“STUDY

OF CLINICAL PROFILE, INDICATIONS,

COMPLICATIONS AND OUTCOME OF
TRACHEOTOMISED PATIENTS IN THE RURAL
POPULATION”

Under the guidance of Dr P.T. Deshmukh (Prof & HOD, E.N.T.)

- Dr Arjun Panicker
(Junior Resident, ENT)
 INTRODUCTION
• Tracheostomy is one of the most frequently performed procedures in the Intensive
Care Unit (ICU).1,2 The decision of when and how to perform a tracheostomy is
often subjective and depends on the experience and often it is individualized to
the patient.1,2

• The word ‘tracheostomy’ comes from the Greek, meaning "I cut the trachea". The
tracheostomy is a procedure that exteriorizes the trachea to the skin of the neck
by a surgical incision into the trachea, producing a more permanent
fistula/opening.3

• A tracheotomy refers to any procedure that involves opening the trachea

(temporary opening) to the creation of the stoma and the stoma itself.3
• The foremost avowed description of tracheostomy on Egyptian tablets dates back to 3600
BC.6 The reliable and scientific successful tracheostomy was first done by Antonio Musa
Brasavola in 1546 to relieve airway obstruction in a patient with enlarged tonsils.7

• With the introduction of antisepsis and improved anesthesia at end of the nineteenth
century, this situation improved. By the early 20th century tracheostomy became much
safer with the refinement in the technical aspects of the procedure by the famous surgeon
Chevalier Jackson.8

• These principles of the operation described by him remain the same to the present day. In
recent times, tracheostomy is more indicated for prolonged assisted ventilation than for
upper respiratory tract obstruction.

• With the various innovations and advances in procedure and instrumentation in the recent
years there is significant improvement in the patient prognosis and outcome.
The functions of tracheostomy are:
• Prolonged ventilation 
• Removal of secretions
• Upper airway obstruction
• As part of another procedure (surguries of oral cavity or pharynx)

• The indications for tracheostomy include acute respiratory failure

with anticipated need for assisted ventilation, upper respiratory tract
obstruction, difficult tracheal intubation or airway, failure to wean
from mechanical ventilation and copious secretions.
COMPLICATIONS
The complications of tracheostomy can be categorized into immediate,
intermediate and long term complications.

The immediate complications of tracheostomy are anaesthetic complications,

hemorrhage, air embolism, recurrent laryngeal nerve injury, local damage, apnea
and cardiac arrest.

 Intermediate complications include surgical emphysema pneumomediastinum,

pneumothorax, tubal obstruction by crusts or secretions, tracheal necrosis, tracheo-
oesophageal and trachea-arterial fistula, perichondritis and dysphagia.

 Some of the long term complications are tracheal stenosis, difficult decannulation,
disfiguring scar and tracheocutaneous fistula.
• The mortality rates with tracheostomy patients are often high as it is
commonly done in patients with acute respiratory failure requiring
assisted ventilation.

• The patients undergoing tracheostomy were seen to have longer ICU

and hospital stay, higher hospital costs and discharged to in-patient
facility for long-term care with trained nursing staff and also providing
rehabilitation.13
AIM AND OBJECTIVES
Aim :
• “ To study of clinical profile, indications, complications and outcome of
tracheostomised patients in the rural population”
 

Objectives :
• To study the demographic profile of tracheostomised patients.
• To study the indications for tracheostomy.
• To study the peri-opereative & post-op complications in tracheostomised patients.
• To study the outcome of tracheostomised patients.
 MATERIAL AND METHODS
• Study design
Observational (prospective cohort)

• Study setup
All the patients requiring tracheostomy in AVBRH Sawangi (M),

Wardha were studied.

• Sample size
50 patients tracheostomized by surgical tracheostomy (ST)
• METHODOLOGY:

• The patients included in the study from underwent surgical tracheostomy in emergency and
elective manner.

• Mostly vertical incision was employed with appropriate alterations for paediatric patients.

• In all the patients the PVC cuffed type of tracheostomy tube of appropriate size was used.
Adequate and diligent post operative care along with the care of the tracheostomy tube was
ensured.

• Data of the tracheostomised patients included demographic profile (age,sex), primary

diagnosis, indication for tracheotomy, surgical technique, duration of the tracheotomy
before decannulation, hospital stay and outcome such as complications, mortality and
prognosis of the patient at the end of three months.
• Patients were followed-up during hospital stay and the outcomes in the domain of —
disease-related, mechanical ventilation-related, and process of care-related were
studied. Disease-related outcomes assessed were in-hospital mortality and 90-day
mortality.

• The 90-day survival was assessed through telephonic inquiry. Following discharge from
the hospital, patients or their family members were contacted over the telephone on
Day 90 (from the day of intubation) or later to assess the vital status of the patient.

