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1.  Ten-year experiences with Tracheostomy at a University teaching hospital in Northwestern Tanzania: A retrospective review of 214 cases 
Background
Tracheostomy remains a very important life saving surgical procedure worldwide and particularly in our environment where patients present late in upper airway obstruction. Little work has been done on this subject in our environment and therefore it was necessary to conduct this study to describe our own experiences with tracheostomy, outlining the common indications and outcome of tracheostomized patients in our setting and compare our results with those from other centers in the world.
Methods
This was a 10-year retrospective study which was conducted at Bugando Medical Centre from January 2001 to December 2010. Data were retrieved from patients' files kept in the Medical record department and analyzed using SPSS computer software version 15.0. Ethical approval to conduct the study was obtained from relevant authority before the commencement of the study.
Results
A total of 214 patients were studied. The male to female ratio was 3.1: 1. The majority of patients were in the 3rd decade of life. The most common indication for tracheostomy was upper airway obstruction secondary to traumatic causes in 55.1% of patients, followed by upper airway obstruction due to neoplastic causes in 39.3% of cases. The majority of tracheostomies (80.4%) were performed as an emergency. Transverse skin crease incision was employed in all the cases. Post-tracheostomy complication rate was 21.5%. Complication rate was significantly higher in emergency tracheostomy than in electives (P < 0.001). The duration of temporary tracheostomy ranged from 8 days to 46 months, with a median duration of 4 months. Tracheostomy decannulation was successively performed in 72.4% of patients who survived. Mortality rate was 13.6%. The mortality was due to their underlying illnesses, none had tracheostomy-related mortality.
Conclusion
Upper airway obstruction secondary to trauma and laryngeal tumors still remains the most common indication for tracheostomy in our centre and tracheostomy is still a life saving procedure in the surgical management of airway despite complications which are seen more commonly in paediatric patients. Most of tracheostomy related complications can be avoided by meticulous attention to the details of the technique and postoperative tracheostomy care by skilled and trained staff.
doi:10.1186/1749-7922-6-38
PMCID: PMC3221617  PMID: 22074571
Tracheostomy; Indications; Outcome; Tanzania
2.  Early tracheostomy in closed head injuries: experience at a tertiary center in a developing country – a prospective study 
Background
An important factor contributing to the high mortality in patients with severe head trauma is cerebral hypoxia. The mechanical ventilation helps both by reduction in the intracranial pressure and hypoxia. Ventilatory support is also required in these patients because of patient's inability to protect the airway, persistence of excessive secretions, and inadequacy of spontaneous ventilation. Prolonged endotracheal intubation is however associated with trauma to the larynx, trachea, and patient discomfort in addition to requirement of sedatives. Tracheostomy has been found to play an integral role in the airway management of such patients, but its timing remains subject to considerable practice variation. In a developing country like India where the intensive care facilities are scarce and rarely available, these critical patients have to be managed in high dependency cubicles in the ward, often with inadequately trained nursing staff and equipment to monitor them. An early tracheostomy in the selected group of patients based on Glasgow Coma Score(GCS) may prove to be life saving.Against this background a prospective study was contemplated to assess the role of early tracheostomy in patients with isolated closed head injury.
Methods
The series consisted of a cohort of 50 patients admitted to the surgical emergency with isolated closed head injury, that were not considered for surgery by the neuro-surgeon or shifted to ICU, but had GCS score of less than 8 and SAPS II score of more than 50. First 50 case records from January 2001 that fulfilled the criteria constituted the control group. The patients were managed as per ATLS protocol and intubated if required at any time before decision to perform tracheostomy was taken. These patients were serially assessed for GCS (worst score of the day as calculated by senior surgical resident) and SAPS scores till day 15 to chart any changes in their status of head injuries and predictive mortality. Those patients who continued to have a GCS score of <8 and SAPS score of >50 for more than 24 hours (to rule out concussion or recovery) underwent tracheostomy.
All these patients were finally assessed for mortality rate and hospital stay, the statistical analysis was carried out using SPSS10 version.
The final outcome (in terms of mortality) was analyzed utilizing chi-square test and p value <0.05 was considered significant.
Results
At admission both tracheostomy and non-tracheostomy groups were matched with respect to GCS score and SAPS score.
The average day of tracheostomy was 2.18 ± 1.0038 days.
