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Prophylactic minitracheotomy in lung resections
J THORAC
CARDIOVASC SURG
1991;101:895-900
Prophylactic minitracheotomy in lung resections A randomized controlled study Thirty c~utive patients undergoing lung resections were randomized into two groups: Group A (n = 15) received minitracheotomy postoperatively and group B (n = 15) were control patients. Postop-
erative respiratory course was monitored by serial clinical assessments, chest x-ray examination, arterial blood gases, sputa bacterial cultures, and the patient's requirement and response to chest physiotherapy. The two groups were similarly matched in age (mean 58.5 years), smoking habits, pulmonary functions, and surgical procedures. Postoperative pulmonary complications of collapse/ consolidation developed in 11 patients (two in group A and nine in grCMJP B) (p < O.03~ Four patients (all in group B) required minitracheotomy in addition to antibiotics and chest physiotherapy to treat their pneumonia. Chest physiotherapy requirement was less in group A than in group B, with a mean number of sessions of seven in group A and eight in group B and a mean total time of 92 minutes in group A and 112 minutes in group B. The mean duration of minitracheotomy was 4.13 days. Minor temporary SymptolllS resulted from the minitracheotomy in eight patients (42%) and included discomfort, voice changes, subcutaneous emphysema, and stridor. There was one case of long-term morbidity (5%)-skin scarring from wound infectionat the site of the minitracheotomy. No postoperative deaiM resulted. We conclude that the prophylactic use of minitracheotomy is safe and effective in decreasing postoperative respiratory complications in patients undergoing lung resections.
Muta M. Issa, MBBCh, Davina M. Healy, MBBCh, Hassan A. Maghur, FRCS (Glas.), and DavidA. Luke, FRCS (Irel.), Dublin, Ireland
Minitracheotomy is a procedure of percutaneous tracheal cannulation with a small-bore tube (4 mm in diameter) placed through the cricothyroid membrane that provides constanttracheal accessfor sputum suction. It was developed by Matthews and Hopkinson! in 1981. They reported on its effective therapeutic role in the management of patients with sputum retention and atelectasis and complimented its simplicity, low morbidity, and lack of mortality. Similar satisfactory experiences were reported subsequently.e? The condition of postoperative sputum retention is
From the Department of Surgery, The Royal City of Dublin Hospital, Trinity College, School of Medicine, Dublin, Ireland. Received for publication Oct. 3,1989. Accepted for publication May 14, 1990. Address for reprints: Muta M. Issa, MB, Department of Surgery, S-067, Stanford University Medical Center, 300 Pasteur Dr., Stanford, CA 94305.
12/1/22571
commonand potentiallylethal if it remains untreated. It usually develops between the second and sixth postoperative days and can progress rapidly and cause death by triggering "a vicious cycle." By far the best policyis prevention. Although prophylactic measures such as early mobilization, breathing exercises, chest physiotherapy, and intermittent positive-pressure breathing can besuccessful, they are oftenstressfuland exhaustingto patients, particularly the old and poor-risk patients who undergo major abdominal or thoracic operations. To date the reported literature has concentrated mainly on the therapeutic effectiveness of minitracheotomy rather than on its preventive role.With this in mind weset up a randomized controlledstudy to evaluate the prophylactic role of minitracheotomyin patients undergoingthoracotomyfor lung resection. Patients and methods All patients undergoing lung resections during the 4-month period from February to June 1987 were randomized into two groups: Group A underwent postoperative minitracheotomy
895
The Journal of Thoracic and Cardiovascular
8 9 6 Issa et al.
Surgery
Fig. 1. The Mini-Trach II kit includes a minitracheotomy cannula, an introducer, a guarded scalpel, a standard ventilation connector, two neck ribbons, and a !OF-gauge suction catheter.
Table I. Chest physiotherapy assessment categories Total sessions Good Intermediate Poor
<7 8 >8
Emergency sessions
Total time (min) or or
<90 90-120 >120
None None or
Yes
with a Mini-Trach II kit (by Portex UK Ltd.), and group B were control patients. Preoperatively lung ventilatory volumes were assessed by the standard pulmonary function test and baseline arterial blood gases. Patients also received preoperative instructions on deep breathing with the use of incentive spirometry. The minitracheotomy was performed in the operating room after completion of the thoracotomy. While the patient is intubated and in the supine position, 2 to 3 ml of 1% lidocaine hydrochloride (Xylocaine) is injected locally in the area of the cricothyroid membrane. The patient is then extubated. A I em vertical midline skin stab is made with the guarded scalpel (Fig. I) and is extended through the cricothyroid membrane into the airway. The introducer is then passed through the incision into the trachea to guide the passage of the minitracheotomy cannula over it. As soon as the minitracheotomy cannula is in place, the introducer is removed and a !OF-gauge suction catheter is passed to remove any existing blood and secretions. Finally the minitracheotomy cannula is secured to the skin by two 3-0 nylon sutures and neck tapes, and the patient is transferred to the intensive care unit where he/she stays during the initial postoperative period. The group B control patients were similarly transferred to the intensive care unit for the initial postoperative period.
