Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4597_Библиотеки_им_академика_М_И_Перельмана.pdf
272
Tracheostomies
optimal voice restoration. A physician, Brook (2009), provides a discussion of
his own experience as a patient with a total laryngectomy undergoing voice
rehabilitation with a TEP. He reported the following experience:
The task of talking again was most challenging and frustrating. I was unable
to speak for over 2 months and later wished I had used an electrolarynx
during that period. . . . I . . . realized that this field was not only a science, but
also an art. . . . I soon realized that this process was going to be a long pro-
cess of trial and error, repeated TEP failures due to leaks, and learning how
to master the art of sealing the housing of the heat-moisture exchanging
filter. . . . Fortunately, things improved significantly with the passage of time
and the reduction of the neck edema.
Patients who are about to undergo a total laryngectomy have a number of
choices, only one of which is a puncture procedure. The speech-language pathologist will provide advice to the patient and family as they proceed through
the process.
Ventilator-Dependent Tracheostomized Patients
The newest airway, developed by Dr. Eric Blom, enables a ventilator-dependent
patient with a larynx to maintain positive-pressure ventilation while still diverting some airflow into the larynx and creating voice. This new device facilitates airflow around the tube and into the patient’s larynx, vibrating the vocal
folds. In all cases where the tube is used to facilitate speech as well as respiration, the patient’s respiratory airflow must be adequate to move through the
prosthesis and vibrate whatever tissues produce voice. If airflow is low or the
patient has poor respiratory strength, these prostheses will provide suboptimal
results. Similarly, the patient’s articulatory ability must be adequate to shape
the vibratory airflow into speech sounds and words.
Balancing Breathing, Speech, and Swallowing
There are many conditions that may affect the patient’s ability to produce speech
or breathe with the respiratory tube in place, and the clinician who introduces
these tubes or airflow devices must be able to identify the precipitating condition (Hess, 2005a, 2005b). The patient’s airflow may be inadequate or the device
may be clogged with mucous or other secretions.
The upper aerodigestive tract is important in respiration, swallowing, and
speech and voice production. The trachea’s role in respiration is obvious, as it
delivers air to the lungs. Its role in swallowing, while critical, is often not entirely recognized.
The upper aerodigestive tract delivers airflow stimulation to the larynx and
other structures of the upper airway. This stimulation contributes to vocal fold
closure. Patients who are mechanically ventilated for even a short period of time
often lose their vocal fold closure when they attempt to vocalize. This problem
often requires speech therapy to stimulate vocal fold movement. Airway closure
during swallow is necessary to protect the airway from food or liquid. The prevention of aspiration is essential to reduce the risk of pneumonia due to food
Chapter 9 Special Considerations for the Patient With a Laryngectomy
entering the lungs. Again, patients may need intensive therapy to facilitate or
improve airway closure during swallow. Maintaining upper airway function is
critical to successful swallowing and speaking as well as respiration.
Swallowing Function With Ventilator-Dependent Patients
Swallowing and respiration are reciprocal processes. Swallowing normally occurs toward the beginning of exhalation; thus, it is usually helpful to present
food to the patient at that time. Since a mechanical ventilator controls the respiratory cycle, the patient cannot fully coordinate exhalation time with swallowing. If the patient has slow oral or pharyngeal stages of swallowing that
cannot be completed during the time allocated for exhalation by the ventilator,
the swallow may be disrupted by the next inspiration. If the patient restarts
inspiration early, any residual food may be directed into the airway. The inflated
cuff of the tracheostomy tube in a ventilator-dependent patient interferes with
laryngeal elevation and, thus, reduces closure of the entrance of the airway. In
turn, food or liquid may enter the airway and be aspirated after the swallow.
