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Pediatric Tracheostomy
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P.C.M. Filho et al.
Tracheostomy andObesity
AndréLeonardode CastroCosta, MarcusAntônio
de MelloBorba, DanielaSilvaSantos,
andTerencePiresde Farias
Epidemiology
The Obesity Medicine Association denes obesity as “a chronic, relapsing, multifactorial neurobehavioral disease, wherein an increase in body fat promotes adipose
tissue dysfunction and abnormal fat mass physical forces, resulting in adverse metabolic, biomechanical, and psychosocial health consequences” [1].
Being overweight or obese—dened as having excess body weight in relation to
height according to the World Health Organization (WHO)—is associated with
genetic, behavioral, socioeconomic, and environmental factors.
A.L. de CastroCosta, M.D., M.Sc. (*)
Department of Stomatology, Federal University of Bahia, Salvador, Bahia, Brazil
Department of Head and Neck Surgery, Aristides Maltez Hospital, Salvador, Bahia, Brazil
Department of Head and Neck Surgery, Portuguese Hospital, Salvador, Bahia, Brazil
e-mail: costaalc@gmail.com
M.A. de MelloBorba, Ph.D.
Faculty of Medicine, Department of Experimental Surgery and Surgical Specialties,
Federal University of Bahia, Salvador, BA, Brazil
Department of Head and Neck Surgery, Portuguese Hospital, Salvador, BA, Brazil
Department of Head and Neck Surgery, Aristides Maltez Hospital, Salvador, BA, Brazil
D.S. Santos, M.D.
Depattment of Head and Neck Surgery, Portuguese Hospital, Salvador, BA, Brazil
T.P. de Farias, M.D., Ph.D., M.Sc., Researcher.
Department of Head and Neck Surgery, Brazilian National Cancer Institute—INCA,
Rio de Janeiro, RJ, Brazil
Department of Head and Neck Surgery, Pontical Catholic University,
Rio de Janeiro, RJ, Brazil
© Springer International Publishing AG 2018
T.P. de Farias (ed.), Tracheostomy, https://doi.org/10.1007/978-3-319-67867-2_9
161
162
A.L. de CastroCosta et al.
Table 1 Common classications of body weight in adults and children
Adults
Age Indicator Normal weight Overweight
b
≥20years
BMI (kg/m
2
) 18.50–24.99
≥25.00 ≥30.00
Preobesec:
25.00–29.99
Obese
a
Class 1:
30.00–
34.99
Class 2:
35.00–
39.99
Class 3:
≥40.00
Children
International
WHO 2006
d
0–6months BMI Z or
>−2 to ≤2 SDs >2 to ≤3 SDs
>3 SDs
WH Z
At risk of
overweight:
>1 to ≤2 SDs
WHO 2007
IOTF
e
f
2–18years Growth curve
5–19years BMI Z
>−2 to ≤1 SD >1 to ≤2 SDs
BMI=25 BMI=30
>2 SDs
for BMI at
age 18
g
US
2–19years BMI
percentile
≥5th to <85th ≥85th to
<95th
≥95th
BMI body mass index, CDC Centers for Disease Control and Prevention, IOTF International
Obesity Task Force, SD standard deviation, WH weight-for-height, WHO World Health Organization,
Z z score
a
Per WHO 2000 classications, in BMI as kg/m2 [139]. These categories, if not the exact terminology, of adult weight status have been adopted by other major health organizations, including the
US National Heart, Lung, and Blood Institute and National Institute of Diabetes and Digestive and
Kidney Diseases
b
In the USA, typically “class” is referred to as “grade.” Obesity has an unofcial cut point of BMI
≥27kg/m
c
Preobesity has an unofcial cut point of 23 to <27kg/m2 in Asian populations
d
Per the WHO 2006 classications, BMIZ are BMI zscores, and WHZ are WH zscores, based
2
in Asian populations
on age- and sex-specic growth standards for children aged 0–60 months. In children aged
<2years, weight-for-length is used
e
Per the WHO 2007 classications, BMIZ are BMI zscores based on age- and sex-specic growth
standards and references for children aged 5–19years
f
Per Cole etal. [140], for the IOTF, based on age- and sex-specic curves dened to pass through
BMIs of 25 or 30kg/m
g
Per the CDC 2000 classications, BMI percentiles are based on age- and sex-specic growth
2
at the age of 18years, for children aged 2–18years
references for children aged 2–19years
The criteria currently most widely used for classifying weight-to-height is the
body mass index (BMI: the body weight in kilograms, divided by squared height in
meters) (Table1) in adults, which ranges from underweight or wasting (<18.5kg/m
2
to severe or morbid obesity (≥40kg/m2). Children have many specic and geographical criteria, which are also detailed in Table1 [2, 3].
In 2013, an estimated one in three adults worldwide was overweight or
obese, and adult obesity exceeded 50% in several countries around the globe.
)
Tracheostomy andObesity
While the prevalence of adult obesity in the developed world seems to have
stabilized, the global prevalence of obesity in children and adolescents, as well
as adult obesity in developing countries, is still increasing. In addition, some
developed countries continue to observe an increasing prevalence of extreme
classes of obesity [2].
More than half of the Brazilian population (56.9%)—about 82 million people—
were classied as overweight or obese in 2013 [4]. In this same year, it was reported
that obesity affected one in ve Brazilians aged 18years or older, most of whom
were women (24.4% versus 16.8% of men). Over a 10-year period, obesity among
women aged 20years or older rose from 14.0% in 2003, according to the Household
Budgets Survey, to 25.2% in 2013, according to the National Health Survey. Among
men, this rate grew more modestly, from 9.3% to 17.5%. The accumulation of
abdominal fat was also more frequently found in the female sex, affecting 52.1% of
women and 21.8% of men [5].
