Aspiration Pneumonia

Prevention of Aspiration in Putients with Trucheostomies

David K. Bone, M.D., J. Lucian Davis, M.D.,

George D. Zuidema, M.D., and John L. Cameron, M.D.

ABSTRACT Previous work has documented the incidence of aspiration in

patients with tracheostomies to be very high. This has been suggested as a
reason for the frequent pulmonary complications seen in patients with
tracheostomies. I n this study, two modified tracheostomy tube cuffs were
evaluated as to their ability to act as a mechanical barrier and prevent
aspiration. Forty spontaneously breathing patients with tracheostomies were
studied. Utilizing an Evans blue dye test for aspiration, 151 (87%) of the 15
patients with standard tracheostomy tubes aspirated. Aspiration in the two
study groups in which modified tracheal cuffs were used was decreased to 17%
(2/12) and 15% (2/13). It is suggested that by proper tracheostomy cuff design,
the high incidence of aspiration in patients with tracheostomies can be decreased.

T he incidence of atelectasis and bronchopneumonia in patients with

tracheostomies is extremely high. The pathogenesis of these
complications is not entirely clear. The aspiration of oropharyngeal
contents recently has been proposed as one of the main etiological factors
responsible for these pulmonary complications [3, 41. A previous study from
our institution demonstrated evidence of aspiration in 69% of a group of
surgical patients with tracheostomies [3]. In an attempt to decrease this high
incidence, tracheostomy tube cuff modifications were studied to evaluate
their ability to act as a barrier to aspiration.

Clinical Material and Methods

A test to detect aspiration in patients with tracheostomies has previously
been reported [3]. T o perform this test, four drops of an aqueous solution of
Evans blue dye is placed on the patient’s tongue every 4 hours. Routine
suctioning and tracheostomy care are then delivered. Any evidence of bluish
discoloration of tracheostomy secretions obtained on suctioning through the
tracheostomy tube is considered positive evidence of aspiration. The test is
continued for 48 hours.

From the Department of Surgery, T h e Johns Hopkins Medical Institutions, Baltimore, Md.
Supported by National Institutes of Health Grant No. 1 RO 1 HL15779.
Presented a t the Tenth Anniversary Meeting of T h e Society of Thoracic Surgeons, Los
Angeles, Calif., Jan. 28-30, 1974.
Address reprint requests to Dr. Cameron, Department of Surgery, T h e Johns Hopkins Med-
ical Institutions, Baltimore, Md. 21205.

30 THE ANNALS OF THORACIC SURGERY

 Aspirat ion Pneumonia

FIG. 1 . Plastic tracheostomy tube with

small-volume, high-pressure cuff used in
Group I , which, along with uncufled
metal tubes, was the standard tracheos-
tomy tube. T h e cuff was generally deflated
during the period of the study.

Forty spontaneously breathing medical and surgical patients with recent

tracheostomies were included in this study. The 13 women and 27 men
ranged in age from 20 to 83 years. The indications for tracheostomy were
pulmonary insufficiency, bronchopulmonary toilet, or postoperative care
after a head and neck operative procedure. The interval between the
performance of the tracheostomy and the initiation of the study period
varied between 1 and 15 days.
Patients were alternately assigned to one of three groups. In Group I
(control) the patient’s tracheostomy tube was replaced with a standard
uncuffed metal tracheostomy tube or a small-volume, high-pressure cuffed
tube (Fig. l), usually with the cuff deflated. Patients assigned to Group I1
had their tube replaced with a high-volume, low-pressure cuffed tube (Fig. 2)
with the cuff inflated to the minimum pressure allowing an airtight seal.
Patients in Group I11 had a tracheostomy tube with a large polyurethane
sponge-filled cuff (Fig. 3) inserted at the onset of the study. Air was initially
withdrawn from the cuff to collapse the sponge and permit insertion. Once
inserted, the sponge was allowed to expand and form an airtight seal with
the trachea. After the appropriate tube had been inserted, the Evans blue
dye test was started and carried out for a consecutive 48-hour period. At the
termination of the study the protocol tracheostomy tube was removed, and a
tracheostomy tube identical to thk one in use prior to the study was
reinserted.

VOL. 18, NO. 1, JULY, 1974 31

BONE E T AL.

FIG. 2. Plastic tracheostomy tube with

high-volume, lowpressure cuff used in
Group I I . T h e cuff was inflated during
the entire period of the study.

