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4]

Original Article

Pattern of tracheostomy-related complications and its

determinants in Kano: a ten-year single institution
experience
ABSTRACT
Background: Tracheostomy is the surgical creation of an opening into the trachea. Reported complication rates of tracheostomy are
varied and depends on the study design, study population, patients’ follow-up and the definition of the different complications. We reviewed
the pattern of tracheostomy-related complications and its determinants. Methods: This study was a 10-year retrospective review of
patients who had tracheostomy in the study area between January 2008 to December 2017. Case files of the patients were retrieved,
reviewed, and information extracted. Results: Of the 149 patients, the male: female ratio was 3.8:1 with age range of 6 months to 86
years. The peak age group was 1−10 years. Foreign body aspiration and head and neck neoplasia were the two most common admitting
diagnoses; 56 (37.6%) and 55 (36.8%) respectively. The most common indication was upper airway obstruction (129, 86.6%). Emergency
tracheostomy was most commonly done (126, 84.6%) and majority of the tracheostomies were done under general anaesthesia (101,
67.8%). Trainee ENT surgeons performed the most tracheostomies (108, 72.5%). Surgical decanulation was done for 5 (3.4%) of the
patients. The complication and mortality rates were 42.3% and 2.6% respectively. The most common period of complication was early
postoperative period (46, 73.0%), and the most common complications were tube blockage and tube displacement (26, 41.3% and 11,
17.5%) respectively. The analyzed variables were not statistically significant determinants of tracheostomy-related complications among the
patients. Conclusion: Tracheostomy-related complications are common, usually in the early postoperative period and usually involve
blockage or displacement of the tube.
Keywords: Adult, complications, determinants, paediatric, tracheostomy

INTRODUCTION 1.6%.[3,4] The tracheostomy complication rate in the

Tracheostomy is the surgical creation of an opening into
the trachea which is maintained with a tube, aimed at
creating an alternative airway in critically ill patients or
patients with other indications. Tracheostomy is one of the
oldest surgical procedures on record, dating back as far as
3600 B.C.E in Egypt.[1] Tracheostomy today is one of the
most frequently performed procedures in critically ill
patients, and is one of the cornerstones (in addition to
surgically placed enteral feeding tubes) that help improve
the lives of patients who are ventilator-dependent or have
lost their native airway (e.g., post-laryngectomy
patients).[2]
present era is comparably lower, and most complications
are minor, however, there remains the potential for life-
threatening events.[5] Complications of tracheostomy can
occur intraoperatively, in the early postoperative period or
the late postoperative period.[6,7,8] Early complications
ABDULRAZAK AJIYA
Department of Otorhinolaryngology, Faculty of Clinical Sciences,
College of Health Sciences, Bayero University, Kano, Nigeria
Address for correspondence: Dr. Abdulrazak Ajiya, Department of
Otorhinolaryngology, Faculty of Clinical Sciences, College of Health
Sciences, Bayero University, Kano, Nigeria.
E-mail: ajiyaabdulrazak@yahoo.com

In previous reviews, the overall complication rate of Submission: 9 December 2019 Revision: 29 April 2020
tracheostomy ranged from 6.7-48% with a mortality of Acceptance: 14 May 2020 Published: 11 September 2020

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DOI: How to cite this article: Ajiya A. Pattern of tracheostomy-related complications

10.4103/jomt.jomt_43_19 and its determinants in Kano: a ten-year single institution experience. J Med Trop
2020;22:93-9.

© 2020 Journal of Medicine in the Tropics | Published by Wolters Kluwer - Medknow 93