The blue dye test may be used at the bedside for a tracheostomized patient (Thompson-Henry & Braddock, 1995; Tippett & Siebens, 1996). This test
screens for the presence of aspiration. The patient is given measured amounts
of blue-dyed foods, and the tracheostomy is suctioned immediately after the
swallow for the presence of the blue-dyed foods, which would indicate aspiration. The test does not reveal the anatomic or physiologic cause(s) of aspiration,
however, which is critical information. If the result is clearly positive (i.e., bluedyed material is coughed or suctioned from the tracheostomy), the clinician
should recommend a modified barium swallow to determine the cause of the
aspiration and define the type of therapy needed. If blue-tinged secretions are
later suctioned from the tracheostomy tube, the conclusion should not necessarily be that the patient is aspirating. The normal flow of secretions is downward from the mouth and pharynx, and it is quite normal for blue dye to mix
with secretions and gradually coat the trachea. Also, the patient may aspirate
on certain food consistencies and not on others.
273
Quality of Life
Because of the life-changing nature of the procedure and its sequelae, there are
numerous studies assessing quality of life in the patient who has undergone a laryngectomy. Van den Brink and investigators (2006) studied 90 patients in the first
3 months following discharge after surgery for head and neck cancer. They found
three factors that strongly associated with poorer quality of life: laryngectomy,
lower levels of education, and being single. They also found that the dimensions
of loss of control and physical self-efficacy worsened during this time period.
Lennie, Christman, and Jadack (2001) studied the eating-related experiences and educational needs of people following total laryngectomy. Most participants were not satisfied with the information they received from health
care professionals and were unprepared for the potential alterations in eating
following total laryngectomy. Ninety percent of the participants experienced
a change in one or more aspects of eating. The most prominent changes were
decreased sense of smell, decreased taste, decreased enjoyment of eating, and
274
Tracheostomies
increased time required to eat meals. The investigators concluded that total laryngectomy produced significant changes in factors related to eating that could
affect nutritional intake and quality of life.
Terrell and others (2004) studied a sample of 570 patients with upper aerodigestive cancers. The presence of a feeding tube had the most negative impact on
quality of life, followed by medical comorbidities, the presence of a tracheostomy
tube, chemotherapy, and neck dissection. They found that those patients who
took the survey more than 1 year after their diagnosis had improved quality of
life in the domains of physical health and more favorable scores for pain, social
functioning, speech, and emotion. Furthermore, factors such as age, education
level, sex, race, and marital status were significant predictors of quality of life.
The authors postulated that the feeding tube and the process of tube feeding
were constant reminders of the patients’ disease in spite of the completion of
therapy and/or eradication of the cancer. They also suggested that patients were
less likely to enjoy the social aspects of eating due to their dysphagia. Limitations on activities such as going out to dinner may explain the decrements in
social functioning and emotion for patients with feeding tubes.
Hanna and colleagues (2004) studied the differences in quality of life for patients who underwent total laryngectomy with radiation therapy compared to
those who underwent chemo-radiation (chemotherapy and radiation therapy) for
laryngeal preservation. They found no significant differences in demographics and
overall quality of life scores; however, they found some differences in the subscales.
Patients in the surgery and radiation therapy group experienced greater difficulties in social functioning, sensory disturbances (e.g., taste and smell), coughing,
and greater use of pain medication compared to the chemo-radiation group. By
comparison, chemo-radiation patients reported problems with dry mouth.
Eadie and Doyle (2005) compared quality of life in two male patient populations in two different hospital systems; the patients studied underwent total
laryngectomy and used tracheoesophageal speech as their primary method of
communication. One group of patients had higher quality of life measures in the
domains of communication, eating, pain, and emotion. The authors reasoned
that the better scores were due to a higher level of education and membership
in a support group.
Su, Xian, Chai, Jiang, and Luo (2004) compared quality of life scores in patients who underwent a partial laryngectomy to those with a total laryngectomy
and found significantly higher composite quality of life scores in the first group.
They also found significant enhancements in physical function, laryngeal function, psychological state, and the ability to live independently in the partial
laryngectomy group.
Quality of life seems to be affected by both treatment courses and social factors. In general, there is a trend toward improved quality of life and improved
physical functioning with the following conditions: less invasive forms of laryngectomy, higher education, and the presence of a supportive environment.