All patients performed hourly deep-breathing exercises with the aid of incentive spirometry. In addition, group A patients received hourly suctioning of the airways through the minitracheotomy cannula during the initial 6 hours postoperatively and thereafter on an "as required" basis. All patients received postoperative chest physiotherapy three times a day until they were capable of clearing their bronchial secretions themselves. Parenteral narcotics were used before chest physiotherapy sessionsfor pain control. Intercostal and epidural blocks were not used. Chest physiotherapy consisted of chest percussion and vibration and postural drainage, in addition to deep breathing and coughing. At the same time humidified oxygen was administered, and intermittent positive-pressure breathing was given concomitantly. Chest physiotherapy sessionswere performed by two senior pulmonary physiotherapists who subsequently reviewed the patients' requirements and categorized them accordingly into one of three categories (good, intermediate, or poor) (Table 1). The postoperative respiratory course was assessed by serial clinical examinations, daily chest x-ray examination, and arterial blood gases. Arterial blood gases were standardized by drawing the blood samples a half hour after the morning session of chest physiotherapy while the patient was breathing room air. For the first 5 postoperative days, sputum samples were sent on a daily basis for microscopic examination and aerobic bacterial cultures, and thereafter when clinically indicated. The high frequency of postoperative laboratory and radiologic monitoring was purely related to the investigative nature of the study and would not have been indicated under normal circumstances. Postoperative pneumonia was diagnosed when three criteria were fulfilled: (I) fever (temperature exceeding 38.5° C) and leukocytosis; (2) presence of new radiologic infiltrate on chest x-ray films; and (3) increase in sputum production with large
Volume 101 Number 5 May 1991
897
Prophylactic minitracheotomy in lung resections
Table II. Age and sex distribution of the patients Group A Group B Total
Number
Age range (yr)
Mean age (yr)
Men
15
25-74 34-72
57.21
11
11
4
u
59.80 57.85
25-74
30
Women
1
24
6
Table III. Smoking habits and ventilatory pulmonary volumes of the patients Pulmonary function test
Group A (n = 15) Group B (n = 15) Total
Smokers
Normal
Abnormal
Obstructive*
Restrictivei
10
7
8
1
5
23
1
2
~ 13
1
1
.u
...2
17
2
9
Both
6
'Obstructive; forced expiratory volume in one second >5% below the predicted normal value. tRestrictive; vital capacity >20% below the predicted normal value.
numbers of granulocytes and singlebacterialspecies on Gram's stain.When pneumonia wasdiagnosed, it was treated with the appropriate antibiotics accordingto the invitrosensitivity result. The Mini-Trach cannula was removed when the patient was able to cough sufficiently to clear the bronchial secretions.
Results A total of 30 patients (24 men and six women) participated in the study. There were 15 patients in group A and 15 in group B. Patients ages ranged between 25 and 74, with a mean age of 57.8 years. Twenty-three patients smoked cigarettes (10 in group A and 13 in group B). Seventeen patients had abnormal pulmonary function tests (eight in group A and nine in group B). Two of them were nonsmokers (both in group A). Two patients had obstructive lung disease (forced expiratory volume in 1 second <5% below the predicted normal value), nine patients had restrictive lung disease (vital capacity>20% below the predicted normal value), and six patients had both. The age and sex distribution, smoking habits, and pulmonary function tests were similarly matched between the two groups (Tables II and III). Twenty-six patients had malignant lung tumors (20 squamous cell carcinomas, three adenocarcinomas, two large cell carcinomas, and one oat cell carcinoma), and four had benign lung disease (two bronchiectasis, one mycetoma, and one chondroma). Thirteen patients underwent pneumonectomies (seven in group A and six in group B), 15 underwent lobectomies, one with tracheal sleeveresection (seven in group A and eight in group B), and two underwent segmentectomies (one in group A and one in group B). One patient underwent emergency lung resection for life-threatening hemoptysis from an infiltrating adenocarcinoma of the lung; the remaining procedures were elective.
Postoperatively a total of 11 patients (36%) had pneumonia, two (13%) in group A and nine (60%) in group B. This difference was statistically significant (p < 0.03; x2 test). Pneumonia developed between 1 and 5 days postoperatively (mean 2.2 days). Bacterial cultures of sputum identified Haemophilus influenzae in six (54%), Streptococcus pneumoniae in three (27%), Escherichia coli in one (9%), and Pseudomonas aeruginosa in one (9%). These patients were treated with the appropriate antibiotics in addition to chest physiotherapy, and this resulted in total resolution in seven patients. In the remaining four patients (all in group B) the respiratory condition deteriorated despite the aggressive chest physiotherapy, intermittent positive-pressure breathing, and nasotracheal suctioning, which was poorly tolerated by the patients. Bronchoscopy was contemplated but not done, a clinical decision probably influenced by our satisfactory experience with the minitracheotomy. Thus, instead, minitracheotomy cannulas were placed in all four patients to aid in clearing the excess bronchial secretions, with subsequent full resolution of the pneumonia. The length of stay in the intensive care unit ranged from 2 to 7 days in group A (mean 3.0 days) and from 2 t08 days in group B (mean 4.1 days) (Table IV). With regard to physiotherapy, the number of sessions required ranged from 6 to 11 (mean of 7 in group A and 8 in group B), and the total time ranged from 55 to 235 minutes (mean of 92 minutes in group A and 112 minutes in group B). Although the overall requirement of chest physiotherapy was less in group A than in group B, the difference did not reach statistical significance. Despite that, the patients in group A attained a more favorable physiotherapy assessment category than those in group B (Table V).
The Journal of Thoracic and Cardiovascular
8 9 8 Issa et al.
Surgery
Table IV. Length ofpostoperative stay in intensive care unit Group A (n = 15)
GroupS (n = 15)
Postoperative days
inlCU
8
5
2
4
1
1
2* 3* 3*
3 4 5
2* 1*
6 7 8
'Patients with postoperative pneumonia.