The GCS scores on days 1, 2, 3, 4, 5, 10 between tracheostomy and non-tracheostomized group were comparable. However the difference in the GCS scores was statistically significant on day 15 being higher in the tracheostomy group.Thus early tracheostomy was observed to improve the mortality rate significantly in patients with isolated closed head injury
Conclusion
It may be concluded that early tracheostomy is beneficial in patients with isolated closed head injury which is severe enough to affect systemic physiological parameters, in terms of decreased mortality and intubation associated complications in centers where ICU care is not readily available. Also, in a selected group of patients, early tracheostomy may do away with the need for prolonged mechanical ventilation.
doi:10.1186/1471-227X-5-8
PMCID: PMC1266359  PMID: 16236181
3.  AB 63. Management of complex benign post-tracheostomy tracheal stenosis with bronchoscopic insertion of silicon tracheal stents, in patients with failed or contraindicated surgical reconstruction of trachea 
Journal of Thoracic Disease  2012;4(Suppl 1):AB63.
Background
Tracheal stenosis is a potentially life-threatening condition. Tracheostomy and endotracheal intubation remain the commonest causes of benign stenosis, despite improvements in design and management of tubes. Post-tracheostomy stenosis is more frequently encountered due to earlier performance of tracheostomy in intensive care units, while the incidence of post-intubation stenosis has decreased with application of high-volume low-pressure cuffs. We present tracheal stenting in complex post-tracheostomy stenoses.
Patients and methods
We inserted tracheal silicone stents (Dumon) under general anaesthesia through rigid bronchoscopy in two patients with benign post-tracheostomy stenoses: a 39-year old woman treated for acute respiratory failure (dyspnoea, hemoptysis, alveolar bleeding, attributed to seronegative lung vasculitis) who initially underwent surgical resection and end-to-end anastomosis, but developed restenosis (anastomotic granulation/scarring), and suffered continuous relapses after multiple bronchoscopic interventions, underwent silicone stenting (length 4.5 cm, diameter 12 mm). A 20-year old man treated for severe head trauma after a car accident developed a long tracheal stricture involving the subglottic larynx (lower posterior part), having inflamed tracheostomy site tissues (positive for methicillin resistant staphylococcus aureus), underwent silicone stenting (length 7 cm, diameter 14 mm).
Results
The airway was immediately re-establish, without complications (tracheal rupture/pneumomediastinum, bleeding). At 15 and 10 months follow-up (respectively) there was no stent migration, luminal patency was maintained without: adjacent structure erosion, secretion adherence inside the stents, granulation at the ends. Tracheostomy tissue inflammation was resolved (2nd patient), new infection was not noted. The patients maintain good respiratory function and will be evaluated for scheduled stent removal.
Conclusions
In symptomatic benign tracheal stenosis the gold standard is surgical reconstruction (often after interventional bronchoscopy). Stenting is reserved for symptomatic tracheal narrowing deemed inoperable due to local or general reasons: inflammation, long strictures, previous failed operation, poor respiratory, cardiac or neurological status. When stenting is decided, silicone stent insertion is considered treatment of choice in the presence of inflammation and/or when removal is desirable. Silicone stents are removable, resistant to microbial colonization and are associated with minimal granulation. In benign post-tracheostomy stenosis silicone stenting was safe and effective in re-stenosis after surgery and multiple bronchoscopic interventions, and in long stenosis in the presence on inflammation and poor neurological status.
doi:10.3978/j.issn.2072-1439.2012.s063
PMCID: PMC3537415
4.  Management of complex benign post-tracheostomy tracheal stenosis with bronchoscopic insertion of silicon tracheal stents, in patients with failed or contraindicated surgical reconstruction of trachea 
Journal of Thoracic Disease  2012;4(Suppl 1):32-40.
Tracheal stenosis is a potentially life-threatening condition. Tracheostomy and endotracheal intubation remain the commonest causes of benign stenosis, despite improvements in design and management of tubes. Post-tracheostomy stenosis is more frequently encountered due to earlier performance of tracheostomy in the intensive care units, while the incidence of post-intubation stenosis has decreased with application of high-volume, low-pressure cuffs. In symptomatic benign tracheal stenosis the gold standard is surgical reconstruction (often after interventional bronchoscopy). Stenting is reserved for symptomatic tracheal narrowing deemed inoperable, due to local or general reasons: long strictures, inflammation, poor respiratory, cardiac or neurological status. When stenting is decided, silicone stent insertion is considered the treatment of choice in the presence of inflammation and/or when removal is desirable. We inserted tracheal silicone stents (Dumon) under general anaesthesia through rigid bronchoscopy in two patients with benign post-tracheostomy stenosis: a 39-year old woman with failed initial operation, and continuous relapses with proliferation after multiple bronchscopic interventions, and a 20-year old man in a poor neurological status, with a long tracheal stricture involving the subglottic larynx (lower posterior part), and inflamed tracheostomy site tissues (positive for methicillin resistant staphylococcus aureus). The airway was immediately re-establish, without complications. At 15- and 10-month follow-up (respectively) there was no stent migration, luminal patency was maintained without: adjacent structure erosion, secretion adherence inside the stents, granulation at the ends. Tracheostomy tissue inflammation was resolved (2nd patient), new infection was not noted. The patients maintain good respiratory function and will be evaluated for scheduled stent removal. Silicone stents are removable, resistant to microbial colonization and are associated with minimal granulation. In benign post-tracheostomy stenosis silicone stenting appeared safe and effective in re-stenosis after surgery and multiple bronchoscopic interventions, and in long stenosis, involving the lower posterior subglottic larynx in the presence on inflammation and poor neurological status.