Summary
There are three types of surgical laryngectomy procedures: the supraglottic laryngectomy, the hemilaryngectomy, and the total laryngectomy. The supraglottic
Chapter 9 Special Considerations for the Patient With a Laryngectomy
and hemilaryngectomy are procedures that retain parts of the larynx, and recovery is relatively rapid. The severity of swallowing difficulties varies based on
the extent of the surgical resection involved. In contrast, a total laryngectomy
involves the removal of the entire laryngeal apparatus, and the stump of the
trachea is pulled forward to form a stoma. Because there is no longer a connection between the trachea and the digestive tract, there is no risk of aspiration,
although these patients may experience problems with dysphagia.
The restoration of voice also depends on the type of surgery involved. Supraglottic and hemilaryngectomy patients can benefit from exercises to strengthen
the voice and swallowing. TEP can be used in patients with total laryngectomies
to create esophageal speech by vibrating tissue in the pharyngoesophagus.
In summary, the successful use of laryngectomy and/or tracheostomy tubes
and the management of respiratory function depend on a multidisciplinary approach and careful assessment by all team members. Generally, this team includes
the speech-language pathologist, the nurse, the respiratory therapist, the patient’s
physician, and others involved in assessment and treatment of the patient.
Key Points
Patients who undergo supraglottic and hemilaryngectomy may require ■
speech therapy, but they reestablish functional swallowing and retain the
ability to use their natural voice; however, the patient with a total laryngectomy must learn new methods of phonation.
■
Patients may have difficulty swallowing after laryngectomy, particularly
with an inflated cuff on the tracheostomy tube.
■
TEP, used only with total laryngectomy patients, creates a passageway
between the trachea and esophagus and uses airflow to vibrate the tissue
of the pharyngoesophagus.
■
The quality of life following total laryngectomy can be characterized by
changes in self-image perception as well as social factors and may encompass affective disorders.
275
References
American Cancer Society. (2009). All about laryngeal and hypopharyngeal cancer. Retrieved
July 4, 2009, from http://www.cancer.org/docroot/CRI/content/CRI_2_4_1X_What_are_the_
key_statistics_for_Laryngeal_and_Hypopharyngeal_cancer_23.asp?rnav=cri
Brook, I. (2009). A physician’s experience as a cancer of the neck patient. Surgical Oncology,
doi:10.1016/j.suronc.2009.05.005.
Cavalot, A. L., Ricci, E., Schindler, A., Roggero, N., Albera, R., Utari, C., et al. (2009). The impor-
tance of preoperative swallowing therapy in subtotal laryngectomies. Otolaryngology—
Head and Neck Surgery, 140(6), 822–825.
Deschler, D. G., Bunting, G. W., Lin, D. T., Emerick, K., & Rocco, J. (2009). Evaluation of voice
prosthesis placement at the time of primary tracheoesophageal puncture with total laryn-
gectomy. Laryngoscope, 119(7), 1353–1357.
Dettelbach, M. A., Gross, R. D., Mahlmann, J., & Eibling, D. E. (1995). Effect of the Passy-Muir
valve on aspiration in patients with tracheostomy. Head and Neck, 17(4), 297–302.
Diedrich, W. M., & Youngstrom, K. A. (1966). Alaryngeal speech. Springfield, IL: Thomas.
Dobbins, M., Gunson, J., Bale, S., Neary, M., Ingrams, D., & Brown, M. (2005). Improving pa-
tient care and quality of life after laryngectomy/glossectomy. British Journal of Nursing,
14(12), 634–640.
276
Tracheostomies
Eadie, T. L., & Doyle, P. C. (2005). Quality of life in male tracheoesophageal (TE) speakers. Jour-
nal of Rehabilitation Research and Development, 42(1), 115–124.
Hanna, E., Sherman, A., Cash, D., Adams, D., Vural, E., Fan, C. Y., et al. (2004). Quality of life for
patients following total laryngectomy vs. chemoradiation for laryngeal preservation. Arch
Otolaryngology—Head and Neck Surgery, 130(7), 875–879.
Hess, D. R. (2005a). Facilitating speech in the patient with a tracheostomy. Respiratory Care,
50(4), 519–525.
Hess, D. R. (2005b). Tracheostomy tubes and related appliances. Respiratory Care, 50(4),
497–510.