In a total of 19 minitracheotomycannulas placed (15 in group A and four in group B), there was only one instance of initial difficulty with the placement of the cannula. In this patient identification of the anatomy was obscured by the presenceof excess subcutaneousfat in a short neck. No significant bleeding was encountered on placementof the minitracheotomycanulas in any patient. Eight patients (42%) experienced minor symptomsfrom the minitracheotomycannula, whichincludeddiscomfort in the neck in four (21%), voicechanges in four (21%), surgical emphysema in two (10.5%), and stridor in one (5.3%). These symptoms were mild and temporary and resolved with no sequelaeoncethe cannula was removed. In one patient (5.3%) in group B in whom a minitracheotomy cannula was placed after the diagnosis of postoperative pneumonia, wound infection developed in the minitracheotomysite,and it wastreated successfully with antibiotics. However,healing resulted in some skin scarring, and the appearance of a skin dimple on swallowing. On the other hand, the rest of the patients (n = 18)healed with satisfactory cosmetic results. The duration of minitracheotomyranged from 2 to 14 days (mean 4.13 days), and after removal skin healing was complete within 3 to 5 days. No long-termsequelae were encounteredfrom the minitracheotomyon 6-month follow-up. However, two patients died of their malignant disease (one had a malignant bronchopleural fistula and the other, widespread metastasis). Death occurred 2 months and 6 months after operation, respectively. Discussion
Before undertaking this study we performed minitracheotomyin more than 40 patients in a varietyof clinical situations that required tracheobronchial toilet, and we learned about its valuable role. This experience, together with similar other reports,2-S encouraged us to study the potentialprophylacticroleof minitracheotomyin thoracic operations. We have shown in this randomized pro-
spective and controlled study that minitracheotomy is effective in reducingpostoperative pneumoniain patients undergoing lung resection. Our patient population wasat high risk of having respiratory complications postoperatively. Seventy-six percentweresmokers, 56%had abnormal pulmonary function tests, and 86% had lung cancer with some degree of obstruction and potentiallyinfected distal lung segments. All underwentmajor thoracicoperations with a considerable amount of postoperative pain, resulting in further reduction in breathing ability. These factors may explainthe overallhigh rate of postoperative pneumonia (36%) that resulted despite the strict criteria used in the diagnosis. Nevertheless this is stillsurprisingly higher than the expected rate of postoperative pneumonia.The twogroupsseemwellmatched with regard to age, pulmonary function, smokinghistory,type of procedure, and postoperative care. This did raise a question in our minds about a possibility of an unapparent biased,or undetermined, factor that might have increased the number ofadverseeventsin the controlarm. However, we are unable to find such a contributing reason. From the nursingand the physiotherapy pointsofview, the minitracheotomy provided easy access to the bronchial tree in comparisonwith the standard nasal and oral routes. Physiotherapyrequirement was significantly less in group A than in group B (mean total of 93 minutesin group A versus 112 minutes in group B), and in turn the former group obtained more favorable physiotherapy assessment scores(see Table IV). It is possible that individualvariationscould haveinterferedwith the scoringof the physiotherapy assessment categories. An example would be the uncooperative patient who requires extra sessions and time. In an effort to minimizethis, however, we tried to be as objective in our assessment as the situation allowed. One could argue that the clinicalimpression of an experienced chest physiotherapist may have superiorcorrelationto the true situation than a set of figures and numbers. The lackof seriouscomplications in our seriesmaywell be a reflection of our familiarity with minitracheotomy beforeundertaking this clinicalproject,but it may alsobe explainedby the ideal circumstancesat the time of minitracheotomy placement. These include (1) operating room facilities with perfect positioning and easy access, (2) the presenceof an endotracheal tube initiallyto help in delineatingthe surface anatomy and to allowfor more adequate local anesthesia injection, and (3) operator comfort with the presenceof anesthesiologist back-up at the time, should urgent reintubation berequired. Although the surgical technique of minitracheotomy appears simple, its safe execution demands complete
Volume 101
Prophylactic minitracheotomy in lung resections 8 9 9
Number 5 May 1991
Table V. Chest physiotherapy requirements and physiotherapy assessment categories (PAC) of the patients PAC Sessions * Group A Group B
7 8
Total time*
Poor
Moderate
Good
92 112
3 6
I 3
II 6
'Average per patient.
familiarity with the surface anatomy of the area and the Mini-Trach II kit (Portex UK Ltd., Kent, U.K.). The operator must also be aware of the potential complicationsthat can arise, must know how to manage them and, more important, how to prevent them in the first place. We stress the importance of these issues and highlight some of the technical aspects we found helpful. In all patients we marked the skin at the lower border of the thyroid cartilage and at the upper border of the cricoid cartilage, that is, the area of the cricothyroid membrane, to outline accurately the exact site of entrance to the airway. A minimum of 5 ml of anesthetic agent is injected into the cricothyroid region; then gentle pressure is applied to the area to aid diffusion of the fluid locally. This provides satisfactory anesthesia to minimize movement of the larynx by the patient at the time of insertion of the cannula. It also aids in restoring the original surface anatomy so that the operator can once again palpate definitely the edges of the cartilages. We found this maneuver very helpful in patients who have a fat, short neck. The skin stab should be vertical and in the midline to minimize the risk of injury to blood vessels, the most vulnerable of which are the anterior jugular veins. The introducer must be passed swiftly through the stab wound. If there are any delays and the patient decides to cough or swallow,there is a possibilityoflosing the track. We routinely urge the patient to stay still at the time of insertion,and we prefer keeping the guarded blade in the track until the introducer is in the operator's hand ready to be passed and the patient is settled down. The use of lubrication on the outer surface of the cannula and between the cannula and the introducer facilitates their easy passage into the airway. We also prefer suturing the flaps of the Mini-Trach cannula to the skin as well as using neck ribbons to prevent cannula dislodgment. The potential complications of minitracheotomy are bleeding,inhalation of the cannula, subcutaneous emphysema, alteration in voice,and infection. Bleeding is by far the commonest, and it occurs when the anterior jugular veins are injured when the incision is made. These veins are at high risk when congested, that is, in cardiac failure, when tracheal deviation is present, or with an off-
the-midline stab. Fortunately and in the majority of cases the bleeding is of minor degree and subsides spontaneously or by applying pressure while keeping the airway clear by suctioning the trickling blood. Occasionally, however, bleeding is perfuse and fails to stop, becoming potentially life threatening and necessitating surgical exploration to establish hemostasis. To date three such cases have been reported.v" two of which resulted in death.s-? In the patient who survived, the authors also reported a further complication of displacement of the minitracheotomy cannula into a main bronchus during endotracheal intubation. However, they were able to remove it successfully,by means of a rigid bronchoscope.f Inhalation of the minitracheotomy cannula has also been reported.P: 9-11 However, with the introduction of the new minitracheotomy cannula with flanges (see Fig. 1), which replaced the previously used pediatric endotracheal tube, this has probably become a complication of the past. The new cannula can also be spigotted by an attached plug to closeit when not in use. This prevents the patient from breathing air through it, that is, it prohibits bypassing the moisturizing media of the upper respiratory tract and thus overcomesthe problem of dry bronchial secretions. It also prevents dilution of the inspired oxygen content in patients receiving oxygen treatment.F Surgical emphysema occurs from forceful coughing after the stab incision. It does not occur after removal of the cannula since its matured tract does not allow communication with the subcutaneous fat. Emphysema is usually of minor degree and resolves without long-term sequelae. There has been one report in the literature of severe subcutaneous emphysema developing within 2 hours of minitracheotomy that required endotracheal ventilation for its subsequent uneventful recovery'? Patients with minitracheotomy cannulas may have temporary alteration in voicequality, and this was seen in four of our patients (21%). All four patients recovered their normal voices within a few days of removal of the cannula. Campbell and colleagues'! reported no permanent changes of laryngeal function in 14 patients studied prospectively before and after minitracheotomy. Interestingly, a high incidence (50%) of incidental dysphonia
9 0 0 Issa et al.
