THIEME

Original Research

Tracheostomy in the Intensive Care Unit: a

University Hospital in a Developing Country
Study
Mohammad Waheed El-Anwar1 Ahmad Abdel-Fattah Nofal1 Mohammad A. El Shawadfy1
Ahmed Maaty2 Alaa Omar Khazbak1

1 Department of Otorhinolaryngology, Head and Neck Surgery, School Address for correspondence Ahmad Abdel-Fattah Nofal, MD,
of Medicine, Zagazig University, Zagazig, Egypt Department of Otorhinolaryngology, Head and Neck Surgery, School
2 Department of Anesthesia and Intensive Care Units, School of of Medicine, Zagazig University, Zagazig 46166, Egypt
Medicine, Zagazig University, Zagazig, Egypt (e-mail: [email protected]).

Int Arch Otorhinolaryngol

Abstract Introduction Tracheostomy is the commonest surgical procedure in intensive care

units (ICUs). It not only provides stable airway and facilitates pulmonary toilet and
ventilator weaning, but also decreases the direct laryngeal injury of endotracheal
intubation, and improves patient comfort and daily living activity.
Objective The objective of this study is to assess the incidence, indications, timing,
complications (early and late), and the outcome of tracheostomy on patients in the
intensive care units (ICU) at a university hospital in a developing country.
Methods This study is an observational prospective study. It was performed at the
otolaryngology department and ICU new surgery hospital on 124 ICU admitted
patients. We collected patients’ demographic records, cause of admission, indications
of tracheostomy, mechanical ventilation, and duration of ICU stay. We also gathered
patientś tracheostomy records including the incidence, timing, technique, type, early
and late complications, and outcome. All tracheostomized patients received follow-up
for 12 months.
Results The indication for tracheostomy in ICU patients was mostly prolonged
intubation (80.5%), followed by diaphragmatic paralysis (19.5%). All tracheostomies
were done by the open approach technique. Tracheostomy for prolonged intubation
Keywords was done within 17 to 26 days after intubation with a mean of 19.4
2.07 days.
► tracheostomy Complications after tracheostomy were 13.9% tracheal stenosis and 25% subglottic
► endotracheal stenosis.
intubation Conclusion Prolonged endotracheal intubation is the man indication of tracheostomy,
► ICU performed after two weeks of intubation. Although there were no major early
► mechanical complications, laryngotracheal stenosis is still a challenging sequel for tracheostomy
ventilation that needs to be investigated to be prevented.

received DOI http://dx.doi.org/ Copyright © by Thieme Publicações Ltda,

February 19, 2016 10.1055/s-0036-1584227. Rio de Janeiro, Brazil
accepted ISSN 1809-9777.
April 12, 2016
Tracheostomy in Intensive Care Unit El-Anwar et al.

Introduction the tracheostomy tube is secured in place and is patent.

