Emergency care of patients with tracheostomies: A 7-year review

Review

Emergency Care of Patients With Tracheostomies: A 7-Year Review THERESA HACKELING, MD,* RUDOLPH TRIANA, MD,t O. JOHN MA, MD,* WILLIAM SHOCKLEY, MDt The emergency department (ED) care of a patient with a tracheostomy tube can be problematic because of difficulty with patient communication, urgency of airway control, and unfamiliarity with tracheal equipment. The objective of this study was to characterize complications of tracheostomy patients seen in the ED and provide management techniques. A retrospective study was conducted on all patients with tracheostomy complications who presented to a university, tertiary-care ED over a 7-year period. Data obtained included age, gender, operative indication, complication, time of complication, vital signs, and ED management. Descriptive statistics were used to analyze the data. During the study period, 35 patients were evaluated in the ED for 60 complications. The 60 complications were categorized into six groups: 20 (33%) patients presented with dislodged tracheal tubes, 11 (18"/0)presented with plugged tracheal tubes, 18 (30%) had infection, 7 (11%) had bleeding, 1 (3%) had a pnuemothorax, and 3 (5%) had tracheal/stomal stenosis. Review of the complications that place tracheostomy patients at high risk in conjunction with a review of the literature enabled the development of a standard approach to dealing with patients with tracheostomies that can facilitate proper care of the patients in the ED. (Am J Emerg Med 1998;16:681-685. Copyright © 1998 by W.B. Saunders Company) Caring for a patient with a tracheostomy can be anxietyprovoking because of problems with patient communication, urgency of airway control, and unfamiliarity with tracheal equipment. Tracheostomy patients may present to the emergency department (ED) with airway obstruction, bleeding, or infection. An understanding of tracheal anatomy, tracheal equipment, and the complications and management of tracheostomies can assist the emergency physician in managing these patients. Since there has been a paucity of emergency medicine literature describing the ED care of tracheostomy patients, the objective of this study was to characterize complications of tracheostomy patients evaluated in the ED and provide management techniques.

From the *Department of Emergency Medicine and tDepartment of Otolaryngology, University of North Carolina, Chapel Hill, NC. Manuscript received March 13, 1997, returned April 2, 1997; revision received May 6, 1997, accepted June 20, 1997. Address reprint requests to Dr Hackeling, Department of Emergency Medicine, Campus Box #7594, University of North Carolina School of Medicine, Chapel Hill, NC 27599-7594. Key Words:Airway,trachea, tracheostomy, otolaryngology, tracheitis, cellulitis, bronchitis. Copyright © 1998 by W.B. Saunders Company 0735-6757/98/1607-001758.00/0

METHODS This retrospective study was conducted on all patients with tracheostomy complications who presented to the ED between April 1, 1988 and April 1, 1995. The ED was a university, tertiary-care referral center with an annual volume of 38,000. Patients seen directly by an otolaryngology consultant were not included in this study. This study was approved by the institution's Investigational Review Board. Patients' ED and hospital records were reviewed for the following: age, gender, indication for tracheostomy, complication, time from procedure to complication, vital signs on arrival in the Ell), and ED management. Tracheostomy complications were categorized into six groups: dislodged tracheal tube, plugged tracheal tube secondary to mucous plugging or granuloma, bleeding in or near the tracheal tube site, infection, tracheal or stomal stenosis, and pneumothorax. Unstable vital signs were defined as a heart rate of > 100 beats/rain, respiratory rate of >20 breaths/min, or a systolic blood pressure of <90 mm Hg. The medical records were reviewed by two of the authors (TH and RT), who were trained for this investigation. The research teams met frequently during the investigation period to maintain consistency in data gathering and resolve disputes. Standardized abstraction forms were used. Descriptive statistics were used to analyze the data.