The Journal of Thoracic and Cardiovascular Surgery
was found in the patients at their initial assessment, emphasizing the importance of monitoring speech before and after minitracheotomy. Other rare complications reported include partial obstruction from kinking of the minitracheotomy cannula," misplacement of the cannula, leading to perforation of the trachea.P and displacement of the cannula out of the larynx into the esophagus. 16 This latter complication developed during high-frequency jet ventilation through the minitracheotomy cannula. The use of this technique was first reported by Matthews and colleagues'? in the management of patients with respiratory failure. With regard to infection at the minitracheotomy site, we were unable to find any reports in the literature, even though this was the only cause oflong-term morbidity in this series. We report that 42% of our patients with minitracheotomy had some minor and temporary symptoms that resolved without sequelae once the cannula was removed. Not only were these symptoms well tolerated by all patients but they were not even noticed by the majority of patients until they were specifically asked. The emphasis, then, is on the fact that they are more like side effects than like complications. Finally we conclude that prophylactic use of minitracheotomy in patients undergoing lung resection is safe and can reduce the rate of postoperative respiratory complications. We emphasize that proper conduct and safety of minitracheotomy demand complete familiarity with the procedure by the surgeon. We point out that in our study the rate of postoperative pneumonia was unusually high in the control group, without any apparent selection. From the data available at present, it is not possible to determine any high-risk subgroups of patients in whom this prophylactic measure can be used more selectively. Therefore, until further prospective studies with larger patient populations are undertaken to determine possible high-risk subgroups, the use of prophylactic minitracheotomy should be considered based on the individual surgeon's experience and clinical judgment. We thank Ann P. O'Sullivan, MISCP, and Barbara B. Rooney, MISCP, Department of Physiotherapy, The Royal
City of Dublin Hospital, Ireland, for their help and expert advice with the chest physiotherapy. REFERENCES 1. Matthews HR, Hopkinson RB. Treatment of sputum retention by minitracheotomy. Br J Surg 1984;71:147-50. 2. Lewis GA, Hopkinson RB, Matthews HR. Minitracheotomy. Anaesthesia 1986;41:931-5. 3. Preston 1M, Matthews HR, Ready AR. Minitracheotomy: new technique for tracheal suction. Physiotherapy 1986; 72:494-7. 4. Matthews HR. Minitracheotomy and the control of sputum. Surg Annu 1988;20:39-57. 5. Pedersen J, Schurizek BA, Melsen NC, Juhl B. Minitracheotomy in the treatment of postoperative sputum retention and atelectasis. Acta Anaesthesiol Scand 1988;32: 426-8. 6. Gwynn BR, Mostafa SM. Complications of mini-tracheotomy. J R Coll Surg Edinb 1984;29:381. 7. Wagstaff A, Sparling R, Ryan DW. Minitracheotomy [Letter]. Anaesthesia 1987;42:216. 8. Hart AM, Cashman IN, Baldock GJ, Dick JA. Minitracheotomy in the treatment of sputum retention. Intensive Care Med 1987;13:81-2. 9. Yeoh NTL, Wells FC, Goldstraw P. A complication of minitracheotomy. Br J Surg 1985;72:633. 10. Charnley RM, Verma R. Inhalation of a minitracheotomy tube. Intensive Care Med 1986;12:108-9. 11. Leach AB. Inhalation of a minitracheotomy tube. Anaesthesia 1986;41:338. 12. Corke CF, Somerville ID, Reid PM, Keyworth SA, Goodwin JE. Oxygen therapy and minitracheotomy [Letter]. Anaesthesia 1985;40:820. 13. Campbell JB, Watson MG, Povey L, Shenoi PM. Minitracheotomy and laryngeal function: a prospective study. J Laryngol Otol 1988;102:49-52. 14. Stokes DN. Re-insertion of minitracheotomy. Anaesthesia 1987;42:782-3. 15. Tran Y, Hedley R. Misplacement of a minitracheotomy tube [Letter]. Anaesthesia 1987;42:783. 16. Ravalia A, Stockwell MA. Displacement of a minitracheotomy tube during high frequency jet ventilation. Anaesthesia 1987;42:1306-7. 17. Matthews HR, Fischer BJ, Smith BE, Hopkinson RB. Minitracheotomy: a new deliverysystem for jet ventilation. J THORAC CARDIOVASC SURG 1986;92:673-5.
