conclusions: The present findings indicate that male gender and tracheotomy duration are important risk factors for TAP in patients undergoing major oral cancer surgery. Ó 2015 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1-5, 2015
The risk of complications is increased during the postoperative period; in surgical procedures, the respiratory system is frequently affected. In a large meta-analysis, the incidence of postoperative pulmonary complications (PPCs) reported in patients un-
dergoing non-thoracic surgery varied widely from 2 to 19%.1 Major head and neck surgery most often results in upper airway obstruction, which in turn causes edema of the larynx, pharynx, and posterior tongue and requires the use of bulky reconstructive
*Department Head, Department of Oral and Maxillofacial Surgery,
Dr Li and Mr Yuan contributed equally to this work. Address correspondence and reprint requests to Prof Ruan:
Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University
Department of Nursing, Ninth People’s Hospital affiliated to
School of Medicine, Shanghai, China. yDepartment Head, Department of Oral and Maxillofacial Surgery,
Shanghai Jiaotong University, 639 Zhizao Ju Road, Huangpu District,
Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University
Shanghai, 200011, People’s Republic of China; e-mail: sunbook_
School of Medicine, Shanghai, China.
[email protected]
zProfessor, Department of Oral and Maxillofacial Surgery,
Received May 29 2015 Accepted August 24 2015
Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
Ó 2015 American Association of Oral and Maxillofacial Surgeons
xResident, Jiangnan University School of Medicine, Wuxi, Jiangsu,
0278-2391/15/01263-X
China.
http://dx.doi.org/10.1016/j.joms.2015.08.018
kProfessor, Department of Nursing, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
1 FLA 5.4.0 DTD YJOMS56953_proof 22 September 2015 12:10 am CE AH
Q2
57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112
113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168
2
RISK FACTORS FOR PNEUMONIA DURING TRACHEOTOMY
flaps. Bilateral neck dissection surgery or removal of the mandible, tongue, and floor of the mouth is even more risky.2 The incidence of PPC has been shown to vary among patients after head and neck surgery, which was considered intermediate in a large meta-analysis.3 Although elective tracheostomy is performed as part of this surgical procedure, patients easily develop PPCs.4 Therefore, the incidence of PPC in patients after head and neck surgery is 15 to 46%.5 For instance, pneumonia has been reported at an overall postoperative rate of at least 20%.6 Ong et al6 suggested that 73 patients treated with major head and neck surgery were sufficient for analysis: 37 patients (47%) had pulmonary complications that progressed to pneumonia in 29 (40%). Petrar et al4 found that major head and neck surgery results in increased risk for PPCs, with advanced age and hypertension strongly related to PPCs. Decreased lung function and postsurgical atelectasis have emerged as important risk factors for pneumonia.6 Previous meta-analyses have reported that cigarette smoking is an independent predictor of PPCs.3,7 Tracheostomy and anesthesia lasting longer than 4 hours are other known risk factors for pneumonia in head and neck surgery.8 An increased incidence of pulmonary complications delays recovery, demands greater intensive care, increases hospital stay, and obviously leads to higher health care costs. In this study, all patients underwent oral oncology resection, free flap transplantation, and tracheostomy after surgery. The authors assessed other risk factors for their roles in the occurrence of pneumonia.
Materials and Methods This retrospective study was approved by the institutional research ethics board to review data of patients after oral cancer surgery at a tertiary care center in Shanghai, China. Data recorded from admission and anesthesia records included age, gender, basic diseases (including diabetes, hypertension, and cardiovascular disease), preoperative smoking, and alcohol use. Patients were considered smokers when currently smoking or had a smoking history of 10 pack-years during their lifetime. Patients with unrecorded current smoking status or history of cigarette use were counted as nonsmokers. Preoperative comorbidities were obtained from hospitalization documents. Duration of tracheostomy and tumor site were determined from hospital charts. Inclusion criteria were an age older than 18 years, anesthesia time longer than 3 hours, procedure requiring tracheotomy, and free tissue transfer repair without postoperative mechanical ventilation. Patients with pre-existing pulmonary disease were excluded.