A B
FIG. 3 . ( A ) Plastic tracheostomy tube with sponge-filled cuff. T h e cuff is open to ambient
air. (B) Before the tube is inserted, air has to be evacuated from the sponge-filled C U ~ .

32 THE ANNALS OF THORACIC SURGERY

 Aspiration Pneumonia

TABLE I . EVANS BLUE DYE TEST FOR ASPIRATION

No. of
Type of Tube Patients Positive Aspiration Test
Standard tracheostomy tubes 15 13 (87%)
(Group I)
High-volume, low-pressure cuffs I3 2 (15%)
(Group 11)
Sponge-filled cuffs 12 2 (17%)
(Group 111)

Results
Aspiration was detected in 13 of the 15 patients (87ojb) in the control
group. In Group I1 (high-volume, low-pressure cuffed tubes) aspiration
occurred in 2 of the 13 patients (15y0). In Group I11 (sponge-filled cuffed
tubes) aspiration occurred in 2 of the 12 patients (17y0) (Table 1). T h e
presence of a nasogastric tube, head and neck operative procedure, depressed
mental status, or a constant supine position did not appear to correlate with
the incidence of aspiration (Table 2).
An attempt was made to evaluate the pulmonary status of each patient
and to determine whether it remained stable, improved, or deteriorated
during the 48-hour study period. As seen in Table 3, the control group did
the poorest; but because of the small numbers of patients involved and the
short duration of the study, the significance of this is difficult to evaluate.

Comment
Pulmonary complications are frequent in patients with tracheostomies.
T h e pathogenesis of these complications is unclear and difficult to re-
construct. Many patients with tracheostomies have pulmonary disease to
start with, and this is the reason for the initial tracheostomy. Others,
however, have the tracheostomy only for pulmonary toilet or as a
consequence of a head and neck operative procedure. In all these patients,
new pulmonary complications following the performance of a tracheostomy
are common. Lapses in sterile technique during tracheostomy tube
suctioning, intrapulmonary hydrostatic fluid shifts in the immobile ill

TABLE 2. FACTORS PREDISPOSING T O ASPIRATION

Factors in Aspiration
Depressed
Nasogastric Head-Neck Mental Supine
Group Tubes Operation Status Position
I (15 patients) 11 4 4 1
I1 (13 patients) 8 3 6 0
I11 (12 patients) 11 2 6 0

VOL. 18, NO. 1, JULY, 1974 33

BONE ET AL.

TABLE 3. 'PULMONARY STATUS DURING TRACHEOSTOMY STUDY

Pulmonary Status
Stable or
Group Improved Deteriorated
I (15 patients) 12 3
I1 (13 patients) 13 0
I11 (12 patients) 11 1

patient, and decreased tidal volume probably all contribute in some part to
these pulmonary complications. However, we have recently documented that
the majority of patients with tracheostomies aspirate and propose that this is
a major factor that predisposes many patients with tracheostomies to
pulmonary problems [3]. It is well documented that massive aspiration,
particularly of gastric contents, leads to serious pulmonary problems that
carry a very high mortality [l]. Lesser amounts of aspiration, involving
oropharyngeal secretions, could easily destroy surfactant and lead to
atelectasis and bronchopneumonia. Experimentally, it has been shown that
even the aspiration of saline leads to a decrease in pulmonary compli-
ance [2].
Our previous work demonstrated the incidence of aspiration in a group
of surgical patients with tracheostomies to be 69%. It was proposed that the
tracheostomy itself in some manner interferes with normal glottic closure
and strongly predisposes patients to aspiration. I n the initial study, two-
thirds of the patients had tracheostomy tubes in place with inflated small-
volume, high-pressure cuffs. T h e remaining patients had the cuffs deflated or
had an uncuffed metal tube in place. T h e small inflated cuffs proved to be
no protection against aspiration, since the incidence of a positive Evans blue
dye test was identical in both groups. I n addition to not providing an
adequate mechanical barrier to aspiration, these small cuffs have proved to
be a source of severe tracheal injury [6, 71. T h e mechanism appears to be
related to the extremely high pressures needed in the cuff to achieve an
airtight seal with the trachea. T h e result of these high intracuff pressures is
that lateral tracheal wall pressures often exceed 100 mm. Hg [S]. These high
pressures are greater than the capillary perfusion pressure in the submucosal
plexuses, and progressive ischemia and necrosis of the mucosa and
underlying cartilage occur.
In an effort to decrease the incidence of tracheal injury, newer designs
for tracheostomy tube cuffs have been developed and evaluated [5, 81. These
generally have employed large-volume, low-pressure cuffs with a large contact
area between cuff and trachea. Studies have demonstrated that these tubes
can be left in place with the cuff inflated for longer periods of time without
causing tracheal damage. T h e same cuff design changes that make tracheal
injury less likely theoretically also should provide a more effective