CARDIOVASC SURG
1991;101:895-900
Prophylactic minitracheotomy in lung resections A randomized controlled study Thirty c~utive patients undergoing lung resections were randomized into two groups: Group A (n = 15) received minitracheotomy postoperatively and group B (n = 15) were control patients. Postop-
erative respiratory course was monitored by serial clinical assessments, chest x-ray examination, arterial blood gases, sputa bacterial cultures, and the patient's requirement and response to chest physiotherapy. The two groups were similarly matched in age (mean 58.5 years), smoking habits, pulmonary functions, and surgical procedures. Postoperative pulmonary complications of collapse/ consolidation developed in 11 patients (two in group A and nine in grCMJP B) (p < O.03~ Four patients (all in group B) required minitracheotomy in addition to antibiotics and chest physiotherapy to treat their pneumonia. Chest physiotherapy requirement was less in group A than in group B, with a mean number of sessions of seven in group A and eight in group B and a mean total time of 92 minutes in group A and 112 minutes in group B. The mean duration of minitracheotomy was 4.13 days. Minor temporary SymptolllS resulted from the minitracheotomy in eight patients (42%) and included discomfort, voice changes, subcutaneous emphysema, and stridor. There was one case of long-term morbidity (5%)-skin scarring from wound infectionat the site of the minitracheotomy. No postoperative deaiM resulted. We conclude that the prophylactic use of minitracheotomy is safe and effective in decreasing postoperative respiratory complications in patients undergoing lung resections.
Muta M. Issa, MBBCh, Davina M. Healy, MBBCh, Hassan A. Maghur, FRCS (Glas.), and DavidA. Luke, FRCS (Irel.), Dublin, Ireland
Minitracheotomy is a procedure of percutaneous tracheal cannulation with a small-bore tube (4 mm in diameter) placed through the cricothyroid membrane that provides constanttracheal accessfor sputum suction. It was developed by Matthews and Hopkinson! in 1981. They reported on its effective therapeutic role in the management of patients with sputum retention and atelectasis and complimented its simplicity, low morbidity, and lack of mortality. Similar satisfactory experiences were reported subsequently.e? The condition of postoperative sputum retention is
From the Department of Surgery, The Royal City of Dublin Hospital, Trinity College, School of Medicine, Dublin, Ireland. Received for publication Oct. 3,1989. Accepted for publication May 14, 1990. Address for reprints: Muta M. Issa, MB, Department of Surgery, S-067, Stanford University Medical Center, 300 Pasteur Dr., Stanford, CA 94305.
12/1/22571
commonand potentiallylethal if it remains untreated. It usually develops between the second and sixth postoperative days and can progress rapidly and cause death by triggering "a vicious cycle." By far the best policyis prevention. Although prophylactic measures such as early mobilization, breathing exercises, chest physiotherapy, and intermittent positive-pressure breathing can besuccessful, they are oftenstressfuland exhaustingto patients, particularly the old and poor-risk patients who undergo major abdominal or thoracic operations. To date the reported literature has concentrated mainly on the therapeutic effectiveness of minitracheotomy rather than on its preventive role.With this in mind weset up a randomized controlledstudy to evaluate the prophylactic role of minitracheotomyin patients undergoingthoracotomyfor lung resection. Patients and methods All patients undergoing lung resections during the 4-month period from February to June 1987 were randomized into two groups: Group A underwent postoperative minitracheotomy
895
The Journal of Thoracic and Cardiovascular
8 9 6 Issa et al.
Surgery
Fig. 1. The Mini-Trach II kit includes a minitracheotomy cannula, an introducer, a guarded scalpel, a standard ventilation connector, two neck ribbons, and a !OF-gauge suction catheter.
Table I. Chest physiotherapy assessment categories Total sessions Good Intermediate Poor
<7 8 >8
Emergency sessions
Total time (min) or or
<90 90-120 >120
None None or
Yes
with a Mini-Trach II kit (by Portex UK Ltd.), and group B were control patients. Preoperatively lung ventilatory volumes were assessed by the standard pulmonary function test and baseline arterial blood gases. Patients also received preoperative instructions on deep breathing with the use of incentive spirometry. The minitracheotomy was performed in the operating room after completion of the thoracotomy. While the patient is intubated and in the supine position, 2 to 3 ml of 1% lidocaine hydrochloride (Xylocaine) is injected locally in the area of the cricothyroid membrane. The patient is then extubated. A I em vertical midline skin stab is made with the guarded scalpel (Fig. I) and is extended through the cricothyroid membrane into the airway. The introducer is then passed through the incision into the trachea to guide the passage of the minitracheotomy cannula over it. As soon as the minitracheotomy cannula is in place, the introducer is removed and a !OF-gauge suction catheter is passed to remove any existing blood and secretions. Finally the minitracheotomy cannula is secured to the skin by two 3-0 nylon sutures and neck tapes, and the patient is transferred to the intensive care unit where he/she stays during the initial postoperative period. The group B control patients were similarly transferred to the intensive care unit for the initial postoperative period.