The practices of the authors’ clinic are similar to those found in other major head and neck cancer centers, as described in contemporary reports in the field (elective tracheostomy is a common procedure in patients after head and neck surgery). A gastric feeding tube was implanted before transfer to the intensive care unit (ICU) in a fully awake state, where oxygen was provided through a tracheotomy. After the operation, all patients were routinely treated with antibiotics. PRIMARY OUTCOME VARIABLE
The primary outcome was tracheotomy-associated pneumonia (TAP). Diagnosis of pneumonia was contingent on at least 2 of the following criteria: persistent (ie, $24 hours) fever (>37.5 C), purulent sputum volume increase (20%), new shadowing on chest radiograph, or persistent (ie, $2 days) localized signs at chest examination (crackles, bronchial breathing, wheeze, or pleural rub).6 Chest radiographs were assessed by a respiratory physician (J.K.) who was blinded to patients’ postoperative therapy. DATA COLLECTION
Data were obtained retrospectively on patients undergoing oral oncology surgery with tracheostomy from January 2012 to December 2013 in the authors’ hospital unit. Data regarding overall outcomes were collected for 523 cases, although comprehensive operation details were available for 482 patients. All procedures included neck dissection with or without reconstructive surgery. Tracheotomies were carried out by the surgical team. STATISTICAL ANALYSIS
Data analysis was performed using SPSS 16 (SPSS, Inc, Chicago, IL). Univariate analyses were carried out by c2 test; logistic regression analysis was conducted using statistically relevant factors to identify independent risk factors for TAP; data are presented as unadjusted odds ratios (ORs) and 95% confidence intervals (CIs). A P value less than .05 was considered statistically significant.
Results PATIENT DATA
The present study included 482 patients (334 men and 148 women; 20 to 88 yr old; 58.28 13 yr). There were 197 (40.87%) cases of tongue carcinoma, 61 (12.66%) cases of cancer of the floor of the mouth, 54 (11.2%) cases of buccal mucosa carcinoma, 64 (13.28%) cases of jaw malignant neoplasm, 15 (3.11%) cases of palate carcinoma, 70 (14.52%) cases of gingiva carcinoma, and 21 (4.4%) cases of
FLA 5.4.0 DTD YJOMS56953_proof 22 September 2015 12:10 am CE AH
Q1
169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224
3
LI ET AL
225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280
Table 1. SINGLE-FACTOR ANALYSIS OF RISK FACTORS FOR PULMONARY INFECTION
Pulmonary Infection, n (%) Q8
Gender Men Women Age (yr) <50 50-59 $60 Smoking history Yes No Alcohol history Yes No Basic disease Yes No Oral tumor site Tongue Floor of mouth Buccal mucosa Jaw Palate Gingiva Oropharynx Duration of tracheostomy (days) 7-10 11-15 16-20 >20
Affected (n = 95)
Unaffected (n = 387)
75 (78.9) 20 (21.1)
259 (66.9) 128 (33.1)
29 (30.5) 19 (20) 47 (49.5)
83 (21.4) 118 (30.5) 186 (48.1)
46 (48.4) 49 (51.6)
140 (36.2) 247 (63.8)
31 (32.6) 64 (67.4)
99 (25.6) 288 (74.4)
55 (57.9) 40 (42.1)
142 (36.7) 245 (63.3)
36 (37.9) 11 (11.6) 14 (14.7) 14 (14.7) 4 (4.2) 9 (9.5) 7 (7.4)
161 (41.6) 50 (12.9) 40 (10.3) 50 (12.9) 11 (2.8) 61 (15.8) 14 (3.6)
29 (30.5) 32 (33.7) 16 (16.8) 18 (18.9)
Value
P Value
5.075
.024
5.691
.058
4.773
.029
1.914
1.167
0.949
.33
2.962
.085
21.148
.0001
196 (50.6) 132 (34.1) 30 (7.8) 29 (7.5)
Li et al. Risk Factors for Pneumonia During Tracheotomy. J Oral Maxillofac Surg 2015.
TRACHEOTOMY-ASSOCIATED PNEUMONIA
oropharyngeal cancer. These patients underwent cancer resection with tracheotomy, free tissue transfer reconstruction, postoperative oxygen, and dynamic observation in the ICU without postoperative mechanical ventilation.