Routine care, as well as prompt management of postoperative
Tracheostomy is the commonest surgical procedure in inten- complication, can be facilitated by ensuring that proper
sive care units (ICUs).1,2 There are four main general indica- equipment and supplies are quickly available (tracheostomy
tions for tracheostomy: long term mechanical ventilation, tube of the same size and 1size smaller, endotracheal tubes of
weaning failure, upper airway obstruction, and airway appropriate sizes with intubation equipment, and physiolog-
protection.3 Tracheostomy in ICU is usually performed for ical saline).
patients with prolonged mechanical ventilation.4 No percutaneous dilatational tracheostomy (PDT) was
Tracheostomy does not only provide stable airway and operated in the current study.
facilitate pulmonary toilet and ventilator weaning, it also We collected data as regarded to demographic patients’
decreases the direct laryngeal injury of endotracheal intuba- record, cause of admission, indications of tracheostomy,
tion, and improves patient comfort and daily living activity mechanical ventilation and duration of ICU stay. Tracheos-
such as mobility, speech, and eating.5,6 tomy records were also gathered including the incidence of
Furthermore, early tracheostomy decreases the ventilator tracheostomy, timing, technique, type, early and late compli-
time, the incidence of ventilator-associated pneumonia (VAP), cations, and the patients’ outcome had been reported.
length of ICU stay, and overall length of hospital stay.7 All tracheostomized patients received follow-up for
There are two main tracheostomy techniques: surgical 12 months post hospital discharge.
tracheostomy (ST), first described in 19098 and performed
by surgeons, and percutaneous dilatational tracheotomy Statistical Analysis
(PDT), described in 19859 and performed by surgeons, We performed a statistical analysis using SPSS 14.0 statistical
internists, or anesthetists. software for Windows (SPSS Inc., Chicago, USA). The signifi-
So far, the choice of tracheostomy techniques has been a cance level was set at p < 0.05. We used the t-test for
matter of debate, and it is primarily made in accordance with quantitative data and chi-square test for qualitative data.
the surgeoń s preference rather than by evidence.7,10,11
The aim of this study was to assess the incidence, indica-
Results
tions, timing, early and late complications, and outcome of
tracheostomy in ICU patients of a university hospital in a This study includes 124 ICU patients; 108 male (87.1%) and 16
developing country. female (12.9%) with ages ranging from 12 to 67 years. The
mean age was 40.7
13.4 years. Tracheostomy was per-
formed for 36 patients (29%).
Patients and Methods
All the patients had surgical tracheostomy (ST); 3 (8.3%)
Study Design female and 33 (91.7%) male. The indication for tracheostomy
This prospective study took place at the otorhinolaryngology was prolonged intubation in 29 (80.5%) patients and dia-
department and ICU of the new surgery hospital, Zagazig phragmatic paralysis in 7 (19.5%) patients.
University Hospitals, Egypt, from June 2013 to June 2014. All All the tracheostomies were surgical tracheostomy (ST)
enrolled subjects or their relative signed an informed consent and done in the operative theater with otolaryngology sur-
after explanation of the research purpose. geons. So no percutaneous dilatational tracheostomy (PDT)
was recorded or tracheostomy done by anesthetists. Hori-
Methods zontal collar incision with mid tracheostomy and removal of
All the patients who needed surgical tracheostomy (ST) were part of the tracheal cartilage was used in all cases except in
transferred to the neighboring operation theater in the same children, with no tracheal flap.
floor within the same hospital (Zagazig new surgery hospital). Surgical emphysema, attributed to small tracheostomy
During the transfer, all patients were assisted by a portable tube size, was reported in three cases (8.3%) and resolved
mechanical ventilator. Upon arrival to the operating room, the spontaneously. There were no other intraoperative or early
patient underwent a noninvasive blood pressure monitoring, post-operative complications and all the patients left the ICU
5 ECG leads, pulse oximetry, and capnogram for end tidal CO2 with the tracheostomy tube. Out of the three most common
monitoring. Anesthesia was induced with propofol 1–2 mg/kg, tracheostomy emergencies (hemorrhage, tube dislodgement,
fentanyl 1–2 mcg/kg, and cis-atracurium 0.1 mg/kg. Then, the and tube obstruction),1 we encountered two cases of tubal
lungs were mechanically ventilated to maintain end tidal CO2 obstruction in the current study and treated it by changing
tension between 30 to 35 mm Hg. Anesthesia was maintained the tube (►Table 1).
with isoflurane 1–1.5% in 50% oxygen air. Otolaryngology During follow-up after discharge from ICU, 5/36 (13.9%)
surgeons performed all the tracheostomies. At the end of the patients showed tracheal stenosis; 1 (2.8%) needed surgery
procedure, the surgeon introduced the tracheostomy tube and 1 (2.8%) depended on double lumen permanent trache-
with gradual withdrawal of the endotracheal tube. Then, the ostomy while the remaining tracheal stenosis was mild and
patients returned to the ICU, assisted by the portable mechan- tolerable to the patients. On the other hand, 9/36 (25%) had
ical ventilator. subglottic stenosis; all were performed after 21 days of
In the ICU, the immediate postoperative priorities of care endotracheal intubation, and none of them required surgical
for a patient with a new tracheostomy include ensuring that interference (►Table 1).

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 Tracheostomy in Intensive Care Unit El-Anwar et al.

Table 1 Indications, complications of tracheostomy and duration between endotracheal intubation and tracheostomy

Tracheostomy Number (percent)

Indications Prolonged intubation 29 (80.5%)
Diaphragmatic paralysis 7 (19.5%)
Complications Surgical emphysema 3 (8.3%)
Tube obstruction 2 (5.6%)
Tracheal stenosis 5/36 (13.9%)
Subglottic stenosis 9/36 (25%)
Duration between endotracheal intubation and tracheostomy Range 17 to 26 days
Mean 19.4
2.07 days

