Tracheotomy Management Update

Two abstracts presented at the 2007 Combined Otolaryngology Spring Meeting (COSM) reflect where the news lies with the subject of tracheotomy: raising the index for suspicion for tracheal stenosis following percutaneous tracheotomy1 and better educating non-otolaryngologists who manage tracheotomy patients.2

Potential for Complications

In many medical institutions, percutaneous tracheotomy (PCT) techniques have become popular because of the advantages of this technique over open tracheotomy, which include cost effectiveness, safety, and ease and speed of performance. The use of PCT at the patient’s bedside means decreasing the need to transport a very ill patient to the operating theater. Studies comparing open tracheotomy and PCT have not shown a significant difference in morbidity and mortality between the two procedures. Closer attention to the duration of tracheotomy tube placement and the size of tracheotomy tubes has reduced rates of long-term sequelae. However the potential for the development of tracheal stenosis, a dangerous complication, requires a more careful look, said otolaryngologists at Thomas Jefferson University Hospital in Philadelphia.

Maurits Boon, MD

“This institution has long history of dealing with tracheal stenosis,” said Maurits Boon, MD, an attending physician at Thomas Jefferson. Louis H. Clerf, MD, who was one of the founders of otolaryngology and a professor at Jefferson Medical College, was instrumental in recognizing some of the complications that occur with high tracheotomy and describing how the technique should be performed.

In 2006 eight patients were referred to the otolaryngology–head and neck surgery department for management of tracheal stenosis following percutaneous dilational tracheotomy. In each case CT findings of anterior tracheal ring or cricoid compression and destruction were noted. In all cases, endoscopy revealed stenosis secondary to anterior tracheal wall or anterior cricoid collapse. Revision operations were necessary to correct the damaged tracheal wall due to narrowing of the tracheal lumen.

The impetus for examining the potential association of tracheal stenosis with PCT has its parallel in earlier experimental studies. “In the 1970s [investigators] did dog studies in which they made a cross incision in the trachea and [inserted] a trach tube,” said Dr. Boon. “They had a very high rate of stenosis because the procedure crushed a tracheal ring into the airway and then [it scarred over]. Our theoretical concern is that we are now doing very similar things with percutaneous tracheotomy…and in fact we have seen some patients after percutaneous tracheotomy who have developed significant stenoses that in some respects have been hard to correct.”