RESULTS During the study period, 35 patients were evaluated in the ED for 60 tracheostomy-related complications. Fourteen of the 35 patients presented more than once, with one patient presenting five times. Nineteen (54%) of the 35 patients were male; 16 (46%) were female. Patient ages ranged from 8 months to 81 years. Nineteen (54%) patients had head and neck cancer, which was the most common indication for tracheostomy. Of these 19 patients, 18 had a partial laryngectomy with placement of a tracheostomy and only 1 patient had a complete laryngectomy with a tracheostomy tube in place secondary to stomal stenosis. Six (17%) patients had obstructive sleep apnea, which was the second most common indication for tracheostomy. The other indications for tracheostomy are listed in Table 1. The 60 complications were categorized into six groups (Table 2). Twenty (33%) patients had displaced tracheal tubes. Of these 20 patients, 2 presented in acute respiratory distress with unstable vital signs. One patient had the tracheal tube easily replaced without any sequela, while the other patient suffered a respiratory arrest and was unable to 681

682

AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 16, Number 7 • November 1998

TABLE1. Indications forTracheostomy Indication

No. of Patients

Cancer Head injury Anoxia

19 3 1 1 6 1 1 1 2

Cerebral vascular accident Obstructive sleep apnea

Vocal cord paralysis Central apnea Polymyositis Laryngotracheomalacia

be resuscitated despite successful reinsertion of the tracheal tube. The other 18 patients presented with stable vital signs and had successful tracheal tube reinsertion; however, 5 patients required the placement of a tracheal tube one size smaller. Eighteen (51%) patients presented with an infection. The infections was subdivided into two groups: (1) peritracheal cellulitis, and (2) bronchitis, tracheitis, or pneumonia. Four patients presented with cellulitis and the other 14 were diagnosed with either bronchitis, tracheitis, or pneumonia. The 4 patients with peritracheal cellulitis were discharged home on oral antibiotics. Eleven of the 14 patients with tracheitis or pneumonia were admitted for intravenous antibiotics. Three of the patients diagnosed with bronchitis were discharged home on oral antibiotics. Eleven (31%) patients presented with a plugged tracheal tube secondary to either granuloma formation or mucous plugging. Of these 11 patients, 5 presented with unstable vital signs. In each case, the tracheal tube was removed, secretions were suctioned, and a visual exam was performed to identify the obstructing component. In 3 of the cases, granulomatous tissue was identified and required silver nitrate cautery. No further complications were reported following ED treatment. Seven (20%) patients presented with complications related to bleeding from the tracheal tube site. The amount of bleeding was not quantified although all patients presenting with bleeding had stable vital signs. In each case, the bleeding was controlled in the ED with local hemostatic measures. Only one patient had brisk bleeding requiring local skin exploration to achieve hemostasis in the ED. No evidence of tracheoinnominate artery fistula was noted in any patient. Three (5%) patients presented with airway obstruction secondary to tracheal stenosis, which was diagnosed by fiberoptic visualization in the ED. One (2%) patient presented with a pneumothorax, which was managed by tube thoracostomy. The time from the tracheostomy until a postprocedureTABLE 2. Six Groups of Tracheostomy-Related Complications Group Tracheal stenosis Infection Tracheal plug

Bleeding Dislodged tracheal tube Pneumothorax

No. of Complications 3 18 11 7 20 1

related complication was recorded for 51 of the 60 complications. The average time until complication was 3.5 years, with a range of 4 days to 8 years. The median number of days was 4 months. DISCUSSION

Tracheostomies have been performed since ancient times. In BC 100, Asclepiades of Bismuth, a Greek physician, was credited with performing the first tracheostomy. 1 In the 1700s, George Martin developed more sophisticated techniques by using the first inner cannula on a tracheotomy tube. 2 The technique was popularized in 1833 when Trousseau reported more than 2,000 cases of tracheotomy for diphtheria-induced upper airway obstruction. In the 20th century, Chevalier Jackson standardized the technique of tracheostomy and decreased the operative mortality of tracheostomy from 25% to the modern day standard of less than 1%. 3 A standard tracheotomy is a surgical procedure that provides temporary tracheal access through an incision tracheostoma that enters the trachea between cartilaginous rings. The tracheal stoma tract closes after removal of the cannulating tube. In contrast, the term tracheostomy refers to a surgical procedure that creates a permanent opening in the airway by suturing the skin to the anterior tracheal walP (Figure 1). Current indications for tracheostomy include the maintenance of airway patency in patients with functional or mechanical airway obstruction, the provision of airway access for suctioning retained airway secretions, the prevention or limitation of aspiration in patients with glottic dysfunction, and the management of patients who require long-term airway access for ventilatory support. 4-6 A firm grasp of the anatomy of the tracheal tree can assist emergency physicians in the management of tracheostomy patients. An adult trachea is 11 cm in length. There are 18 to 22 cartilaginous rings, with approximately two rings per centimeter.7 The only complete cartilaginous ring in the airway is the cricoid cartilage of the larynx. The remainder of the rings are C-shaped, connected posteriorly by the membranous portion of the trachea. 7 The blood supply of the trachea is shared with the esophagus laterally and with the main bronchi below. Above, the supply is from the inferior thyroid artery, which has a branch coursing downward to supply both the esophagus and trachea. 7 In our review of tracheostomy-related complications presenting to the ED, the most common complication was a displaced tracheal tube. Familiarity with the tracheal anatomy and equipment facilitates replacement of the tracheal tube (Figures 2 and 3). When accidental decannulation occurs, the patient should be positioned with the neck extended. The tracheostomy tube can be replaced if the tracheal window can be clearly identified. Initial insertion of a smaller-sized cannula or placement of a guide catheter, such as a nasogastric tube, over which a tracheotomy tube is inserted may assist in reintubation. 4,8 If the tracheal lumen is not clearly seen, a pediatric laryngoscope blade with a light source may assist with exploration of the wound and airway visualization. In patients with thick necks, initial placement of a cuffless pediatric translaryngeal endotracheal tube to rapidly secure the airway followed by delayed recannulation with a tracheal tube may be required. 4 It is important to