All patients performed hourly deep-breathing exercises with the aid of incentive spirometry. In addition, group A patients received hourly suctioning of the airways through the minitracheotomy cannula during the initial 6 hours postoperatively and thereafter on an "as required" basis. All patients received postoperative chest physiotherapy three times a day until they were capable of clearing their bronchial secretions themselves. Parenteral narcotics were used before chest physiotherapy sessionsfor pain control. Intercostal and epidural blocks were not used. Chest physiotherapy consisted of chest percussion and vibration and postural drainage, in addition to deep breathing and coughing. At the same time humidified oxygen was administered, and intermittent positive-pressure breathing was given concomitantly. Chest physiotherapy sessionswere performed by two senior pulmonary physiotherapists who subsequently reviewed the patients' requirements and categorized them accordingly into one of three categories (good, intermediate, or poor) (Table 1). The postoperative respiratory course was assessed by serial clinical examinations, daily chest x-ray examination, and arterial blood gases. Arterial blood gases were standardized by drawing the blood samples a half hour after the morning session of chest physiotherapy while the patient was breathing room air. For the first 5 postoperative days, sputum samples were sent on a daily basis for microscopic examination and aerobic bacterial cultures, and thereafter when clinically indicated. The high frequency of postoperative laboratory and radiologic monitoring was purely related to the investigative nature of the study and would not have been indicated under normal circumstances. Postoperative pneumonia was diagnosed when three criteria were fulfilled: (I) fever (temperature exceeding 38.5° C) and leukocytosis; (2) presence of new radiologic infiltrate on chest x-ray films; and (3) increase in sputum production with large
Volume 101 Number 5 May 1991
897
Prophylactic minitracheotomy in lung resections
Table II. Age and sex distribution of the patients Group A Group B Total
Number
Age range (yr)
Mean age (yr)
Men
15
25-74 34-72
57.21
11
11
4
u
59.80 57.85
25-74
30
Women
1
24
6
Table III. Smoking habits and ventilatory pulmonary volumes of the patients Pulmonary function test
Group A (n = 15) Group B (n = 15) Total
Smokers
Normal
Abnormal
Obstructive*
Restrictivei
10
7
8
1
5
23
1
2
~ 13
1
1
.u
...2
17
2
9
Both
6
'Obstructive; forced expiratory volume in one second >5% below the predicted normal value. tRestrictive; vital capacity >20% below the predicted normal value.
numbers of granulocytes and singlebacterialspecies on Gram's stain.When pneumonia wasdiagnosed, it was treated with the appropriate antibiotics accordingto the invitrosensitivity result. The Mini-Trach cannula was removed when the patient was able to cough sufficiently to clear the bronchial secretions.
Results A total of 30 patients (24 men and six women) participated in the study. There were 15 patients in group A and 15 in group B. Patients ages ranged between 25 and 74, with a mean age of 57.8 years. Twenty-three patients smoked cigarettes (10 in group A and 13 in group B). Seventeen patients had abnormal pulmonary function tests (eight in group A and nine in group B). Two of them were nonsmokers (both in group A). Two patients had obstructive lung disease (forced expiratory volume in 1 second <5% below the predicted normal value), nine patients had restrictive lung disease (vital capacity>20% below the predicted normal value), and six patients had both. The age and sex distribution, smoking habits, and pulmonary function tests were similarly matched between the two groups (Tables II and III). Twenty-six patients had malignant lung tumors (20 squamous cell carcinomas, three adenocarcinomas, two large cell carcinomas, and one oat cell carcinoma), and four had benign lung disease (two bronchiectasis, one mycetoma, and one chondroma). Thirteen patients underwent pneumonectomies (seven in group A and six in group B), 15 underwent lobectomies, one with tracheal sleeveresection (seven in group A and eight in group B), and two underwent segmentectomies (one in group A and one in group B). One patient underwent emergency lung resection for life-threatening hemoptysis from an infiltrating adenocarcinoma of the lung; the remaining procedures were elective.
Postoperatively a total of 11 patients (36%) had pneumonia, two (13%) in group A and nine (60%) in group B. This difference was statistically significant (p < 0.03; x2 test). Pneumonia developed between 1 and 5 days postoperatively (mean 2.2 days). Bacterial cultures of sputum identified Haemophilus influenzae in six (54%), Streptococcus pneumoniae in three (27%), Escherichia coli in one (9%), and Pseudomonas aeruginosa in one (9%). These patients were treated with the appropriate antibiotics in addition to chest physiotherapy, and this resulted in total resolution in seven patients. In the remaining four patients (all in group B) the respiratory condition deteriorated despite the aggressive chest physiotherapy, intermittent positive-pressure breathing, and nasotracheal suctioning, which was poorly tolerated by the patients. Bronchoscopy was contemplated but not done, a clinical decision probably influenced by our satisfactory experience with the minitracheotomy. Thus, instead, minitracheotomy cannulas were placed in all four patients to aid in clearing the excess bronchial secretions, with subsequent full resolution of the pneumonia. The length of stay in the intensive care unit ranged from 2 to 7 days in group A (mean 3.0 days) and from 2 t08 days in group B (mean 4.1 days) (Table IV). With regard to physiotherapy, the number of sessions required ranged from 6 to 11 (mean of 7 in group A and 8 in group B), and the total time ranged from 55 to 235 minutes (mean of 92 minutes in group A and 112 minutes in group B). Although the overall requirement of chest physiotherapy was less in group A than in group B, the difference did not reach statistical significance. Despite that, the patients in group A attained a more favorable physiotherapy assessment category than those in group B (Table V).
The Journal of Thoracic and Cardiovascular
8 9 8 Issa et al.
Surgery
Table IV. Length ofpostoperative stay in intensive care unit Group A (n = 15)
GroupS (n = 15)
Postoperative days
inlCU
8
5
2
4
1
1
2* 3* 3*
3 4 5
2* 1*
6 7 8
'Patients with postoperative pneumonia.