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Ajiya: Pattern of tracheostomy-related complications and its determinants in Kano
include bleeding from the operative site, injury to the larynx
or tracheal mucosa, forced insertion of tracheostomy
cannula resulting in pneumomediastinum, pneumothorax,
hemorrhage, wound complications and misplacement of
cannula, while tracheal stenosis, laryngeal stenosis, and
failed re-insertion of cannula are some of the late
complications.[9]
Despite the possible complications that could follow the
procedure of tracheostomy, the decision to place a
tracheostomy is made in consideration of the benefits
versus the risks of the procedure.[10]
Several studies have reported morbid obesity, emergency
tracheostomy as opposed to elective, pediatric
tracheostomy as opposed to adult, and the surgeon
experience as some of the factors associated with
increased rate of complications following
tracheostomy.[5,11-15] In addition, tracheostomy
complications vary according to the method of
tracheostomy, intra- and postoperative care, duration of
intubation, and medical conditions of the patient.[16]
Alternative procedures for airway maintenance include
endotracheal intubation, cricothyrotomy, and
[4,11,17]
percutaneous dilational tracheostomy.
There is paucity of information on tracheostomy-related
complications despite it been a common life-saving
procedure in the study area. This study aimed to bring to
light our experience on the subject of tracheostomy, the
complications, determinants of the complications, and the
outcome of the procedure.
MATERIALS AND METHODS
This was a retrospective review of patients who had
tracheostomies performed at the Department of
Otorhinolaryngology, Aminu Kano Teaching Hospital,
Kano, Nigeria over a 10-year period between January
2008 and December 2017.
This study included all patients who underwent
tracheostomy at the hospital during the period under
study. Patients who had incomplete or missing
information were excluded from the study.
Data were retrieved from the patients’ case files
collected from the medical records department. The
information was entered into a preformed
questionnaire. The data included: demographic profile
(age, sex), main presenting complaint, duration of
presenting complaint, primary diagnosis, indication,
94 Journal of Medicine in the Tropics | Volume 22 | Issue 2 | July-December 2020
venue of tracheostomy, duration of the procedure
(between skin incision and placement of T-tube), type
of tracheostomy, timing of tracheostomy, surgeon’s
rank, anaesthetic technique, timing of first
tracheostomy tube change, technique of decanulation,
additional procedure performed, timing of complication,
and type of complication.
The primary diagnosis was categorized based on aetiology
into trauma, infection/inflammation, neoplasm, congenital
airway disease, foreign body aspiration and others. The
indication for tracheostomy was divided into upper
airway obstruction, respiratory insufficiency, bronchial
toileting, and as adjunct to head and neck surgeries.
Complications related to tracheostomy was classified as:
intraoperative, immediate postoperative (within the first
24hours after surgery), early postoperative (within the
first 2 weeks after surgery), and late postoperative
(beyond 2 weeks).
All tracheostomies were done open under local or general
anesthesia as indicated, via a transverse incision done by
ENT surgeons and trainee ENT surgeons while trained
nurses carried out postoperative tracheostomy care. An
electric suction machine was provided at bedside for
suction as needed. Tracheostomy decannulation was
carried out when the indication had been resolved with
satisfactory maintenance of the airway. All decannulation
were performed in the ward and/or clinic as required.
Patients were then kept under observation for 24 hours
after decanulation before discharge. Air sealed dressing
was kept over the stoma allowing for healing by
secondary intention. Patients and caregivers were
counseled to present at the hospital immediately
should respiratory distress occur. First follow-up was
done after 2 weeks.
Ethical approval obtained from the institutional ethical
review committee of the hospital.
Statistical analysis
The statistical analysis was done using statistical product
and service solution (SPSS) version 23.0 (SPSS, Chicago
IL, USA). The median, interquartile range and age range
were calculated for continuous variables whereas
proportions and frequency tables were used to
summarize categorical variables. Chi-squared test was
used to compare proportions with statistical
significance set at a P value of < 0.05. Multivariate
logistic regression analysis was used to determine
predictor variables that predicted occurrence of
complications.
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Ajiya: Pattern of tracheostomy-related complications and its determinants in Kano

Figure 1: Comparison of tracheostomy-related complications in adults and children

RESULTS and 44 (29.5%) respectively. The procedure of tracheostomy

Over a ten-year period between January of 2008 to
December of 2017, a total number of 192 patients had
tracheostomy at the department of otorhinolaryngology,
Aminu Kano Teaching Hospital (AKTH), Kano, Nigeria.
Only 149 patients satisfied the inclusion criteria and were
included in the study.
Among the 149 patients reviewed, 118 (79.2%) were males
and 31(20.8%) were females with a male: female of 3.8:1. The
age of the patients ranged from 6 months to 86years with a
median age of 8 years and an interquartile range of 39.0. The
peak age was in the age group 1–10 years [Table 1].
Those that presented to the hospital within 24 hours of
commencement of symptoms were in the majority, 42
(28.2%), while foreign body aspiration and head and neck
neoplasm were the two most common diagnoses among the
patients that had tracheostomy: 56 (37.6%) and 55(36.8%),
respectively. The most common indication for tracheostomy
among the patients was upper airway obstruction, 129
(86.6%) [Table 1].
The majority of the tracheostomies were done as
emergency: 126 (84.6%), temporary tracheostomies: 130
(87.2%), and were done under general anaesthesia: 101
(67.8%). Predominantly the patients had foreign body
removal from the airway and direct laryngoscopy with
biopsy for aerodigestive tract masses as additional
procedures done alongside the tracheostomy; 52 (34.9%)
Journal of Medicine in the Tropics | Volume 22 | Issue 2 | July-December 2020
lasted between 30 minutes to 1hour in most cases; 131
(87.9%) and was carried out mostly during the day; 80
(53.7%). Trainee ENT surgeons performed the most
procedures; 108(72.5%), with the theatre been the venue
in 144 cases (96.6%) [Table 1].
The first tube change among the patients was commonly
carried out after the first 72 hours post-operatively, 99
(66.4%). Most of the patients were decanulated using
normal serial tube blockage, 85 (57.0%) [Table 1].
The complication rate among our patients was 42.3% with
mortality of 2.6%. The most common complications seen
among our patients were tube blockage and tube
dislodgement, 26 (41.3%) and 11 (17.5%), respectively [Table 1].
Failed decanulation was most commonly encountered
among the paediatric age group [6 (17.1%)] compared to
adults [1 (3.6%)] [Figure 1]. Early postoperative
complications were the predominant among the patients
as seen in 46 (73.0%) patients. Intraoperative and late
complications were seen in [3 (5%)] and [14 (22%)] of the
patients respectively.
There were more complications among children, female
patients, those with upper airway obstruction,
tracheostomy done in ICU, emergency tracheostomy,
procedures done by consultants, those done under local
anaesthesia and those done in the evenings. However, none
were significant predictors of complications among the
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Ajiya: Pattern of tracheostomy-related complications and its determinants in Kano