HACKELING ET AL • ED CARE OF PATIENTS WITH TRACHEOSTOMIES

FIGURE 1. Tracheal flap. remember that improper placement of the tracheal tube into a false lumen can occur. Confirmation of location of the tube can be obtained by feeling (not hearing) good breaths out of the tracheal tube itself, or by inserting a catheter into the

~~

trachea that should pass easily and not be obstructed. In addition confirmation can be obtained by looking into the lumen with a nasopharyngeal scope through the tracheal tube. Infectious complications of tracheostomies accounted for 18 complications in this study. Favorable conditions for tracheostomy-related infection are created by exposure to contaminated oral secretions, infected sputum, floracolonizing ventilators, and trauma from frequent tracheal manipulation. 8 In patients with tracheostomy-induced ceUulitis, Stiles 9 reported that Staphylococcus aureus, Pseudomonas, and Monilia were the organisms most frequently cultured. None of the patients in this study presented with mediastinitis, a potentially fatal complication of cellulitis if untreated. ~ Treatment includes aggressive wound care, frequent dressing changes, antibiotic ointment to the site, and oral antibiotic therapy. Five of the 15 patients in our series who presented with pneumonia, bronchitis, or tracheitis were admitted. Since many of these patients have weakened cough reflexes and poorly functioning cilia, which limit their ability to fight infection, admission for intravenous antibiotic therapy is warranted for patients who present toxicappearing or who demonstrate significant hypoxia. Tracheal tube obstruction has been reported in approximately 2.5% of tracheostomies. ~ In our review, 11 patients presented with tracheal tube obstruction. Since tracheostomies bypass the air humidifying system of the upper airway, they may produce thick and dry secretions that often cause airway obstruction. Additionally, the cough reflex that normally clears the tracheobronchial tree may be weakened. Secretions may act by a ball-valve mechanism, allowing air in but restricting outward ventilation. Atelectasis may result from aspiration of mucus plugs, necessitating removal of the plug by bronchoscopy. I Dried crusts, secretions, and other obstructing lesions should be removed manually to facilitate ventilation. If profuse and thick secretions are prominent at the tracheal tube lumen, immediate suctioning for 10 to 15 seconds (after 100% pre-oxygenation) may establish patency and ventilatory flow. Sterile saline may be instilled to loosen secretions and aid in suctioning. Table 3 reviews the steps for suctioning and preventing mucus plugging. Tracheostomy-related hemorrhage most commonly occurs between the first and third postoperative week. 1°-12All minor bleeding can be controlled by cautery and light packing of the peristomal region with petroleum jelly gauze around the tracheostomy tube skin edges. All patients with tracheal wound bleeding should have the tracheal tube removed followed by examination of the tracheal stoma. A nasopharyngeal scope should be inserted into the stoma to further assess the extent and site of bleeding. Tracheoinnominate artery fistula is a rare but lifethreatening complication, occurring in approximately 1% of tracheostomies. 7,I°,1~,13 Emergency physicians must be able to recognize and initially manage this problem. Most tracheoinnominate artery fistulas result from direct pressure from the elbow of the tracheal cannula against the innominate artery. 14This problem can be a result of the creation of the tracheostomy stoma lower than the fourth tracheal ring, by downward migration of the tracheal stoma secondary to leverage on the tracheostomy tube, or by a high-lying innominate artery, particularly in a young, thin patient. 13,14

Inner Tracheostomy

Obturator

Tube

Cuff

InflaUtor

FIGURE 2. Contents of the tracheostomy tube.

