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COMPARATIVE STUDY OF ENDOTRACHEALINTUBATION AND TRACHEOSTOMYIN EMERGENCIES : A REVIEW OF 70 CASES
Mr Juvekar*, R V Juvekar**
*Sr. Registrar; **Ex. Hon. Prof. and Head; Dept. of Otorhinolaryngology, LTM Medical College and Hospital, Mumbai and Prof. and Head, KJ Somaiya Medical College and Hospital, Mumbai.
The present study comprises a series of 70 patients who were either intubated or tracheostomised in emergencies in the intensive care units and trauma ward of a teaching general hospital in Mumbai. The early and delayed complications of intubation and tracheostomy have been studied. The factors preventing complications of intubation and tracheostomy were studied. It was found that tracheostomy is a safer alternative to intubation when a prolonged artificial airway is required. Also the earliest closure of tracheostomy is most desirable in the paediatric age group.
INTRODUCTION
Patients have been intubated for more than 48 hours in the medical, respiratory, surgical trauma and paediatric intensive care units by resident doctors on duty. Tracheostomy is thought as an important life saving procedure in many conditions and has now become a well established procedure with more specific indications in the intensive care units in our hospitals.
MATERIAL AND METHODS
A comparative study of indications, complications and consequences of intubation and tracheostomy was done in 70 critically ill patients. Of them 40 patients were intubated for variable period of 48 hours to 7 days by the medical or surgical emergency staff. The tubes used were portex tubes, baxter tubes, and India rubber tubes.
A standard tracheostomy procedure was performed by ENT residents with removal of the disc of the tracheal cartilage in unintubated patients on admission or on intubated patients 2-7 days after intubation. The tracheostomy tubes were portex cuffed tubes or metal (German silver) tubes.
Optimal care was provided to all the tracheostomised patients. Ten patients expired during the stay in intensive care units due to their poor general condition after the primary pathology like head injuries. Patients were evaluated after 1 month, 3 months, and 6 months, after extubation or decannulation.
OBSERVATIONS
Of the 70 cases, 40 (57%) were intubated in this group, 30 (75%) were adults and 10 were children (Table 1). Nineteen patients (47.5%) developed immediate but temporary complications like vocal cord oedema, or arytenoid congestion. Twenty seven patients (67.5%) were intubated for a period of 5-7 days (Table 2).
No. of patients intubated : 40 (57%)Type of tube No. of patients Duration of Intubation No. of Patients Developing Complications Portex 27 5-7 days 13 Baxter 8 3-5 days 6 India rubber 5 3-4 days 3
Immediate temporary complications of intubation 19/40 (47.5%)Type of tube Vocal cord oedema Arytenoid congestion Portex 7 4 Baxter 5 India rubber 2 1 Seven patients (17.5%) developed delayed complications including a) vocal cord ulceration, b) subglottic stenosis, c) vocal cord polyps and d) intubation granulomas. Portex intubation tubes and baxter intubation tubes had slightly higher percentage of delayed complications than India rubber intubation tubes (Table 3).
Delayed complications : 7/40 (17.5%)Type of Vocal cord Subglottic Polyp at anterior Intubationtube ulceration stenosis commisure granuloma Portex 2 1 Baxter 2 1 India rubber 1 Of the 40 patients tracheostomised there were 24 adults and 6 children. Twenty five patients (83.3%) were tracheostomised by a portex tracheostomy tube. Of these 6 cases (15%) developed immediate complications. Five patients were tracheostomised by a metal tracheostomy tube of which 4 patients (developed immediate temporary complications. The duration of tracheostomy varies from a period of 5-15 days. The immediate temporary complications included surgical emphysema, granulations at the tracheal stroma, bleeding and pneumothorax (Tables 4 and 5).
DISCUSSION
Of the intubated patients, 70% had the endotracheal tube for more than 5 days and 30% less than 5 days. It was seen that longer the duration of intubation, higher was the incidence of complications. 26 (65%) of the intubated patients
No of patients tracheostomised -30 (24 - Adults, 6 - Children)Type of tube used No. of patients tracheostomised Duration No. of patients developing temporary complications Portex 25 5-15 days 6 Metal 5 10-15 days 4
Temporary complications of tracheostomy : 10 (33%)Type of tube Surgical emphysema Granulation over the stoma Bleeding Pneumothorax Portex 2 (subsided within 24 hrs) 1 3 1 Metal 3 (subsided within 18 hrs) had complications of which 2 patients (7.6%) had subglottic stenosis. The probable cause being the 1) prolonged intubation, 2) failure to deflate the cuff at regular intervals, 3) larger size of tubes and 4) over inflation of the cuff lead to mucosal ulceration, ischaemic necrosis and granulation formation, ultimately leading to subglottic stenosis. The use of high volume, low-pressure cuff is also recommended along with an early decision of tracheostomy to prevent these complications.
Patients, who developed vocal cord oedema, arytenoid congestion, and polyps at the anterior commissure, mainly presented with hoarseness of voice one month after extubation. Vocal cord oedema and congestion were treated by voice rest, antibiotics, steam inhalation and steroids. Polyps and intubation granulomas were excised by microlaryngoscopy.
Tracheostomy was done in 30 patients of these 80% were adults and 20% were children. Nine (30%) of these patients developed temporary complications. Five patients (16%) developed surgical emphysema, which subsided within 18-24 hours. All patients with surgical emphysema were children. The most probable causes for surgical emphysema were 1) difficult dissection during the procedure, leading to the opening up of the subcutaneous tissues, 2) too tight closure of the skin causing the escape of air in the subcutaneous planes, 3) disparity between the tracheostomy tube and the tracheal stroma, 4) the use of an uncuffed tube and 5) an inexperienced surgeon.
All 3 patients (10%) troublesome bleeding during the procedure was controlled by local pressure and ligatures.
One patient who had pneumothorax was child with a subglottic foreign body. While doing the tracheostomy there was damage to the pleura and subsequently pneumothorax. The foreign body slipped in the right main bronchus. The foreign body was removed immediately by rigid bronchoscopy. The pneumothorax settled within 5 days after an intercostal drain was inserted.
One patient (3%) developed granulations over the tracheal stroma 15 days after tracheostomy. These granulations were excised.
Thus the complications of tracheostomy were more only in the paediatric age group. Most of the complications were temporary in nature and easily treated. However the complications with prolonged intubation, were more frequent than with tracheostomy.
Early tracheostomy should be done electively after the dire emergency (usually 24-48 hours) to prevent the complications of prolonged intubation. However it is seen that tracheostomy is more dangerous in children than in adults. The chances of development of tracheal stenosis are also greater in children than adults due to their smaller size of the tracheal diameter. Also repeated chest infections and dependence on the easy tracheostomy airway add to the problem. This makes de-cannulation difficult.
It needs to be emphasized that complications of prolonged intubation can be minimised considerably with necessary precautions like selecting the proper size of the tube, proper intubation under vision, sufficient inflation of the cuff, intermittent deflation of the cuff, regular suctioning with sterile catheter the usage of high volume low pressure cuff whenever available.
Thus prolonged endotracheal intubation is more hazardous and prone to complications than elective tracheostomy by an expert. However the decision regarding the choice between endotracheal intubation and tracheostomy in a critically ill patient is a difficult one and is always taken by a combined team effort.
ACKNOWLEDGEMENT
We sincerely thank Dr. RA Shirhatti, Dean, (LTM Medical College and Hospital) and Dr. RA Bradoo Associate Prof. and Head Department of Otorhinolaryngology LTMG Medical College and Hospital, Sion, Mumbai - 400 022 for their valuable help and guidance.
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