doi:10.3978/j.issn.2072-1439.2012.s002
PMCID: PMC3537388  PMID: 23304439
Airway obstruction/therapy; tracheal stenosis/therapy; stents; airway stenting; benign tracheal stenosis
5.  Tracheostomy timing and the duration of weaning in patients with acute respiratory failure 
Critical Care  2004;8(4):R261-R267.
Introduction
The effect of various airway management strategies, such as the timing of tracheostomy, on liberation from mechanical ventilation (MV) is uncertain. We tested the hypothesis that tracheostomy, when performed prior to active weaning, does not influence the duration of weaning or of MV in comparison with a more selective use of tracheostomy.
Patients and methods
In this observational prospective cohort study, surgical patients requiring ≥ 72 hours of MV were followed prospectively. Patients undergoing tracheostomy prior to any active weaning attempts (early tracheostomy [ET]) were compared with patients in whom initial weaning attempts were made with the endotracheal tube in place (selective tracheostomy [ST]).
Results
We compared the duration of weaning, the total duration of MV and the frequency of fatigue and pneumonia. Seventy-four patients met inclusion criteria. Twenty-one patients in the ET group were compared with 53 patients in the ST group (47% of whom ultimately underwent tracheostomy). The median duration of weaning was shorter (3 days versus 6 days, P = 0.05) in patients in the ET group than in the ST group, but the duration of MV was not (median [interquartile range], 11 days [9–26 days] in the ET group versus 13 days [8–21 days] in the ST group). The frequencies of fatigue and pneumonia were lower in the ET group patients.
Discussion
Determining the ideal timing of tracheostomy in critically ill patients has been difficult and often subjective. To standardize this process, it is important to identify objective criteria to identify patients most likely to benefit from the procedure. Our data suggest that in surgical patients with resolving respiratory failure, a patient who meets typical criteria for a trial of spontaneous breathing but is not successfully extubated within 24 hours may benefit from a tracheostomy. Our data provide a framework for the conduct of a clinical trial in which tracheostomy timing can be assessed for its impact on the duration of weaning.
Conclusion
Tracheostomy prior to active weaning may hasten liberation from ventilation and reduce complications. However, this does not reduce the overall duration of MV.
doi:10.1186/cc2885
PMCID: PMC522847  PMID: 15312227
respiratory failure; tracheostomy; weaning
6.  Fractured metallic tracheostomy tube in a child: a case report and review of the literature 
Introduction
Tracheostomy is a common airway procedure for life support. The fracture of the tracheostomy tube is a rare complication. We report a case of a 14-year-old boy whose fractured stainless steel tracheostomy tube dislodged into the tracheobronchial tree. We include a literature review and proposed recommendations for tracheostomy care.
Case presentation
A 14-year-old Thai boy who had a stainless steel tracheostomy tube presented with a complaint of intermittent cough for 2 months. During tracheostomy tube cleaning, his parents found that the inner tube was missing. A chest X-ray revealed a metallic density foreign body in his right main bronchus. He underwent bronchoscopic removal of the inner tracheostomy tube and was discharged without further complications.
Conclusion
A fractured tracheostomy tube is a rare complication. Appropriate cleaning and scheduled replacement of the tracheostomy tube may prevent this complication.
doi:10.1186/1752-1947-4-234
PMCID: PMC2918633  PMID: 20678211
7.  Bilateral pneumothoraces and pulmonary oedema following tracheostomy induced by acute tracheal obstruction 
BMJ Case Reports  2012;2012:bcr2012006557.