683

684

AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 16, Number 7 • November 1998

A

B

FIGURE 3. (A) Insertion of the tracheostomy tube. (B) Placement of the tracheostomy tube. Sepsis, malnutrition and corticosteroids increase the risk of this complication, t°,15 More than 10 cc of bleeding 48 hours or longer after surgery should alert the emergency physician for possible erosion of the innominate artery, m l Some patients present with premonitory tracheal stoma bleeding (a sentinel bleed) or hemoptysis. This can be mild to severe and should not be taken lightly, as the potential for sudden massive hemorrhage should raise the suspicion for a tracheoinnominate artery fistula. ~4,~6 Removal of the tracheostomy tube followed by nasopharyngeal scope examination or bronchoscopy should be performed to exclude a tracheoinnominate artery fistula. The tracheoinnominate artery fistula would be visualized on the anterior wall of the trachea, inferior to the sternal notch. Angiography is not helpful and can dangerously delay definitive treatment.17 When a patient presents with significant bleeding, hyperinflation of the tracheostomy tube cuff may provide temporary hemorrhage control. 8,17The cuff needs to be inflated at the site of the tracheoinnominate artery fistula. If this is TABLE3. Steps for Suctioning and Removing Mucous Plugging Step 1: Remove and clean the inner cannula. Step 2: Slide in the tracheal tube and suction Step 3: Remove tracheal tube and repeat steps 1 and 2. Be prepared to replace the tracheal tube at all times. Step 4: Reoxygenatewith 100% oxygen after suctioning. Complications of suctioning include coughing, hypoxemia, atelectasis, and dysrhythmias.

unsuccessful, the tracheostomy tube should be replaced by an oral endotracheal tube and the bleeding controlled by digital pressure through the tracheostomy stoma. Extension of the skin incision vertically to the jugular notch may be necessary. 14,16,18,19 Compression of the innominate artery against the posterior aspect of the sternum should provide control during transport to the operating room. This maneuver is considered to be the most reliable technique to stop the hemorrhage. 18 Even with appropriate management, there is only a 25% survival r a t e 9 Tracheal stenosis is often a delayed complication of tracheostomies. 8,9,21 In this study, three patients presented with stenosis diagnosed by the fiberoptic endoscopy. It is not uncommon for these patients to have conditions mimicking asthma, bronchitis, or other respiratory problems. Any patient with a tracheostomy or with a history of being intubated who develops dyspnea, difficulty in clearing secretions, or stridor must be suspected of having an organic obstruction until proven otherwise. Initial symptoms of tracheal stenosis include dyspnea, stridor, wheezing, and inability to clear secretions. Tracheal stenosis related to tracheostomy can develop at the level of the cuff, the tube tip, or at the tracheostoma site. Pressure from the tube results in mucosal ulcerations that become confluent and expose cartilaginous rings that become infected. Ongoing necrosis generates fibrous scar and transmural airway narrowing. 17 Stenosis may develop while the tube is still in place or months after the tube has been removed; however, more commonly it occurs 2 to 6 weeks after decannulation.