163
Causes ofObesity
Obesity is a multifactorial disease, which includes endocrine, immune, environmental, neurobehavioral, and genetic/epigenetic components, and affects numerous
organ systems, increasing the risks of hypertension, thromboembolic events,
asthma, obstructive sleep apnea, stroke, nerve entrapment, psychosocial dysfunction, and a host of other cardiometabolic disorders.
Indications forTracheostomy inObese Patients
Tracheostomy, a procedure commonly performed in the management of critically ill
patients, is increasingly becoming indicated in obese patients.
Recently, a study demonstrated that prolonged ventilation and obstructive sleep
apnea are the main indications for tracheostomy in this population [6].
Percutaneous Versus Open Surgical Techniques
Obese critically ill patients are at greater risk for requiring intubation and prolonged mechanical ventilation; in some cases, it is necessary to perform a
tracheostomy.
Tracheostomy is one of the most common surgical procedures performed in critically ill patients. The prevalence reported in studies around the world varies between
10% and 20% [7].
The relative contraindications to percutaneous tracheostomy include obesity
and a short neck. In an analysis from Oslo of more than 1000 patients undergoing
percutaneous tracheostomy, no risk of complications was found in obese patients.
BMI was recorded in 311 patients from 2006 to 2009. The rate of complications
164
Fig. 1 Exposure of the
trachea before performing
an open tracheostomy
procedure
Fig. 2 Exposure of the
trachea before performing
an open tracheostomy
procedure
A.L. de CastroCosta et al.
(of all kinds) in patients with a BMI of 30 or higher (n=541) was 12.2% compared with 13.0% in nonobese patients (odds ratio [OR] 0.9, 95% condence
interval [CI] 0.3–2.5). The 90-day mortality rates were 30% (95% CI 25–35) and
26% (95% CI 21–31), respectively (p>0.05). The median duration of the percutaneous tracheostomy procedure was 10min in obese patients and 9min in nonobese individuals [8].
The decision to perform percutaneous tracheostomy in a patient with obesity
should take into account factors such as the individual patient’s neck anatomy and
the experience of the performing physician. In addition, the practitioner must be
prepared to convert to an open surgical technique if complications arise during percutaneous tracheostomy.
Sometimes, unusual positions may be required to adequately expose the trachea,
as seen in Figs.1 and 2, prior to the tracheostomy procedure.
15 mm connector
Tape attachment
Tracheostomy andObesity
Types ofTubes
Cuff inflation line
165
Flange
Shaft
Pilot balloon
1-way valve
Fig. 3 Components of standard tracheostomy tubes
Cuff
Distal tip
Tracheostomy tubes are used to facilitate the administration of positive pressure
ventilation, to provide a patent airway in patients prone to upper airway obstruction,
and to provide access to the lower respiratory tract for airway clearance. They are
available in a variety of sizes and styles from several manufacturers. The inner
diameter, outer diameter, and any other distinguishing characteristics (percutaneous, extra length, fenestrated) are marked on the ange of the tube as a guide to the
clinician. Some features are relatively standard among typical tracheostomy tubes
(Fig.3) [9].
In obese patients, due to the thick layer of fat between the skin and the trachea
(Fig.4), the cannula should have some characteristics to facilitate better adaptation,
like an adjustable lenght, for example (Fig.5) If you don’t have this device you can
remove the addipose tissue between the trachea and the skin or put a suture to mobilize and closer the trachea to the skin. These maneuvers may facilitate the tracheostomy tube adjustment and are easier to perform during an open procedure.
Complications
Surgery is technically more difcult in obese patients than in nonobese patients, and
is associated with higher complication rates arising from difculties in accessing
the airway due to anatomy or other medical and anatomical concerns in obese
patients.
complications, primarily related to potentially fatal airway events, such as obstruction, accidental decannulation, and tracheostomy tube displacement. The most
likely cause of these events is increased pretracheal soft tissue thickness (PTSTT),
In particular, obese patients requiring tracheostomy face an increased risk of
166
Fig. 4 Thick layer of fat
in the neck and an
adjustable tracheostomy
tube
A.L. de CastroCosta et al.
which effectively reduces the intratracheal length of the tracheostomy tube.
Agitation, straining, and coughing may all result in decannulation or displacement
of the tube into pretracheal soft tissues. Reinsertion of the tube may prove difcult
as a result of thick pretracheal tissue, which can lead to creation of a false passage.
The use of ultrasound and beroptic bronchoscopy have decreased the incidence
of complications related to percutaneous tracheostomy in obese patients [7], but
neither modality is very feasible or cost effective. Both require specic equipment
and trained specialists, and must sometimes be performed in a timely manner. Some
Tracheostomy andObesity
Fig. 5 Thick layer of fat
in the neck and an
adjustable tracheostomy
tube
167
authors [10] have suggested a practical combination of arm and neck circumference
measurements performed in the supine position to provide an equivalent correlation
that can be used to select a suitable tracheostomy tube. Neck circumference is an
anthropometric measurement that has been signicantly correlated with BMI [6].
According to Cordes etal. [6], a relative risk calculation revealed a 2.823 greater
risk of tracheostomy complications in obese patients. Analysis of variance (ANOVA)
analysis revealed that BMI signicantly inuenced the procedure duration
(p < 0.0001), yet multiple regression analysis found no signicant association
between a greater number of predicted complications and the procedure duration.
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A.L. de CastroCosta et al.