We describe the presentation of bilateral pneumothoraces with pulmonary oedema following an elective tracheostomy. A 69-year-old man underwent panendoscopy following primary chemoradiotherapy for locally invasive vocal cord carcinoma. A tracheostomy was performed for upper airway oedema and necrosis. Postoperatively, acute airway obstruction with profound desaturation developed. Tracheostomy tube suctioning dislodged an airway clot with clinical improvement and restoration of bilateral breath sounds. A chest X-ray subsequently demonstrated bilateral pneumothoraces with marked pulmonary oedema. Management, including chest drain insertion, resulted in stabilisation and subsequent full recovery. This case highlights the potential for more than one cause of life-threatening complication following tracheostomy. The importance of considering multiple pathologies in the setting of severe hypoxia and to institute prompt management is emphasised.
doi:10.1136/bcr-2012-006557
PMCID: PMC4544288  PMID: 22879001
8.  A comparative study of the complications of surgical tracheostomy in morbidly obese critically ill patients 
Critical Care  2007;11(1):R3.
Introduction
There is little objective comparative information about the postoperative complications of tracheostomy in morbidly obese patients. The aim of this study was to determine the incidence and severity of complications associated with open tracheostomy in critically ill morbidly obese patients during hospitalization.
Methods
During a six year period, all consecutive morbidly obese patients (body mass index [BMI] of greater than or equal to 40 kg/m2) who underwent an elective open tracheostomy were compared to a control group (BMI of less than 40 kg/m2) of the same institution. Variables examined included age, gender, BMI, Charlson index, and reasons for tracheostomy. All postoperative tracheotomy-related complications that occurred during hospitalization, including death, were recorded.
Results
A tracheostomy was performed in 89 morbidly obese patients out of 427 critically ill patients. A total of 27 complications were recorded in 22 morbidly obese patients (25%) compared to 65 complications in 49 patients (14%) of the control group (p = 0.03). The majority of these complications were minor in origin. Overall, nine serious events were responsible for two deaths in the morbidly obese compared to seven cases and two deaths in the control group (p = 0.001). Life-threatening complications were attributed to tube obstruction and malpositioning of the tracheostomy after being dislodged. In multivariate analysis, morbid obesity (odds ratio 4.4, 95% confidence interval 2.1 to 11.7) was independently associated with increased risk of tracheostomy-related complications.
Conclusion
In the present series, morbid obesity is associated with increased frequency and life-threatening complications from conventional tracheostomy. Special techniques and operative policies must be applied to overcome loss of airway control.
doi:10.1186/cc5147
PMCID: PMC2151852  PMID: 17222333
9.  Tracheo-brachiocephalic artery fistula after tracheostomy associated with thoracic deformity: a case report 
Introduction
Tracheo-brachiocephalic artery fistulae are critical long-term complications after tracheostomy, reported in 0.6% of patients within three to four weeks after the procedure. In 30% to 50% of cases there is some bleeding prior to onset. Since the onset involves sudden massive bleeding, the prognosis is poor; the reported survival rate is 10% to 30%. The direct cause of bleeding is the formation of a fistula with the trachea subsequent to arterial injury by the tracheostomy tube. Endo-tracheal factors are movement of the tracheostomy tube due to body movement and seizures, pressure exerted by the cuff of the tracheostomy tube, tracheostomy at lower levels, and the fragility of blood vessels and the trachea due to steroid or radiation therapy, and malnutrition. Extra-tracheal factors include prior surgery and deformity and shifting of the trachea and major blood vessels due to congenital kyphoscoliosis or thoracic deformity. There has been no report of the usefulness of contrast-enhanced computed tomography studies to identify the anatomical relationship between the trachea and brachiocephalic artery.
Case presentation
A 27-year-old Mongolian woman with congenital muscular dystrophy who underwent tracheal intubation for airway management due to pneumonia and granulation development developed a tracheo-brachiocephalic artery fistula during the placement of the tracheostomy tube. It was diagnosed by contrast-enhanced chest computed tomography and repaired. About a month later she developed massive airway bleeding during replacement of the tracheostomy tube. Temporary hemostasis was achieved by compression via cuff inflation. A contrast-enhanced chest computed tomography scan demonstrated a narrowed brachiocephalic artery running along and ventral to the tube and a tracheo-brachiocephalic artery fistula was suspected. She underwent brachiocephalic artery resection and aorta, right common carotid artery, and subclavian artery bypass surgery with an innominate vein, tracheoplasty, and partial sternectomy. We noted marked thoracic deformity; the brachiocephalic artery was compressed by the trachea and chest wall resulting in localized wall necrosis and the development of a tracheo-brachiocephalic artery fistula, a fatal complication whose prevention is important.
Conclusions
We suggest that before tracheostomy, the anatomic relationship between the trachea and brachiocephalic artery must be confirmed by contrast-enhanced chest computed tomography scan.
doi:10.1186/1752-1947-5-595
PMCID: PMC3275530  PMID: 22204458
10.  Is tracheostomy suitable for securing airway after facial firearm injuries? 
BACKGROUND:
Head and neck region have many vital structures, and facial firearm injuries (FFIs) more likely lead to life-threatening situations than other body injuies. These injuries have high potential of airway compromise associated with significant morbidity and mortality.