Iseli, T. A., Agar, N.J.M., Dunemann, C., & Lyons, B. M. (2007). Functional outcomes following
total laryngecopharyngectomy. ANZ Journal of Surgery, 77(11), 954–957.
Leder, S. B., Tarro, J. M., & Burrell, M. I. (1996). Effect of occlusion of a tracheotomy tube on
aspiration. Dysphagia, 11(4), 254–258.
Lennie, T. A., Christman, S. K., & Jadack, R. A. (2001). Educational needs and altered eating
habits following a total laryngectomy. Oncology Nursing Forum, 28(4), 667–674.
Logemann, J. A. (1998). Evaluation and treatment of swallowing disorders (2nd ed.). Austin,
TX: Pro-Ed.
Logemann, J. A., Gibbons, P., Rademaker, A. W., Pauloski, B. R., Kahrilas, P. J., Bacon, M., et al.
(1994). Mechanisms of recovery of swallow after supraglottic laryngectomy. Journal of
Speech and Hearing Research, 37(5), 965–974.
Logemann, J. A., Pauloski, B. R., & Colangelo, L. (1998). Light digital occlusion of the tracheostomy
tube: A pilot study of effects on aspiration and biomechanics of the swallow. Head and
Neck, 20(1), 52–57.
Maclean, J., Cotton, S., & Perry, S. (2009). Dysphagia following a total laryngectomy: The ef-
fect on quality of life, functioning, and psychological well-being. Dysphagia, doi 10.1007/
s00455–009–9209–0.
Martin, B.J.W., Logemann, J. A., Shaker, R., & Dodds, W. J. (1994). Coordination between respira-
tion and swallowing: Respiratory phase relationships and temporal integration. Journal of
Applied Physiology, 76(2), 714–723.
Muz, J., Hamlet, S., Mathog, R., & Farris, R. (1994). Scintigraphic assessment of aspiration in
head and neck cancer patients with tracheostomy. Head and Neck, 16(1), 17–20.
Muz, J., Mathog, R. H., Nelson, R., & Jones, L. A., Jr. (1989). Aspiration in patients with head and
neck cancer and tracheostomy. American Journal of Otolaryngology, 10(4), 282–286.
Rademaker, A. W., Logemann, J. A., Pauloski, B. R., Bowman, J. B., Lazarus, C. L., Sisson, G. A., et
al. (1993). Recovery of postoperative swallowing in patients undergoing partial laryngec-
tomy. Head and Neck, 15(4), 325–334.
Scheich, L. (2007). Looking at laryngeal cancer. Nursing2007, 37(5), 50–55.
Shin, T., Maeyama, T., Morikawa, I., & Umezaki, T. (1988). Laryngeal reflex mechanism during
deglutition—observation of subglottal pressure and afferent discharge. Otolaryngology—
Head and Neck Surgery, 99(5), 465–471.
Su, Z. Z., Xian, Z. X., Chai, L. P., Jiang, A. Y., & Luo, F. T. (2004). Investigation and analysis
of quality of life for patients after laryngectomy. Zhonghua Er Bi Yan Hou Ke Za Zhi,
39(6), 364–367.
Terrell, J. E., Ronis, D. L., Fowler, K. E., Bradford, C. R., Chepeha, D. B., Prince, M. E., et al.
(2004). Clinical predictors of quality of life in patients with head and neck cancer. Arch
Otolaryngology—Head and Neck Surgery, 130(4), 401–408.
Thompson-Henry, S., & Braddock, B. (1995). The modified Evan’s blue dye procedure fails
to detect aspiration in the tracheostomized patient: Five case reports. Dysphagia, 10(3),
172–174.
Tippett, D. C., & Siebens, A. A. (1996). Reconsidering the value of the modified Evan’s blue dye
test: A comment on Thompson-Henry and Braddock. Dysphagia, 11(1), 78–79.
van den Brink, J. L., de Boer, M. F., Pruyn, J. F., Hop, W. C., Verwoerd, C. D., & Moorman, P. W.
(2006). Quality of life during the first 3 months following discharge after surgery for head
and neck cancer: Prospective evaluation. Journal of Otolaryngology, 35(6), 395–403.