In a total of 19 minitracheotomycannulas placed (15 in group A and four in group B), there was only one instance of initial difficulty with the placement of the cannula. In this patient identification of the anatomy was obscured by the presenceof excess subcutaneousfat in a short neck. No significant bleeding was encountered on placementof the minitracheotomycanulas in any patient. Eight patients (42%) experienced minor symptomsfrom the minitracheotomycannula, whichincludeddiscomfort in the neck in four (21%), voicechanges in four (21%), surgical emphysema in two (10.5%), and stridor in one (5.3%). These symptoms were mild and temporary and resolved with no sequelaeoncethe cannula was removed. In one patient (5.3%) in group B in whom a minitracheotomy cannula was placed after the diagnosis of postoperative pneumonia, wound infection developed in the minitracheotomysite,and it wastreated successfully with antibiotics. However,healing resulted in some skin scarring, and the appearance of a skin dimple on swallowing. On the other hand, the rest of the patients (n = 18)healed with satisfactory cosmetic results. The duration of minitracheotomyranged from 2 to 14 days (mean 4.13 days), and after removal skin healing was complete within 3 to 5 days. No long-termsequelae were encounteredfrom the minitracheotomyon 6-month follow-up. However, two patients died of their malignant disease (one had a malignant bronchopleural fistula and the other, widespread metastasis). Death occurred 2 months and 6 months after operation, respectively. Discussion
Before undertaking this study we performed minitracheotomyin more than 40 patients in a varietyof clinical situations that required tracheobronchial toilet, and we learned about its valuable role. This experience, together with similar other reports,2-S encouraged us to study the potentialprophylacticroleof minitracheotomyin thoracic operations. We have shown in this randomized pro-
spective and controlled study that minitracheotomy is effective in reducingpostoperative pneumoniain patients undergoing lung resection. Our patient population wasat high risk of having respiratory complications postoperatively. Seventy-six percentweresmokers, 56%had abnormal pulmonary function tests, and 86% had lung cancer with some degree of obstruction and potentiallyinfected distal lung segments. All underwentmajor thoracicoperations with a considerable amount of postoperative pain, resulting in further reduction in breathing ability. These factors may explainthe overallhigh rate of postoperative pneumonia (36%) that resulted despite the strict criteria used in the diagnosis. Nevertheless this is stillsurprisingly higher than the expected rate of postoperative pneumonia.The twogroupsseemwellmatched with regard to age, pulmonary function, smokinghistory,type of procedure, and postoperative care. This did raise a question in our minds about a possibility of an unapparent biased,or undetermined, factor that might have increased the number ofadverseeventsin the controlarm. However, we are unable to find such a contributing reason. From the nursingand the physiotherapy pointsofview, the minitracheotomy provided easy access to the bronchial tree in comparisonwith the standard nasal and oral routes. Physiotherapyrequirement was significantly less in group A than in group B (mean total of 93 minutesin group A versus 112 minutes in group B), and in turn the former group obtained more favorable physiotherapy assessment scores(see Table IV). It is possible that individualvariationscould haveinterferedwith the scoringof the physiotherapy assessment categories. An example would be the uncooperative patient who requires extra sessions and time. In an effort to minimizethis, however, we tried to be as objective in our assessment as the situation allowed. One could argue that the clinicalimpression of an experienced chest physiotherapist may have superiorcorrelationto the true situation than a set of figures and numbers. The lackof seriouscomplications in our seriesmaywell be a reflection of our familiarity with minitracheotomy beforeundertaking this clinicalproject,but it may alsobe explainedby the ideal circumstancesat the time of minitracheotomy placement. These include (1) operating room facilities with perfect positioning and easy access, (2) the presenceof an endotracheal tube initiallyto help in delineatingthe surface anatomy and to allowfor more adequate local anesthesia injection, and (3) operator comfort with the presenceof anesthesiologist back-up at the time, should urgent reintubation berequired. Although the surgical technique of minitracheotomy appears simple, its safe execution demands complete
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Prophylactic minitracheotomy in lung resections 8 9 9
Number 5 May 1991
Table V. Chest physiotherapy requirements and physiotherapy assessment categories (PAC) of the patients PAC Sessions * Group A Group B
7 8
Total time*
Poor
Moderate
Good
92 112
3 6
I 3
II 6
'Average per patient.
familiarity with the surface anatomy of the area and the Mini-Trach II kit (Portex UK Ltd., Kent, U.K.). The operator must also be aware of the potential complicationsthat can arise, must know how to manage them and, more important, how to prevent them in the first place. We stress the importance of these issues and highlight some of the technical aspects we found helpful. In all patients we marked the skin at the lower border of the thyroid cartilage and at the upper border of the cricoid cartilage, that is, the area of the cricothyroid membrane, to outline accurately the exact site of entrance to the airway. A minimum of 5 ml of anesthetic agent is injected into the cricothyroid region; then gentle pressure is applied to the area to aid diffusion of the fluid locally. This provides satisfactory anesthesia to minimize movement of the larynx by the patient at the time of insertion of the cannula. It also aids in restoring the original surface anatomy so that the operator can once again palpate definitely the edges of the cartilages. We found this maneuver very helpful in patients who have a fat, short neck. The skin stab should be vertical and in the midline to minimize the risk of injury to blood vessels, the most vulnerable of which are the anterior jugular veins. The introducer must be passed swiftly through the stab wound. If there are any delays and the patient decides to cough or swallow,there is a possibilityoflosing the track. We routinely urge the patient to stay still at the time of insertion,and we prefer keeping the guarded blade in the track until the introducer is in the operator's hand ready to be passed and the patient is settled down. The use of lubrication on the outer surface of the cannula and between the cannula and the introducer facilitates their easy passage into the airway. We also prefer suturing the flaps of the Mini-Trach cannula to the skin as well as using neck ribbons to prevent cannula dislodgment. The potential complications of minitracheotomy are bleeding,inhalation of the cannula, subcutaneous emphysema, alteration in voice,and infection. Bleeding is by far the commonest, and it occurs when the anterior jugular veins are injured when the incision is made. These veins are at high risk when congested, that is, in cardiac failure, when tracheal deviation is present, or with an off-