34 THE ANNALS OF THORACIC SURGERY

 Aspiration Pneumonia

mechanical barrier to aspiration. Because of the large volume capacity and

elongated shape, there is more contact area between cuff and trachea, which
should create a more satisfactory seal. As a result of these recent
modifications in tracheostomy cuff design, the long-term inflation of a
tracheostomy cuff as a means to prevent aspiration seemed feasible and
warranted further investigation.
The present study confirmed the high incidence of aspiration in patients
with standard tracheostomy tubes. In the two study groups in which
tracheostomy tubes with large-volume, low-pressure, large-contact-area cuffs
were used, the incidence of aspiration was decreased from 87% to 15% and
17yo, respectively. Factors generally thought to predispose patients to
aspiration-such as depressed mental status and nasogastric intubation-
were equally distributed throughout all three groups of patients and cannot
account for the differences in aspiration rates. The mechanism by which
these modified tracheal cuffs protect against aspiration seems clear. The soft
low-pressure cuffs conform better to the anatomy of the trachea. Rather than
sealing the space between the trachea and cuff by progressive inflation of a
high-pressure cuff with resulting distortion of the trachea, the newer cuffs
readily alter their shape to conform to the tracheal rings and spaces over a
large area, allowing for a seal at much lower pressures. I n addition, with less
distortion of the trachea and adjacent esophagus, swallowing is interfered
with less, which also makes aspiration less likely.
Patients included in this study were breathing spontaneously and did
not require mechanical ventilation. Ordinarily such patients would not have
the cuffs on their tracheostomy tubes inflated for prolonged periods because
of the danger of tracheal injury. Based on the experience of others with these
tubes, the 48-hour inflation period used for this test was thought to be safe.
With these safer cuffs, however, the potential danger from aspiration might
outweigh the now decreased possibility of tracheal damage. Further
observation is necessary before routine cuff inflation during spontaneous
breathing can be considered entirely safe. It is clear, though, that the
incidence of aspiration can definitely be decreased by leaving large-volume,
low-pressure, large-contact-area cuffs inflated in patients with tracheostomy
tubes. We would not suggest that either of the newer tracheostomy tubes
tested in this study is ideal. One of the tubes has already proved unsafe
because the cuff has obstructed the distal tube lumen, and the second tube is
very expensive. From this study, then, we are not recommending any specific
tracheostomy tube. What the study does point out, however, is that by
modifying tracheostomy tube and cuff design, the incidence of aspiration can
be decreased. Therefore, in the future, when tracheostomy tubes are
available that are entirely free of risk, a cuff designed specifically to create a
safe seal can be used for prolonged periods of inflation to prevent aspiration
and, it is hoped, the high incidence of pulmonary complications.

VOL. 18, NO. 1, JULY, 1974 35

BONE E T AL.

Re fewnces
1. Awe, W., Fletcher, W., and Jacob, S. The pathophysiology of aspiration
pneumonitis. Surgery 60:232, 1966.
2. Cameron, J., Caldini, P., Toung, J., and Zuidema, G. Aspiration pneumonia:
Physiologic data following experimental aspiration. Surgery 72:238, 1972.
3. Cameron, J., Reynolds, J., and Zuidema, G. Aspiration in patients with
tracheostomies. Surg. Gynecol. Obstet. 136:68, 1973.
4. Cameron, J., and Zuidema, G. Aspiration pneumonia: Magnitude and
frequency of the problem. J.A.M.A. 219: 1194, 1972.
5. Carroll, R., Hedden, M., and Safar, P. Intratracheal cuffs: Performance
characteristics. Anesthesiology 31:275, 1969.
6. Cooper, J., and Grillo, H. Experimental production and prevention of
injury due to cuffed tracheal tubes. Surg. Gynecol. Obstet. 129:1235, 1969.
7. Gibson, P. Aetiology and repair of tracheal stenosis following tracheostomy
and intermittent positive pressure respiration. Thorax 22: 1, 1967.
8. Kamen, J., and Wilkinson, C. A new low pressure cuff for endotracheal
tubes. Anesthesiology 34:482, 1971.