Woodard, T. D., Oplatek, A., & Petruzzelli, G. J. (2007). Life after total laryngectomy: A measure
of long-term survival, function, and quality of life. Archives of Otolaryngology—Head and
Neck Surgery, 133, 526–532.
Complications
and
Emergency
Procedures
Michiel J. Bové and
Linda L. Morris
10
Complications related to tracheostomies can be classified into immediate, early,
and late (Table 10.1). Immediate complications occur during or immediately
after the tracheotomy procedure and include hemorrhage and pneumothorax. Early complications often happen within the first postoperative week and
include pneumonia, stomal infection, pneumomediastinum, pneumopericardium, obstruction, subcutaneous emphysema, and inadvertent decannulation,
which can result in the creation of a false passage or complete loss of the airway. Later complications include the development of mucus plugs, pneumonia
or stoma infection, tracheoinnominate hemorrhage, tracheoinnominate fistula,
tracheoesophageal fistula, tracheocutaneous fistula, stomal stenosis, stomal
granulation tissue, tracheomalacia, tracheal stenosis, mediastinitis, mediastinal
fistula, and tracheocele (DeLeyn et al., 2007; Heffner, 2005; Henderson, Harrington, Izenberg, Dyess, & Silver, 1995; Neema & Manikandan, 2005; Singh,
Fung, & Cole, 2007; St. John & Malen, 2004; Watanakunakorn, 1989; Wright & Van
Dahm, 2003; Yaremchuk, 2003). It should be noted that there may be an overlap
in the time frame in which early, intermediate, and late complications present.
277
278
Tracheostomies
Complications of Tracheostomy
10.1
Immediate Early Late
Hemorrhage ■
Pneumothorax ■
Intra-operative ■
fire
Air embolism
■
The rate of complications has been shown to be significantly elevated in
specific patient populations, such as in the pediatric, post–head trauma, obese,
burn, or seriously debilitated groups (Goldenberg et al., 2000). Published rates
of tracheotomy-related complications vary greatly (5%–65%) and depend on
study design, length of follow-up, and definition of complications (Francois
et al., 2003; Waldron, Padgham, & Hurley, 1990).
The first study to prospectively quantify complications from tracheostomy
was by Dane and King (1975), who observed 40 patients after tracheostomies
were placed. Their study did not involve intraoperative complications. Five percent of patients (2 patients) had significant bleeding from the wound. Another
2 patients had bleeding from stomal granulation tissue. One patient bled upon
decannulation, and another patient bled endotracheally as a result of granulation tissue extending from the stoma to the tracheal lumen. These 2 patients
later developed stomal stenosis. One patient developed tube obstruction, 2
developed bilateral tension pneumothorax during the first tube change, and
4 developed severe necrotizing pneumonia. The investigators followed up all
patients with a bronchoscopic exam. Fifteen patients died while still receiving
mechanical ventilation, all of whom had severe tracheitis. All 25 patients who
were successfully decannulated survived. Of these survivors, 60% had “minimal
deformity” of the trachea, 32% had moderate deformity, and 8% had symptomatic tracheal stenosis.
Pneumonia ■
Stoma infection ■
Pneumomediastinum ■
Pneumopericardium ■
Obstruction ■
Subcutaneous emphysema ■
(crepitus)
Inadvertent decannulation,
■
loss of airway
False passage
■
Mucus plugs ■
Mucus plugs ■
Pneumonia ■
Stoma infection ■
Tracheitis ■
Tracheomalacia ■
Tracheoinnominate ■
hemorrhage
Tracheoinnominate fistula
■
Tracheoesophageal fistula ■
Tracheocutaneous fistula ■
(persistent stoma)
Stomal stenosis
■
Stomal granulation tissue ■
Tracheal stenosis ■
Mediastinitis ■
Mediastinal fistula ■
Tracheocele ■
Chapter 10 Complications and Emergency Procedures
Francois and others (2003) reported a 2-year prospective trial of the complications following tracheostomy performed in the ICU. Out of their group of
118 patients, 86 patients underwent conventional subthyroid tracheotomy, while
32 underwent surgical cricothyroidotomy. Overall, complications occurred in
36 patients (30%), with 4 patients developing two complications. The incidence
of complications was similar between conventional tracheotomy and cricothyroidotomy. There were 6 patients with serious complications (5%), and minor
complications occurred in 30 patients (25%). The two most common complications during the immediate period were pneumothorax and minor bleeding.