• Statistical Analysis:
SPSS 24.0 version and p<0.05 is considered as level of significance.
OBSERVATION & RESULTS
• The present work “Study Of Clinical Profile, Indications, Complications And
Outcome Of Tracheotomised Patients In The Rural Population” was carried
out from June 2018 to June 2020 at AVBRH, Sawangi (M), Maharashtra, India.

• 50 patients during the study period were analyzed for demographic details.

• Various dimensions like clinical diagnosis and indication, duration of

mechanical ventilation, type of procedure, early or late intervention,
complications and outcome were critically studied and recorded.

• Data was analyzed with its statistical significance. Here are the observations.
Table 1: Age wise distribution of patients Table 2: Gender wise distribution of patients
Age Male Female Total
group N % N % N %   Gender N %
0-10 yrs 3 6 - - 3 6  

11-20 yrs 6 12 - - 6 12  
Male 38 76
21-30 yrs 5 10 - - 5 10  

31-40 yrs 3 6 2 4 5 10  

41-50 yrs 7 14 1 2 8 16  
Female 12 24
51-60 yrs 7 14 5 10 12 24  

61-70 yrs 5 10 4 8 9 18  

71-80 yrs 2 4 - - 2 4  
   
Total 50 100
Total 38 76 12 24 50 100  

41.13 ± 20.88 54 ± 12.15 44.22 ± 19.83

Mean ± SD
years years. years.
Table 3: Time of intervention Table 4: Functions of tracheostomy

EARLY LATE TOTAL

Early(0-7 days) Late(>7 days)
    Functions
Gender N % N % N %

N % N % Prolonged ventilation 21 58.33 3 21.43 24 48

Tracheo - bronchial toileting 12 33.33 4 28.57 16 32

Male 30 81.08 8 61.53
Respiratory insufficiency 3 8.33 7 50 10 20

Female 7 18.91 5 38.46 Total 36 72 14 28 50 100

Chi square Value 11.68

Total 37 74 13 26
p-value 0.0028

p value 2.01, p=0.15, significant Significance Significant

Table 5: Indications of tracheostomy
Percentage
CAUSE DIAGNOSIS No of patients
 
Intracerebral hemorrhage 9 18
Extradural haemorrhage 1 2
Sub dural hemorrhage 6 12

  Sub arachnoid hemorrhage 4 8

Head injury Diffuse axonal injury 4 8

Hydrocephalus 4 8
Pneumocephalus 1 2

Total 29 58
Laryngeal malignancy 4 8
Malignancy Oropharyngeal malignancy 1 2

with upper airway obstruction Oral cavity malignancy 1 2

  Thyroid malignancy 1 2
Total 7 14
Laryngeotracheomalacia 1 2
Congenital Tracheal stenosis 1 2
Total 2 4
 Atlanto-axial dislocation 1 2
Lateral listhesis 1 2
Trauma Odontoid fracture 1 2
 
  Cervical spine injury 1 2
 
Total 4 8

Clival tumour 1 2
Osteosarcoma mandible 1 2
Assisted ventilation CP angle meningioma 1 2
  Tuberculosis spine 1 2
  1 2
Spinal cord schwanomma
Total 5 10
CerebroVascular Accident (CVA) 1 2
Guillain Barre Syndrome 2 4
Meningitis 1 2

Total 50 100
Table 6: Duration of mechanical ventilation Table 7: Hospital stay

  EARLY LATE ICU stay (days) Hospital stay (days)

 

Early Late Early Late

No of patients 37 13

Mean 3.35 14.61 Mean 7.2 days 24.3 days 24.97 days 41 days
 

sd 2.08 7.03
SD 5.3 days 4.2 days 19.59 days 15.36 days

t-value 8.84,p-value=0.0001, Significant t-value 2.66,p-value=0.010, Significant

Table 8: Complications (Early & late tracheostomy) Table 8.1: Type of Complication

Early Late Total EARLY LATE Total

 
Complication
N % N % N %
N % N % N %
Bleeding from
2 66.66 1 16.66 3 33.33
Tracheostomy site
Yes 3 8.11 6 46.15 9 18

Subcutaneous
No 34 91.89 7 53.85 41 82
emphysema
1 33.33 - - 1 11.11

TOTAL 37 74 13 26 50 100 Tubal occulusion -   2 33.33 2 22.22

Chi square 9.43

Granulation tissue -   1 16.66 1 11.11
Value Difficult
-   1 16.66 1 11.11
decannulation
p-value 0.0021
Tracheal stenosis     1 16.66 1 11.11

Significance Significant TOTAL 3 33.33 6 66.66 9 100

Table 9.1: Outcome at the time of discharge Table 9.2: Outcome after 3 months

OUTCOME Early Late Total OUTCOME Early Late Total

Improved 25(67.56%) 6(46.15%) 31(62%) Improved 24(64.86%) 2(15.38%) 26(52%)

