The use of tracheostomy following major open cardiac surgery: a review of 64 cases

Abstract

in patients unfdergoing major open-heart surgery are reviewed. The indications and complications are classified, and the high incidence of secondary infection is discussed briefly. Tracheal stenosis or dilatation occurred in six patients (9 4%) and the contributory factors are discussed in greater detail.Tracheostomy is one of the oldest established procedures in surgical practice, but the indications for its use have undergone considerable changes, particularly in the last 25 years (Borman and Davidson, 1963). Its use is again under review (Lancet, 1967) and, as a result of the associated complications, many centres are using alternative methods, such as oro-tracheal and naso-tracheal intubation, even though they may have their own drawbacks (Tonkin and Harrison, 1966).It is therefore pertinent to review the use of tracheostomy in relation to one of the more recent indications-that is, after major open cardiac surgery. MATERIAL AND METHODSAll patients admitted to the intensive care unit at the Brompton Hospital from 1 September 1965 to 31 August 1966 were assessed. The minimum period of follow-up was four months to allow for the development of late complications. Of 179 patients submitted to cardiopulmonary bypass surgery 68 required a tracheostomy for intermittent positive pressure respiration.The case records of 64 of these patients were examined; four were untraced. They consisted of a mixed population whose ages ranged from 6 to 63 years (average 34 years). Two patients had a second tracheostomy, and these are included as separate entities, as they were separated by a sufficient period of time and were, in any case, performed for different indications. There were 41 survivors (65%).TECHNIQUE AND MANAGEMENT All tracheostomies in this series were performed by a member of the sur-1 Present address: West Herts Hospital, Hemel Hempstead, Herts gical team, and all followed a common technique. Under general anaesthesia the method of Bjork (1960), using a transverse skin incision and constructing an anterior tracheal wall flap stitched to the subcutaneous tissues, was used. A plastic (Portex) cuffed tracheostomy tube, of the standard pattern and appropriate size, was inserted and the cuff was inflated just sufficiently to make an airtight seal. A dry dressing only, or skin sutures, were used, and the tracheostomy tube was then connected to a sterile respirator of the intermittent positive pressure type.During the period under review the nursing staff observed the following instructions for the management of the tracheostomy:The cuff was not released for the first 12 hours, and was then released for one minute every four hours following pharyngeal suction. It was then inflated again with just sufficient air to make an airtight seal.Tracheal suction was applied hourly, or more frequently if necessary, via a sterile rubber catheter held by sterile forceps. A 'no-touch' technique was desirable but was not always possible.The wound was cleaned with chlorhexidine

Laryngotracheal obstruction complicating tracheostomy or endotracheal intubation with assisted respiration. A critical review.

“…This is certainly an important cause of damage to the trachea (Gray, 1960;Jackson, 1963 ;Watts, 1963;Stiles, 1965a;Gibson, 1967;Johnston et al, 1967;Nicholls, 1968;Shelly et al, 1969;Jewsbury, 1969;James et al, 1970). It has been suggested that the length of the tracheal damage caused by the cuff may depend upon movement of the tracheostomy tube relative to the trachea, movement increasing the length of the damage (James et al, 1970).…”

“…Gibson (1967) considered that trauma from the cuff and infection were the two main factors responsible for destruction of the full thickness of a segment of the tracheal wall leading either to malacia or stenosis. Johnston et al (1967) thought that infection was one of the three major factors responsible for stenosis (the other two being pressure and movement), a view reiterated by Nicholls (1968). Putney (1955) and Meade (1961) believed it was important to leave the tracheostomy wound open lest abscess formation occur with spread of infection along facial planes to the mediastinum, leading to the production of tracheal stenosis.…”

“…Prophylactic treatment with broadspectrum antibiotics is not advised as it is liable to lead to infection with resistant staphylococci, Gram-negative organisms or moulds. Some workers advise treating tracheostomy wounds with antibacterial agents such as chlorhexidine and polybactrin (Nicholls, 1968) or polybactrin and nystatin (Hunter, 1967), but the application of dry gauze and a strictly aseptic technique is probably just as efficacious. Barrier nursing (Gregory, 1970) may reduce the incidence of infection, but to be effective it has to be strict, and this is tedious.…”

“…Dilatations alone Successful treatment by intermittent dilatations alone has been reported in a proportion of cases by a number of workers (Johnston et al, 1967;Pearson et al, 1968;Nicholls, 1968;Campbell, 1968;May, 1969;Dolton, 1969), but this method is not likely to succeed in mature fibrous stenoses (Deverall, 1967;Pearson et al, 1968;Griulo, 1969a;Jewsbury, 1969;James et al, 1970), especially at cuff or tube-tip level. Stomal stenoses appear to be somewhat more amenable (Grillo, 1 969a).…”

“…Multiple dilatations are usually required, and they may have to be repeated for months or even years (Johnston et al, 1967), but occasionally one will suffice (Nicholls, 1968). Dilatations are usually carried out perorally with a bronchoscope, but they may also be performed through the tracheostomy (Dolton, 1969) in stomal or infrastomal stenoses.…”