One minor episode of bleeding occurred in a patient with a cricothyroidotomy.
In the patients with standard tracheotomies, there was one case of pneumothorax, four episodes of minor bleeding, and one episode of difficult cannulation.
For the early postoperative period, the researchers found 25 early complications, of which 5 were considered major and 20 were considered minor. Major
complications included subglottic stenosis, accidental decannulation causing acute respiratory failure, tracheal fistula, and chronic vocal cord dysfunction. Minor complications included accidental decannulation, laryngeal edema,
stomal granulations, and temporary vocal cord dysfunction. There were 8 minor
complications in the late postoperative phase. These included tracheal granulations, persistent wound, and scar formation. No deaths were attributable to
surgical tracheostomy in this study.
This study had an unusually high percentage of cricothyroidotomies (27%),
and it was reported that this procedure was done mainly in older patients.
Overall mortality rates tended to be higher in these patients, although their
APACHE II scores were not significantly different from those undergoing the
standard tracheotomy procedure. At the end of the 6-month follow-up period,
32 patients (35%) still had a tracheostomy in place, with a similar proportion in
both groups.
A retrospective 10-year study in Israel reviewed 1,130 tracheostomies performed in one hospital from January 1987 through December 1996. None were
percutaneous tracheostomies. Indications included prolonged mechanical ventilation, adjunct to head or neck or chest surgery in which prolonged mechanical ventilation was anticipated; extensive maxillofacial trauma; or upper airway
obstruction. Only three tracheotomies were performed as emergencies; however, none of these three developed any postoperative complications. In this
study, major complications occurred in 49 cases (4.3%) and included subglottic
or tracheal stenosis (21), hemorrhage (9), severe postoperative hemorrhage (7),
massive hemorrhage due to tracheoinnominate fistula (2), tracheocutaneous
fistula (also called persistent fistula or persistent stoma; 6), severe infection (5),
decannulation or tube obstruction (4), subcutaneous emphysema or pneumomediastinum (3), and tracheoesophageal fistula (1; Goldenberg et al., 2000).
In this Israeli study, 8 deaths were directly related to the tracheostomy. Immediate or intraoperative complications included intraoperative hemorrhage,
air embolism, apnea, damage due to adjacent structures, and intraoperative fire.
Early postoperative complications included postoperative hemorrhage, tube
dis lodgement or obstruction, subcutaneous emphysema, pneumothorax, pneumomediastinum, and infection. Late postoperative complications included hemorrhage due to granulation or tracheoinnominate artery fistula, tracheal stenosis,
tracheocutaneous fistula, and tracheoesophageal fistula.
279
280
Tracheostomies
Let us consider each of these complications and the corresponding methods to prevent and/or treat them.
Intraoperative Complications
Intraoperative complications include hemorrhage (usually from the anterior
jugular veins, the thyroid isthmus, or vascular variants such as the thyroid ima
artery), the creation of a false passage, electrocautery-induced airway fire, and
surgical injury to adjacent structures.
The inability to ventilate immediately after placement of the tracheostomy
tube suggests the tube has entered a false passage, usually anterior to the tracheal wall or, rarely, posterior to the trachea into the esophagus. Passing a soft
suction catheter into the newly placed tracheostomy tube helps recognize false
passage cannulation. Also, all retractors and cricoid hooks should be kept in
place until successful cannulation is confirmed to allow for an immediate reattempt at cannulation should difficulties arise.
Hemorrhage
Hemorrhage can occur as a result of laceration of major blood vessels in the
neck during the procedure. Tracheotomies that are placed lower than usual—
below the fourth tracheal ring—have a higher incidence of damage to the innominate artery. Minor bleeding is far more common and is estimated to occur
in up to 40% of cases.