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Analysis showed that 95 of 482 patients (19.71%) met the criteria for TAP. The patients who developed TAP (median age standard deviation, 59 12 yr) showed no statistical differences from those who did not
Table 2. LOGISTIC REGRESSION ANALYSIS OF INDEPENDENT RISK FACTORS AFFECTING PULMONARY INFECTION POSTOPERATIVELY
95.0% CI for Exp (B)
Gender Duration of tracheostomy
0.665 0.527
B
Wald
Sig
Exp (B)
Lower
Upper
0.281 0.113
5.612 21.659
0.018 0.0001
1.945 1.694
1.122 1.357
3.373 2.115
Abbreviation: CI, confidence interval. Li et al. Risk Factors for Pneumonia During Tracheotomy. J Oral Maxillofac Surg 2015.
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RISK FACTORS FOR PNEUMONIA DURING TRACHEOTOMY
develop TAP (59 14 yr; P > .05). Patients with TAP who underwent tracheotomy (15.45 8.48 days) were statistically different from those who did not develop TAP (12.02 5.23 days; P < .0001). ANESTHESIA AND SURGICAL PROCEDURE
All patients underwent tumor resection and neck dissection with or without a reconstructive procedure under intravenous anesthesia and tracheal intubation with mechanical ventilation. Operations were carried out by at least 3 surgeons, and the patients were transferred to the oral and maxillofacial surgical ward after the operation. The surgical procedure lasted an average of 8.85 hours (range, 4 to 14.5 hours). LOGISTIC REGRESSION ANALYSIS FOR DETERMINATION OF SINGLE RISK FACTORS
An association was found between TAP and smoking status, alcohol history, gender, age, duration of tracheotomy, and in combination with other diseases (eg, hypertension, diabetes, and coronary heart disease). Univariate analysis showed that male gender (OR = 1.853; 95% CI, 1.083-3.17; P = .024 to <.05), longer duration of tracheotomy (OR = 1.673; 95% CI, 1.343-2.083; P < .0001), and smoking (OR = 1.656; 95% CI, 1.053-2.604; P = .029 to <.05) were risk factors for TAP (Table 1). Multivariate regression analysis showed that male gender (OR = 1.945; P = .018) and duration of tracheotomy (OR = 1.694; P = .00012) were independently related to an increased risk for postoperative TAP (Table 2).
Discussion In a tertiary general hospital in Shanghai, the incidence of TAP in patients who underwent oral tumor resection with tracheotomy was 19.71%. The results support previous data on pneumonia in patients treated with head and neck surgery. Of 105 patients enrolled in a retrospective cohort study, 47 (44.8%) sustained at least 1 PPC after head and neck cancer resection with tracheostomy and 14 (13.3%) of these patients developed pneumonia.3 Rao et al9 found that 46% of patients who underwent head and neck surgeries of varying complexity developed PPCs, with only 37 of 73 patients requiring tracheostomy. Ong et al6 found that prolonged antibiotic use did not prevent postoperative pneumonia in patients after major head and neck surgery with tracheostomy. Rao et al9 also indicated that advanced age, longer smoking history, tracheostomy, and prolonged anesthesia considerably increased the risk for pulmonary complications. As shown in the present study, age, baseline diseases (diabetes, hypertension, and cardiovascular
disease), and alcohol history did not statistically differ between patients with and those without TAP. Univariate analysis showed that advanced age could be a potential risk factor for TAP (P = .058). However, this finding might have been affected by sample size differences or other parameters. Single-variable analysis showed that the occurrence of TAP was statistically correlated with smoking history, male gender, and duration of tracheotomy. However, when they were placed in the model, the variable with the strongest correlation diluted the independent strength of the related parameters, which then gradually lost their relevant associations. Logistic regression analysis of individual variables yielded valuable information; these variables did not maintain independent importance in the multivariable model. Logistic regression analysis provided a regression coefficient that was used to derive the relative risk. Multivariable analysis showed that only male gender and duration of tracheotomy were independent risk factors for TAP. It is widely known that a history of smoking is an independent risk factor for PPCs after lung, abdominal, and