HACKELING ET AL • ED CARE OF PATIENTS WITH TRACHEOSTOMIES

In patients with severe tracheal stenosis, inspiratory and expiratory stridor may become apparent. According to Heffner and Miller, 4 patients with compromised pulmonary function or neuromuscular disease may not manifest symptoms of tracheal stenosis until increased airway secretions produce respiratory compromise. For the patient with presumed tracheal stenosis, anteroposterior, lateral, and oblique radiographs of the chest can sometimes be helpful because they will show the entire trachea with mediastinal structures rotated to one side and may possibly show evidence of a stenosis, most easily seen when the tracheal tube is out. Anteroposterior copperfiltered views taken with the patient saying "E" show excellent anteroposterior detail of the larynx and the entire trachea to the carina. 17 Computed tomography offers little additional information in stenosis. Bronchoscopy is usually deferred for the operating room. ED management of those patients with stenosis who present in severe respiratory distress include elevation of the head of the bed, cool mist to thin secretions, nebulized racemic epinephrine, and a short course (24 to 48 hours) of corticosteroids. 8 Further treatment requires dilation of the airway by a rigid bronchoscope in the operating room.17 Pneumothorax, a rare complication of tracheostomies, occurs most commonly in patients on ventilators and in pediatric patients because the dome of the pleura often extends above the clavicles in children} Patients breathing against an obstructed airway generate negative intrathoracic pressures, making them susceptible to dissection of air along the pleural plane. A bleb may rupture because of the extreme changes in the transpleural pressure of a patient breathing against an obstruction or as a result of assisted positive pressure ventilation. Several potential limitations exist in this study. Because this was a retrospective chart review, it is subject to all the biases associated with retrospective data analysis. The data regarding time of complication from the tracheostomy procedure were missing in 13 charts. In addition, there were extreme outliers in time of complication from procedure, such as 8 years, which may have skewed the true time course of presenting complications. In conclusion, tracheostomy-related complications that emergency physicians should be familiar with and prepared to manage include dislodged tracheal tube, plugged tracheal tube secondary to mucous plugging or granuloma, bleeding in or near the tracheal tube site, infection, tracheal or stomal

685

stenosis, and pneumothorax. By developing a standard protocol for evaluating and treating patients with tracheostomies, emergency physicians may be able to enhance the ED care for this subset of patients.

REFERENCES 1. Chew JC, Cantrell RW: Tracheostomy: Complications and their management. Arch Otolaryng 1972;96:538-545 2. Bailey B, et al: Tracheostomies. In Head and Neck Surgery-Otolaryngology. Philadelphia, PA, J.B. Lippincott Company, 1993, pp 711-717 3. Jackson C: Tracheotomy. Laryngoscope 1990;19:285-290 4. Heffner JE, Miller KS, et al: Tracheostomy in the intensive care unit: Indications, technique, management. Chest 1986;90:269-274 5. Toye FJ, Weinstein JD: A percutaneous tracheostomy device. Surgery 1969;65:384-389 6. Leinhardt DJ, Mughal M, et al: Appraisal of percutaneous tracheostomy. Br J Surg 1992;79:255-258 7. Grillo HC, Mathisen DJ: Surgical management of tracheal strictures. Surg Clin North Am 1988;68:511-523 8. Tayal VS: Tracheostomies. Emerg Med Clin North Am 1994;12: 707-727 9. Stiles PJ: Tracheal lesions after tracheostomy. Thorax 1965;20: 517-522 10. Jones JW, Reynolds M, Hewitt RL, et al: Tracheoinnominate artery erosion: successful surgical management of a devastating complication. Ann Surg 1977;184:194-204 11. Ross CB, Morris JA. Tracheoinnominate artery fistula: A potentially fatal complication of tracheostomy. J Term Med Soc 1988;81:446-449 12. OshinskyAE, Rubin JS, Gwozoz CS: The anatomical basis for post tracheotomy innominate artery rupture. Laryngoscope 1988;98: 1061-1063 13. Yang FY, Criado E, Schwartz JA, et al: Trachea-innominate artery fistula: Retrospective comparison of treatment methods. South Med J 1988;81:701-706 14. Cooper JD: Trachea-innominate artery fistula: Successful management of 3 consecutive patients. Ann Thorac Surg 1977;24: 439-447 15. Nelms B: Tracheoarterial fistula. In Grillo HC, Eschapasse H (eds): International Trends in General Thoracic Surgery, vol. 2 Philadelphia, PA, Saunders, 1987, 69-73 16. Heffner JE, Miller KS, Saher SA: Tracheostomy in the intensive care unit 2: Complications. Chest 1986;90:430-436 17. Wood DE, Mathisen DJ: Late complications of tracheotomy. Clin Chest Med 1991;12:276-295 18. Roger L: Complications of tracheostomy. South Med J 1969;62: 1496-1500 19. Mathog RH: Delayed massive hemorrhage following tracheostomy. Laryngoscope 1971 ;81:107-119 20. Myers EN, Carrau MRC: Early Complications of tracheotomy, incidence, and management. Clin Chest Med 1991;12:589-595 21. Timmins HH: Tracheostomy: An overview of implications, management, and morbidity. Adv Surg 1973;7:199-233