Poor 11(29.72%) 7(53.84%) 18(36%) Poor 10(27.02%) 3(23.07%) 13(26%)

Expired 1(2.70%) 0(0%) 1(2%) Expired 3(8.10%) 8(61.53%) 11(22%)

Total 37(74%) 13(26%) 50(100%) Total 37(74%) 13(26%) 50(100%)

Chi square Value 4.26 Chi square value 20.40

p-value 0.11 p-value 0.0001

Significance Not significant Significance Significant

SUMMARY
In nutshell our observations are:-

1 ) The mean age of the patients was 44.22 ± 19.83 years with maximum number of patients in 6th &
7th decade of life. Strong male preponderance was observed in the present study with male to female
ratio of 3.16 : 1.

2) 50 patients in our study underwent either early (<7 days) or late (>7 days) tracheostomy. Early
tracheostomy in 37 (74%) patients and late tracheostomy in 13 (26%) was carried out. Thus the ratio of
early and late tracheostomy in our study was 2.84:1 which was found to be statistically significant (p
value= 0.02).

3) Prolonged ventilation (24,48%), followed by trachea-bronchial toileting(16,32%) and respiratory

insufficiency(10,20%) were the various functions for which tracheostomy was performed.

4) The most common indication for tracheostomy was head injury (29,58%) followed by patients with
malignancy of upper airway tract causing obstruction(7,14%).
5) The mean duration of mechanical ventilation in early and late tracheostomy in our study was 3.35±
2.08 days and 14± 7.03 days respectively. This difference was found to be statistically significant ( p
value is 0.0001).

6) In present study, the mean duration of ICU and hospital stay for early tracheostomy was 7.2
±5.3 days and 24.97±19.59 days whereas the mean duration of ICU and hospital stay for late
tracheostomy was 24.3±4.2 days and 41 ±15.36 days respectively; which is statistically significant(p
value is 0.010).

7) Out of the 50 tracheostomy patients the overall prevalence of complications was 18%, the
commonest complication being bleeding from the tracheostomy site. In our study, complications in late
tracheostomy (66.66%) were more common than in early tracheostomy (33.33%). It was also observed
that complications were encountered in emergency tracheostomy (77.77%) more frequently than in
elective tracheostomy(22.22%). This difference was found to be statistically significant (p value is
0.0021).
8) Outcome:
a) At the time of discharge
Of 50 patients,at the time of discharge we found that 1(2%) patient
succumbed to illness, 18(36%) patients had poor prognosis and 31(62%) improved.

b) At the end of three months.

49(98%) patients who were alive at the time of discharge, 10(20%)
patients died during three months taking the overall mortality rate to 11(22%) which
included 3(27.2%) patients of early tracheostomy and 8(72.7%) patients of late
tracheostomy. This was found to be statistically significant (p value is 0.0001)
In one of the notable observations of our study, we found that
majority of the patients of early tracheostomy(64.86%) improved whereas large number
of patients of late tracheostomy died(61.53%).
CONCLUSIONS
• In this prospective observational study of 50 patients various dimensions of
tracheostomy were explored.

• With male preponderance, majority of cases were in 6th and 7th decade with the mean
age of 44.22 ± 19.83 years.

• Prolonged ventilation and trachea-bronchial toileting were the capital reasons for
intervention in form of tracheostomy in almost ¾th of the patients, with head trauma
being the commonest indication.

• One interesting observation emerging out of our study was that despite the fact that
more tracheostomies were done in males than females, the incidence of elective
tracheostomy was more common in females than males which has statistical
significance (p-value is 0.02)
• The time of tracheostomy is crucial in attaining good outcome. 50 patients in our study
underwent either early (<7 days) or late (>7 days) tracheostomy and the ratio of early and
late tracheostomy in our study was 2.84:1.

• The mean duration of mechanical ventilation and the mean duration of ICU and hospital
stay in early tracheostomy was less as compared to late tracheostomy while complications
rate is higher with late and emergency tracheostomy. This difference is statistically
significant .

• At the time of discharge, 2 % mortality was observed which escalated to 22% at the end of
3 months. One of the important feature which surfaced from this study is majority of the
patients of early tracheostomy(64.86%) improved whereas large number of patients of late
tracheostomy died(61.53%)

• This tall and vital observation makes us conclude that in a patient in whom tracheostomy is
indicated, earlier intervention is far more rewarding than the tardy and delayed one.
RECOMMENDATIONS
 
• Earlier intervention (tracheostomy) in patients.

• Study of larger proportion.

• Multi-centric study.

• Longer and scrupulous follow up.

LIMITATIONS

• Limited study period

• Follow up of 3 months as in this study is unadequate

• Lack of comparison of surgical vs percutaneous tracheostomy

THANK YOU