Discussion
DR. R. D. HENDERSON (Toronto, Ont., Canada): I congratulate Dr. Cameron
on an excellent presentation. I have two questions: The first is whether he has
any measurement of the quantity of aspiration that occurs. The method used is a
sensitive one, and trace quantities of aspirate become significant. The second
question is whether he has looked at the end-effect of aspiration and what
possible factors might be involved in determining how severe an infection
develops.
T o illustrate this, we have studied aspiration in patients with hiatal hernia
and in patients with pharyngoesophageal dysphagia associated with recurrent
laryngeal nerve palsy. In the patients with hiatal hernia the aspiration is taking
place in the presence of a normal lung. The aspiration varies in quantity,
frequency, and quality. Of 1,000 patients with hiatal hernia, 264 had
symptomatic aspiration, 58 having pharyngoesophageal dysphagia with food
sticking at the cricopharyngeal junction, coughing, and choking. These patients
were aspirating food and oral contents comparable to that described in the
present paper. Of the group of 58, 23 developed only very minor respiratory
symptoms.
In the second group, 15 patients with bronchogenic carcinoma and recurrent
nerve palsy had major underlying lung disease. Of these patients, 11 developed
pharyngoesophageal dysphagia and 8 of them aspirated. Six of the 8 developed
significant lung infection, and 3 required pharyngoesophageal myotomy to relieve
the aspiration.
The reason I compare these two groups is that in the second group there was
associated lung disease, and aspiration produced major respiratory infection. In
the first group, without lung disease, the aspiration was tolerated well. I think
this is of importance in a patient who has had a tracheotomy and would ask Dr.
Cameron to comment upon the severity of lung disease produced by aspiration in
his patients.
DR. GEORGEJ. MACOVERN (Pittsburgh, Pa.): Recently we attended a
patient in whom a controlled bw-pressure, large-volume, cuffed tracheostomy
tube was continuously inflated for 18 months. The patient was comatose during
this entire period and finally died of his cerebral problem. At postmortem
examination there was no evidence of significant damage to the trachea.
Although this is an extreme example, it does indicate that these large-volume,
low-pressure cuffs can be inflated for a great length of time without producing

36 THE ANNALS OF THORACIC SURGERY

 Aspiration Pneumonia

significant problems and can prevent aspiration pneumonia, as shown in the

foregoing presentation.

DR. CAMERON:I thank Dr. Henderson and Dr. Magovern for their
discussions. In answer to their specific questions, it is very difficult to quantitate
exactly the amount of aspiration these patients have, but I am not sure that is
important. I think the significant point is that if they have an incompetent glottic
closure mechanism with the tracheostomy tube in place, and if they regurgitate
gastric contents or have large quantities of oropharyngeal secretions, they are very
prone to serious aspiration. You can quantitate it somewhat by the color of the
secretions aspirated from the tracheostomy tube and also the frequency with
which they are positive for a 48-hour period.
It is very difficult to evaluate the significance of the minor degxees of
aspiration we are picking up with the Evans blue dye test. I think there are all
gradations, from massive aspiration of gastric contents carrying a 60 to 80%
mortality, to that which is insignificant and probably unnoticed. I think it is
important for everyone to realize that the glottic closure mechanism is
incompetent in a patient with a tracheostomy, and you have to be very careful to
protect these individuals.

NOTICE FROM THE SOUTHERN

THORACIC SURGICAL ASSOCIATION
The Twenty-first Annual Meeting of the Southern Thoracic Surgical Associa-
tion will be held at the Williamsburg Inn and Lodge, Williamsburg, Va., No-
vember 7-9, 1974. Reservations may be made by writing to the Reservations
Manager, The Williamsburg Inn and Lodge, Williamsburg, Va. 23 185.
Application for membership in the Southern Thoracic Surgical Association,
on forms provided by the Association, should be sent directly to George R.
Daicoff, M.D. (Chairman of the Membership Committee), University of Florida
College of Medicine, Gainesville, Fla. 32601. The deadline for application to
membership is September 1, 1974.
Papers that are accepted for the program will be considered for publication
in The Annals and must be submitted to the Editor by October 15, 1974.
JAMES W. BROOKS,M.D.
Secretary-Treasurer

VOI.. 18, NO. 1, JULY, 1974 37