the-midline stab. Fortunately and in the majority of cases the bleeding is of minor degree and subsides spontaneously or by applying pressure while keeping the airway clear by suctioning the trickling blood. Occasionally, however, bleeding is perfuse and fails to stop, becoming potentially life threatening and necessitating surgical exploration to establish hemostasis. To date three such cases have been reported.v" two of which resulted in death.s-? In the patient who survived, the authors also reported a further complication of displacement of the minitracheotomy cannula into a main bronchus during endotracheal intubation. However, they were able to remove it successfully,by means of a rigid bronchoscope.f Inhalation of the minitracheotomy cannula has also been reported.P: 9-11 However, with the introduction of the new minitracheotomy cannula with flanges (see Fig. 1), which replaced the previously used pediatric endotracheal tube, this has probably become a complication of the past. The new cannula can also be spigotted by an attached plug to closeit when not in use. This prevents the patient from breathing air through it, that is, it prohibits bypassing the moisturizing media of the upper respiratory tract and thus overcomesthe problem of dry bronchial secretions. It also prevents dilution of the inspired oxygen content in patients receiving oxygen treatment.F Surgical emphysema occurs from forceful coughing after the stab incision. It does not occur after removal of the cannula since its matured tract does not allow communication with the subcutaneous fat. Emphysema is usually of minor degree and resolves without long-term sequelae. There has been one report in the literature of severe subcutaneous emphysema developing within 2 hours of minitracheotomy that required endotracheal ventilation for its subsequent uneventful recovery'? Patients with minitracheotomy cannulas may have temporary alteration in voicequality, and this was seen in four of our patients (21%). All four patients recovered their normal voices within a few days of removal of the cannula. Campbell and colleagues'! reported no permanent changes of laryngeal function in 14 patients studied prospectively before and after minitracheotomy. Interestingly, a high incidence (50%) of incidental dysphonia
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The Journal of Thoracic and Cardiovascular Surgery
was found in the patients at their initial assessment, emphasizing the importance of monitoring speech before and after minitracheotomy. Other rare complications reported include partial obstruction from kinking of the minitracheotomy cannula," misplacement of the cannula, leading to perforation of the trachea.P and displacement of the cannula out of the larynx into the esophagus. 16 This latter complication developed during high-frequency jet ventilation through the minitracheotomy cannula. The use of this technique was first reported by Matthews and colleagues'? in the management of patients with respiratory failure. With regard to infection at the minitracheotomy site, we were unable to find any reports in the literature, even though this was the only cause oflong-term morbidity in this series. We report that 42% of our patients with minitracheotomy had some minor and temporary symptoms that resolved without sequelae once the cannula was removed. Not only were these symptoms well tolerated by all patients but they were not even noticed by the majority of patients until they were specifically asked. The emphasis, then, is on the fact that they are more like side effects than like complications. Finally we conclude that prophylactic use of minitracheotomy in patients undergoing lung resection is safe and can reduce the rate of postoperative respiratory complications. We emphasize that proper conduct and safety of minitracheotomy demand complete familiarity with the procedure by the surgeon. We point out that in our study the rate of postoperative pneumonia was unusually high in the control group, without any apparent selection. From the data available at present, it is not possible to determine any high-risk subgroups of patients in whom this prophylactic measure can be used more selectively. Therefore, until further prospective studies with larger patient populations are undertaken to determine possible high-risk subgroups, the use of prophylactic minitracheotomy should be considered based on the individual surgeon's experience and clinical judgment. We thank Ann P. O'Sullivan, MISCP, and Barbara B. Rooney, MISCP, Department of Physiotherapy, The Royal
City of Dublin Hospital, Ireland, for their help and expert advice with the chest physiotherapy. REFERENCES 1. Matthews HR, Hopkinson RB. Treatment of sputum retention by minitracheotomy. Br J Surg 1984;71:147-50. 2. Lewis GA, Hopkinson RB, Matthews HR. Minitracheotomy. Anaesthesia 1986;41:931-5. 3. Preston 1M, Matthews HR, Ready AR. Minitracheotomy: new technique for tracheal suction. Physiotherapy 1986; 72:494-7. 4. Matthews HR. Minitracheotomy and the control of sputum. Surg Annu 1988;20:39-57. 5. Pedersen J, Schurizek BA, Melsen NC, Juhl B. Minitracheotomy in the treatment of postoperative sputum retention and atelectasis. Acta Anaesthesiol Scand 1988;32: 426-8. 6. Gwynn BR, Mostafa SM. Complications of mini-tracheotomy. J R Coll Surg Edinb 1984;29:381. 7. Wagstaff A, Sparling R, Ryan DW. Minitracheotomy [Letter]. Anaesthesia 1987;42:216. 8. Hart AM, Cashman IN, Baldock GJ, Dick JA. Minitracheotomy in the treatment of sputum retention. Intensive Care Med 1987;13:81-2. 9. Yeoh NTL, Wells FC, Goldstraw P. A complication of minitracheotomy. Br J Surg 1985;72:633. 10. Charnley RM, Verma R. Inhalation of a minitracheotomy tube. Intensive Care Med 1986;12:108-9. 11. Leach AB. Inhalation of a minitracheotomy tube. Anaesthesia 1986;41:338. 12. Corke CF, Somerville ID, Reid PM, Keyworth SA, Goodwin JE. Oxygen therapy and minitracheotomy [Letter]. Anaesthesia 1985;40:820. 13. Campbell JB, Watson MG, Povey L, Shenoi PM. Minitracheotomy and laryngeal function: a prospective study. J Laryngol Otol 1988;102:49-52. 14. Stokes DN. Re-insertion of minitracheotomy. Anaesthesia 1987;42:782-3. 15. Tran Y, Hedley R. Misplacement of a minitracheotomy tube [Letter]. Anaesthesia 1987;42:783. 16. Ravalia A, Stockwell MA. Displacement of a minitracheotomy tube during high frequency jet ventilation. Anaesthesia 1987;42:1306-7. 17. Matthews HR, Fischer BJ, Smith BE, Hopkinson RB. Minitracheotomy: a new deliverysystem for jet ventilation. J THORAC CARDIOVASC SURG 1986;92:673-5.