The incidence and pathogenesis of tracheal injury following tracheostomy with cuffed tube and assisted ventilation analysis of a 3-year prospective study

Abstract

Observations are reported from a 3‐year prospective study of tracheal injury occurring in patients managed by cuffed‐tube tracheostomy and assisted ventilation in the Respiratory Failure Unit at Toronto General Hospital. When the cuffed tracheostomy tube was finally removed an initial bronchoscopic examination of the trachea was performed. Further clinical and radiological assessments were made 3 weeks and 3 months later, using bronchoscopy when indicated. The incidence of symptomatic tracheal stenosis in 153 patients studied was 21 per cent. Of these strictures, 18 occurred at the level of the tracheostome and 14 at the level of the inflatable cuff. Disability due to airway obstruction was severe in 18 and mild in 14 patients. These mild lesions might easily have remained undetected. Two patients with severe strictures died of airway obstruction before treatment could be instituted, a mortality of 6·2 per cent in patients developing strictures. The remaining 30 strictures required treatment either by dialtation alone or by dilatation and resection of the stricture with tracheal reanastomosis. Two of the 153 patients studied developed chronic tracheo‐oesophageal fistulas. The observations indicate that stenosis can be anticipated before the lesion has developed by the finding of circumferential mucosal ulceration or segmental collapse at the initial per stomal bronchoscopy. Observations from the study prompted the following changes in technique:‐ 1. A modification of the connexions between the tracheostomy tube and the respirator, with a subsequent reduction in symptomatic stenosis at the stomal level. 2. A reduction in the diameter of tracheostomy tubes. 3. A search for a less injurious inflatable cuff. The conclusions reached by this study were as follows:– 1. Tracheostomy tubes of large diameter predispose to the development of strictures at the level of the tracheostome in male patients. 2. The presence of airway infection predisposes to stomal stenosis, and probably to cuff stenosis. 3. Cuff strictures are commoner in female patients than in male patients. 4. Age and pre‐existing lung disease may be important in the production of stomal stenosis. 5. The use of a deliberate routine follow‐up examination to evaluate tracheal injury following tracheostomy and assisted ventilation is a necessary undertaking.

An analysis of 59 cases of tracheal stenosis following tracheostomy with cuffed tube and assisted ventilation, with special reference to diagnosis and treatment

“…Tables Z and ZI summarize some pertinent data relating to the 59 tracheal strictures. T h e prospective study mentioned previously (Andrews, 1971;Andrews and Pearson, 1971) indicated the following conclusions :-I. Tracheostomy tubes of large diameter were associated with an increased incidence of strictures at the level of the original tracheostome.…”

“…Thirty-two of the strictures were seen during a 3-year period of a prospective study which was designed to determine the true incidence of this complication, and to clarify the pathogenesis of tracheal injury in those patients requiring tracheostomy and assisted ventilation. T h e results of this prospective study have been previously reported (Andrews, 1971;Andrews and Pearson, 1971)-…”

“…One of the 4 cases diagnosed bronchoscopically was recognized at routine bronchoscopy performed on all the patients in the prospective study (Andrews, 1971; Andrews and Pearson, 1971) at the time of the final removal of the cuffed tracheostomy tube.…”

“…TRACHEOSTOMY with cuffed tube and assisted ventilation has been used with increasing frequency in the management of respiratory insufficiency over the past 15 years, and tracheal stenosis has become a wellrecognized complication of this type of therapy (Deverall, 1967 ;Gibson, 1967 ;Pearson, Goldberg, and da Silva, 1968;Grillo, 1970;Andrews, 1971;Andrews and Pearson, 1971). T h e present paper is an analysis of 59 symptomatic tracheal strictures treated at Toronto General Hospital between 1963 and 1970, and the diagnosis and treatment of these strictures are discussed.…”

Bronchoscopic dilatation in the management of benign (non‐transplant) tracheobronchial stenosis

“…Despite improvements in respiratory care, including widespread use of low‐pressure, high‐volume cuffed tubes, tracheal stenosis remains a feared complication of prolonged endotracheal intubation and tracheostomy. The reported incidence of tracheal stenosis following tracheostomy ranges from 0.6 to 21% 21,22 and following laryngotracheal intubation ranges from 6 to 21% 23 . In a prospective study, complications of tracheostomy have been reported to be more common and more severe compared to endotracheal intubation 24 .…”