Intraoperative hemorrhage most commonly results from injury to the anterior jugular veins early in the dissection, especially during emergent procedures, or to the thyroid isthmus later in the dissection during attempts to
mobilize it from the anterior tracheal wall or during attempts to divide and
ligate it. High-riding innominate arteries present a significant risk of severe
hemorrhage when the dissection is carried inferiorly.
Prevention.
precede instrumentation to rule out prominent pulses in this region. Bleeding
can be minimized by carefully identifying and staying in the midline, cautiously
dissecting layer by layer, and maintaining a well-lit operative field and retraction of the soft tissues. Patient position and neck extension should be optimized.
If local anesthesia is used, the procedure should not be started until the vasoconstrictive agent in the local anesthetic has taken effect. Structures such as
the anterior jugular vein and the thyroid isthmus should be carefully identified in order to avoid inadvertent trauma and bleeding. An aberrant innominate
artery may traverse anterior to the trachea in the field of dissection, making it
vulnerable to laceration and potentially life-threatening hemorrhage (Grant,
Dempsey, Harrison, & Jones, 2006).
Management.
should be carefully inspected for any bleeding sources. Increases in blood
pressure—either as a result of coughing caused by tube insertion or recovery
of normal blood pressure after relative hypotension during anesthesia—can
Finger palpation in the substernal region should, therefore, always
After the insertion of the tracheostomy tube, the surgical wound
Chapter 10 Complications and Emergency Procedures
disguise apparent bleeding sources during the procedure itself. If necessary,
the tracheostomy tube should be removed to allow for better inspection of the
surgical field for the source of bleeding. Superficial sources of bleeding can
be addressed by mobilizing the flange on the tracheostomy tube while leaving
the cannula in the trachea. Merely packing the wound to obtain hemostasis carries the risk of causing subcutaneous emphysema in the postoperative period.
Pneumothorax
Pneumothorax is usually the result of a traumatic puncture of the pleura. It
is more common in pediatric tracheotomy, where the pulmonary apices are
relatively elevated and therefore more vulnerable within the lower neck. In
adults, this complication usually involves the rupture of a pulmonary bleb in a
patient struggling to breathe during an awake, emergency tracheotomy. Pneumothorax can also result from damage to the posterior tracheal wall during the
tracheal incision or during insertion of the tracheotomy tube. More commonly,
the tracheostomy tube can be inadvertently inserted between the anterior tracheal wall and the anterior mediastinum. The insertion of the tube into this
false passage results in worsening respiratory status after tube insertion and
can be confirmed by the inability to pass a flexible suction catheter into the
tracheal lumen. While some suggest obtaining postoperative radiographs on all
tracheotomy patients, published data suggests this is unnecessary in routine,
uncomplicated, elective cases (Smith, Grillone, & Fuleihan, 1999). These authors suggest restricting chest radiographs to emergency procedures, difficult
procedures, or patients exhibiting signs or symptoms of pneumothorax.
281
Prevention.
performing a tracheotomy and by restricting the dissection to the midline. The
tracheostomy tube should be inserted under direct visualization and good illumination. The ability to suction tracheal contents via a flexible suction catheter
should be immediately confirmed after placement of the tracheostomy tube.
End-tidal CO
Insufflation through the tracheostomy tube should be delayed until these confirmatory measures can be performed to avoid insufflating the mediastinum.
If there remains any doubt about the placement of the tube, retractors can be
placed within the stoma to maintain its patency while the tracheostomy tube is
removed and replaced under direct visualization.
Management.
serting a chest tube.
Pneumothorax is best prevented by establishing an airway before
should be confirmed by the anesthesiologist as soon as possible.
2
When pneumothorax is symptomatic, it should be treated by in-
Intraoperative Fire
Although flammable anesthetic agents are no longer used, fire in the operating
room continues to be a concern, particularly with tracheotomy. Although rare,
airway fires are potentially devastating occurrences. There are approximately
100 intraoperative fires annually in the United States; 10 to 20 are deemed serious, and 2 directly result in death. Seventy percent of these fires are related to
the use of electrocautery near a high concentration of oxygen (Daane & Toth,