Tracheostomy for prolonged intubation was done within ostomy tube, without definitive recommendations due to the
17 to 26 days after intubation with a mean of 19.4
2.07 varied results in different populations and in patients with
days. No tracheostomy was performed within first two weeks distinctive comorbid conditions.12,14 The American College of
of intubation. Chest Physicians recommends consideration of tracheostomy
ICU stay duration ranged between 2 and 100 days with a for patients who require an endotracheal tube for more than
mean (SD) of 15.87 (21.4). This duration ranged between 3 to 21 days.15 Benefits of establishing a tracheostomy rather than
100 days (mean; 33.5
30.9) for tracheostomized patients using an endotracheal tube include a decrease in direct
and ranged between 2 to 60 days (mean; 8.6
10.1) for laryngeal injury as well as improved comfort and daily
intubated patients. Thus, there were significantly longer activities of living such as mobility, speech, and eating.6
durations of ICU stay in tracheostomized patients The tracheostomy tube may be placed surgically or percu-
(t ¼ 3.4253 and p ¼ 0.0019) (►Table 2). taneously. Percutaneous tracheotomy is generally performed
Mechanical ventilation was required in 96/124 (77.4%) of solely on intubated patients and, unlike surgical tracheotomy,
studied patients and 32/36 of the tracheostomized patients it can be performed without direct visualization of the
with near significance difference (Chi-square test: 3.817 and trachea. Bronchoscopy is used to guide and confirm place-
p ¼ 0.05) (►Table 2). ment of the tracheostomy tube within the trachea.16
Surgical placement is done in the operating room or at the
bedside, generally under general anesthesia. A common
Discussion
technique is to create a “trap door” (Bjӧrk flap), by which a
Patients require long-term mechanical ventilation because of small part of the tracheal cartilage is pulled down and sutured
chronic respiratory failure, inability to maintain unassisted to the skin.16 We did not utilize this technique in the current
respiratory function, or failed weaning from ventilatory study and conducted all the cases in the operating theater.
support.12 We estimated that between 2% and 11% of ICU Percutaneous dilational tracheotomy (PDT) is the most
patients who required mechanical ventilation would receive a common technique in most centers, especially in the devel-
tracheostomy.13 oped countries. In study of ICU tracheostomy in the United
Numerous studies aimed to determine the optimal interval Kingdom, PDT is preferred over the surgical technique; in 43%
between orotracheal intubation and placement of a trache- of units, PDT is performed in 95% of cases, in 32.4% of units it is

Table 2 Differences between tracheostomized and non tracheostomized ICU patients

Tracheostomized ICU patients Other ICU patients P value

Cases 0.33 NS
(x2 ¼ 0.943)
Total 36 88
Male 33 (91.7%) 75 (88.2%)
Female 3 (8.3%) 13 (14.8%)
Mechanical ventilation 32/36 (88.9%) 64/88 (72.7%) 0.05 near S
(X2 ¼ 3.817)
Mean ICU stay 33.5
30.9 All ICU patients, 0.0004 S
15.87 (21.4) (t ¼ 3.6365)
For intubated ICU patients 0.0019 S
8.6
10.1 (t ¼ 3.4253)

Abbreviations: ICU, Intensive Care Unit; S, significant; NS, non-significant.

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Tracheostomy in Intensive Care Unit El-Anwar et al.

done in 75–95% of cases, in 16.6% of units it is done in 50 to significantly affected and needed intervention, either with
75% of cases, while in only 8% of units, ST is preferred with PDT surgery or permanent tracheostomy. In our concept, we did
accounting for less than 50% of cases.17 In many studies about not attribute this to the tracheostomy technique per se, but
tracheostomy in ICU in many of European countries, PDT was mostly due to the long intubation period preceding it (more than
usually the preferred technique; in Italy, it accounted for 89% 21 days), particularly since tracheostomy in ICU is elective.
of cases,18 in Germany, 86% of cases,11 in Spain, 72% of cases,19 International and national surveys report as the prevailing
and in the Netherlands, 62% of cases.20 timing of tracheostomy between 7 to15 days.11,17–20,23 Some
Surgical tracheotomy (ST) is the only technique used in our studies consider early tracheostomy to happen within 4 days
center; this is mainly due to the cost effectiveness, which is in of intubation and late tracheostomy after 10 days.25 Thus, we
the favor of ST because of the cost of the PDT insertion set as hope to introduce the concept of earlier tracheostomy to a
well as the otolaryngology surgeoń s easy 24-hour accessibil- greater extent that the current protocol in our center, to avoid
ity to the hospital. Furthermore, insufficient expertise in most of tracheostomy complications.
performing PDT can be added to the cause of preference of ST.
This agrees with the result of other studies21,22 about
Conclusion
tracheostomy in ICU in Nigeria’s teaching hospital in which
all the tracheostomies were surgical tracheostomy. In one of Prolonged endotracheal intubation is the main indication for
the international survey about tracheostomy in ICU; they patients that have undergone tracheostomy performed after
found that ST was the most popular tracheotomy technique two weeks of intubation, in all cases. Although it does not
outside Europe, and was mainly performed by ENT special- present major early complications, laryngeotracheal stenosis
ists.23 Even in some developed countries, such as France, the is still an unresolved sequel for tracheostomy that needs to be
ST technique is still preferred over PDT.24 further investigated so it can be prevented.
The importance of this study is while it was done in the ICU of
a surgery hospital, so it was dealing mostly with surgical cases,
which differ from other studies, which may include non-surgical
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