Table 1: Tracheostomy and its complications Table 1 (Continued)

Variable Number Percentage Variable Number Percentage
Age (years) Day 80 53.7
Less than 1 10 6.7 Evening 55 36.9
1–10 70 47.0 Late night 14 9.4
11–20 7 4.7 Duration of tracheostomy
21–30 15 10.1 Less than 30 mins 13 8.7
31–40 10 6.7 30 mins to 1 hour 131 87.9
41–50 16 10.7 More than 1 hour 5 3.4
51–60 9 6.0 Additional procedure done
61–70 9 6.0 None 25 16.8
71–80 2 1.3 Head and neck cancer resection 6 4.0
More than 80 1 0.7 Direct laryngoscopy with biopsy 44 29.5
Sex Neck exploration 11 7.4
Male 118 79.2 Foreign body removal 52 34.9
Female 31 20.8 Others 7 4.7
Duration of presenting complaints Venue of tracheostomy
Less than 24 hr 42 28.2 Theatre 144 96.6
24–72 hr 23 15.4 Intensive care unit 5 3.4
3 days–1 wk 19 12.8 Surgeon’s rank
1 week–1 month 13 8.7 Consultant 38 25.5
1–6 month 21 14.1 Senior registrar 108 72.5
More than 6 month 31 20.8 Registrar 3 2.0
Diagnosis Foreign body aspiration 56 37.6 First tube change
Head and neck neoplasm 55 36.8 Not changed 16 10.7
Infection/inflammation 15 10.1 Less than 72 hrs 34 22.8
Trauma 19 12.8 Above 72 hrs 99 66.4
Congenital airway disease 4 2.7 Technique of decanulation
Indications Not decanulated 44 29.5
Upper airway obstruction 129 86.6 Normal decanulation 85 57.0
Adjunct to head and neck surgery 9 6.0 Crash decanulation 15 10.1
Respiratory insufficiency 8 5.4 Surgical decanulation 5 3.4
Bronchial toileting 3 2.0 Complications
Nature of tracheostomy Tube blockage 26 41.3
Emergency 126 84.6 Tube dislodgement 11 17.5
Elective 23 15.4 Peristomal granulation 8 12.7
Type of tracheostomy Failed decanulation 7 11.1
Temporary 130 87.2 Subcutaneous emphysema 4 6.3
Permanent 19 12.8 Surgical site infection 2 3.2
Anaesthesia Pneumonia 2 3.2
General 101 67.8 Haemorrhage 1 1.6
Local 48 32.2 Subglottic stenosis 1 1.6
Time of tracheostomy Others 1 1.6
(Continued )

patients (P-values of 0.842, 0.421, 0.079, 0.729, 0.168,
0.270, 0.651, and 0.655 respectively as seen in Table 2).
DISCUSSION
Tracheostomy is a common surgical procedure and is often
associated with complications, usually minor but
occasionally life threatening. In this study, the median
age of our patients was similar to other reviews.[7,11,18-20]
However, other studies reported relatively higher median
age among their patients.[4,21] Patients in their first decade
96 Journal of Medicine in the Tropics | Volume 22 | Issue 2 | July-December 2020
of life were the predominant in this study comparable to
what was reported by similar studies in Nigeria.[18,19] In
other parts of Africa and Asia, studies revealed higher peak
ages.[7,11,21-23] Most series worldwide in agreement with the
findings in this study show a male preponderance among
tracheostomized patients.[4,7,11,18-20,22]
Some authors in Nigeria reported foreign body aspiration
and head & neck neoplasia as the two most common
admitting diagnoses amongst their tracheostomized
patients comparable to the findings of this study.[18,19]
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Ajiya: Pattern of tracheostomy-related complications and its determinants in Kano