cardiac surgery and craniocerebral-associated surgical procedures.10-12 In patients with head and neck cancer, Weber et al13 and Jensen et al14 suggested that a patient’s smoking history is the factor most strongly associated with postoperative pneumonia. Accordingly, exposure to cigarette smoke results in increased susceptibility to infections and major changes in cellular immune responses, promoting chronic inflammation and immune dysfunction.15-17 Because this study used a retrospective design, data on smoking history were collected from medical records. Therefore, there might be a retrospective deviation in the results. Patients who developed postoperative pneumonia had a longer duration of tracheotomy (OR = 1.694; P = .0001). Patients enrolled in the present study were generally in good condition, indicating uniformity of the population. Patients who undergo major head and neck surgery involving a tracheostomy often display pulmonary complications, with pneumonia more frequent after tracheostomy.18 Tracheostomyrelated complications can be alarming, because they can be life-threatening and prolong recovery, extend rehabilitation, and delay discharge from the hospital. Results of binary logistic analysis showed that gender is a risk factor. Of patients with tracheotomy, men were more prone to pneumonia after oral tumor resection. In this study, the authors established that male patients undergoing major oral cancer surgery and tracheotomy are more prone to pneumonia. Infection usually supervened the duration of the tracheotomy. The results also implied that shortening the duration of tracheotomy might lower the rate of TAP. Smoking history
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emerged as risk factor in univariate analysis. Eid et al19 found that decreasing TAP is a continuous multidisciplinary process involving the assessment of multiple performance metrics; in future research, these metrics will be used to investigate the outcomes of patients undergoing major oral cancer surgery and tracheotomy. Acknowledgments The authors are indebted to the staff of the hospital infection control department and medical record archives department and to Dr Jiajie Zang for helpful statistical advice.
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7. Bapoje S, Whitaker J, Schulz T, et al: Preoperative evaluation of the patient with pulmonary disease. Chest 132:1637, 2007 8. Brooks-Brunn JA: Predictors of postoperative pulmonary complications following abdominal surgery. Chest 111:564, 1997 9. Rao MK, Reilley TE, Schuller DE, et al: Analysis of risk factors for postoperative pulmonary complications in head and neck surgery. Laryngoscope 102:45, 1992 10. Nakagawa M, Tanaka H, Tsukuuuma H, et al: Relationship between the duration of the preoperative smoke-free period and the incidence of postoperative pulmonary complications after pulmonary surgery. Chest 120:705, 2001 11. Møller AM, Villebro N, Pedersen T, et al: Effect of preoperative smoking intervention on postoperative complications: A randomized clinical trial. Lancet 359:114, 2002 12. Chu H, Dang BW: Risk factors of postoperative pulmonary complications following elective craniotomy for patients with tumors of the brainstem or adjacent to the brainstem. Oncol Lett 8:1477, 2014 13. Weber RS, Hanking P, Rosenbaum B, et al: Nonwound infections following head and neck oncologic surgery. Laryngoscope 103: 22, 1993 14. Jensen F, Girod DA, Tsue TT, et al: Risk factors for pulmonary complicates in the postoperative head and neck surgery patient. Head Neck 8:372, 1997 15. Mehta H, Nazzal K, Sadikot RT: Cigarette smoking and innate immunity. Inflamm Res 57:497, 2008 16. Feng Y, Kong Y, Barnes PF, et al: Exposure to cigarette smoke inhibits the pulmonary T-cell response to influenza virus and Mycobacterium tuberculosis. Infect Immun 79:229, 2011 17. Hernandez CP, Morrow K, Velasco C, et al: Effects of cigarette smoke extract on primary activated T cells. Cell Immunol 282: 38, 2013 18. Morton RP, Mellow CG, Dorman EB: Chest infection following head and neck surgery: A pilot study. Clin Otolaryngol 15:363, 1990 19. Eid RC, Domingues F, Silva Barreto JK, et al: Successful prevention of tracheostomy associated pneumonia in step-down units. Am J Infect Control 39:500, 2011
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