Table 2: Determinants of complications among tracheostomized et al.[11] in Tanzania similarly reported same. However,
patients other authors reported local anesthesia as most
Variable Odds ratio Confidence interval P-value commonly employed in their series.[20,22,23] The larger
Age (years) proportion of pediatric patients in our study could
Less than 18 1.087 0.479–2.466 0.842 explain this. Similar to this study, Cordes et al.[5] in the
18 and above Referent
United States reported direct laryngoscopy and biopsy as
Sex
the most common additional procedure done alongside
Male 0.696 0.289–1.681 0.421
Female Referent
tracheostomy in their series.
Airway obstruction Referent 0.038–1.196 0.079
Others 0.213 Majority of our patients were successfully decanulated as
Venue was also reported in Southwestern Nigeria by Adetinuola
Theatre 0.669 0.068–6.534 0.729 et al.[19] However, in other studies, the number of patients
ICU Referent successfully decanulated is much lower.[20,22]
Nature of tracheostomy
Emergency Referent 0.075–1.571 0.168
The complication rate in this study is relatively higher than
Elective 0.343
Timing of tracheostomy in other related studies worldwide.[11,12,18-20,23,24,26-29]
Day 0.844 0.401–1.776 0.655 However, some reported similar high rates in their
Evening/late night Referent series.[21,22] Differences in the definition of the
Surgeon’s rank complications and predominance of emergency and/or
Consultant Referent 0.258–1.462 0.270 pediatric tracheostomies in this study could be
Resident doctor 0.614 explanations behind these differences.
Anaesthesia
Local 1.225 0.508–2.953 0.651
General Referent
Absent tracheostomy-related mortality was severally
reported by authors in contrast to the findings of the
current study.[4,24-26] However, in agreement with this
However, foreign body aspiration is relatively uncommon study, mortality rates ranging from 0.6% to 3.1% were
among tracheostomized patients in Asia.[20,21] Moreover, reported by other authors.[19,20,27,28] In addition, Sakai
Adoga et al.[24] in Jos and Onotai et al.[25] in Portharcout, both et al.,[29] in the United States, reported a much higher
in Nigeria, reviewed paediatric tracheostomies and reported mortality rate of 8% in their series.
laryngeal papilloma and foreign body aspiration as the most
common diagnoses in their series. Tube blockage and tube displacement were the most
common tracheostomy-related complications in this
Upper airway obstruction has been reported worldwide as series. Comparable to other similar studies in South
the most common indication for tracheostomy.[11,12,19,23,24] Korea, Brazil, and United States.[4,10,12] Other studies,
The finding of this study is not different. However, several however variously reported bleeding, surgical
other authors reported prolonged intubation as their most emphysema, and stoma infection as the most common
common indication for tracheostomy in contrast to this complication of tracheostomy.[20,21-23,28] Failed
study.[5,7,20,26], This could be due to differences in study decanulation, a late complication of tracheostomy, was
population or study design. common among the pediatric age group in this series.
Onotai et al.[25] similarly reported this in Port Harcourt,
Tracheostomy was most commonly done as an emergency in Nigeria.
this study similar to what some authors reported.[11,18,19,23-
25]
Contrary to this, elective tracheostomy was the Early postoperative tracheostomy-related complications
predominant in other series.[4,7,20,21,26,27] Similarly, were the most common finding in this study, in
differences in study population and design could explain agreement to findings by other authors.[4,10,23] However,
that. Gilyoma et al.[11] in Northwestern Tanzania reported many other similar studies reported late complications as
temporary tracheostomy as the common type of most common.[8,11,12,30] The relatively short follow-up
tracheostomy among their cohort, similar to what was period and incomplete documentation during follow-ups
found in the present study. might explain the differences.

Tracheostomy was most commonly done under general Though several studies documented significant statistical
anesthesia among the patients in this study. Gilyoma correlation between tracheostomy-related complications
Journal of Medicine in the Tropics | Volume 22 | Issue 2 | July-December 2020 97
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Ajiya: Pattern of tracheostomy-related complications and its determinants in Kano
and some variables such as emergency tracheostomy,
children, obesity, type of tube, and smoking
status.[4,5,10,11] The current study, however, in contrast
showed none of the analyzed variables to be
determinants of complications among the patients. In
agreement to this finding, several authors reported
similar findings.[4,20,22,28,29,31]
The retrospective nature of this review, inconsistent follow
up periods for the patients in addition to the large number
of patients excluded due to incomplete records are
limitations to the study.
Pediatric tracheostomy is quite common and foreign body
aspiration is a common admitting diagnosis among the
children. Early postoperative complications are
predominant, and the most common complications
were tube blockage and tube dislodgement. Though
complications were more common among children,
female, those who had emergency tracheostomy, and
other analyzed variables; none of these were
statistically significant determinants of occurrence of
complications.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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