METHODS:
We describe an 11-year-old boy who had received tracheostomy after a FFI complicated with pneumothorax and subcutaneous emphysema 8 hours after the procedure. The patient was treated at the Department of Emergency and Critical Care, Gazi University School of Medicine, Turkey.
RESULTS:
The patient was discharged without any complications from the Critical Care Unit after treatment for five days.
CONCLUSIONS:
Airway management is of utmost importance in resuscitation of FFI, but it is always difficult to secure via the orotracheal route due to the deformed facial structures. Tracheostomy is an option for airway management in FFI affecting head and neck region. However, tracheostomy may be associated with life-threatening complications, which should be closely monitored with early intervention.
doi:10.5847/wjem.j.1920-8642.2011.04.012
PMCID: PMC4129730  PMID: 25215029
Airway obstruction; Emphysema; Firearms; Pediatrics; Tracheostomy
11.  Tracheo-Innominate Artery Fistula after Stroke 
Annals of Rehabilitation Medicine  2012;36(6):876-879.
Tracheo-innominate artery fistula (TIAF) is rare, yet the most fatal complication after tracheostomy. In the absence of immediate diagnosis and surgical management, the mortality rate is very high, because the complication can lead to sudden massive tracheal hemorrhage. Tracheal obstruction and hypovolemic shock are the major life threatening conditions. The 46-year-old woman received tracheostomy tube insertion after stroke. Three months later, there was occurrence of active bleeding at the site of tracheostomy in the patient, who participated in comprehensive rehabilitation program. Immediately, the patient received an endotracheal tube insertion into the tracheostomy site and thus massive bleeding was controlled. The patient was transferred to the intensive care unit, where her breathing was maintained by mechanical ventilation. Based on computed tomography and laryngoscopy, no remarkable findings about TIAF were detected. Nevertheless, transfemoral angiography findings revealed that innominate artery made small luminal outpouching to trachea at the carotid artery and at the subclavian artery bifurcation level, based on which a diagnosis of TIAF was made. She had an operation for TIAF, tracheoplasty with bypass graft. Subsequently, she was discharged after 15 weeks. In the present report, we describe a case of TIAF, which can occur in the patients with tracheostomy tube during rehabilitation.
doi:10.5535/arm.2012.36.6.876
PMCID: PMC3546194  PMID: 23342324
Trachea; Innominate artery; Fistula
12.  Submental Intubation: An Alternative and Cost-Effective Technique for Complex Maxillofacial Surgeries 
Introduction
Management of airway is a significant issue especially in cases of complex maxillofacial trauma like panfacial fractures or concomitant nasoethmoidal injuries, where the nasotracheal intubation is contraindicated or possess a significant problem. In these cases the only other alternative is tracheostomy. Submental intubation is an alternative to tracheostomy and it can be easily performed with little or lesser post-operative complications. This method involves lesser expenses as it does away with longer post-operative stay in the hospital as required by tracheostomy patients.
Technique
The patient is orally intubated with a reinforced armoured tube with a detachable plastic gas connector. An incision is made in the submental area of the patient and a tunnel is prepared from this region to the floor of the mouth through which the proximal end of the tube is diverted. Thus the occlusion of the patient can be checked intraoperatively. After completion of the surgery the proximal end in reintroduced onto the oral cavity and the patient is extubated orally.
Discussion
Originally proposed by Altemir in 1986, this method cannot be used in all cases as it is not without limitations. In spite of these, submental intubation can be a useful alternative to tracheostomy, especially in regions where cost cutting is a major factor in health infrastructure.
Conclusion
Maxillofacial surgeons addressing major facial trauma surgery may have this procedure in mind before opting for tracheostomy. It avoids a lot of complications associated with tracheostomy.
doi:10.1007/s12663-010-0084-x
PMCID: PMC3177441  PMID: 22190802
Submental intubation; Maxillofacial surgery; Tracheostomy; Nasoethmoidal injury
13.  Percutaneous Dilatational Tracheostomy and Surgically Created Thracheostomy in ICU Patients 
Introduction: Following advances of Intensive Care medicine and widespread administration of mechanical ventilation, tracheostomy has become one of the indispensable surgical procedures. During this research we tried to assess and compare two main strategies for doing tracheostomy: Surgically Created Tracheostomy (SCT) and Percutaneous Dilatational Tracheostomy (PDT).
Methods: In a randomized clinical trial, 60 cases of patients who were admitted in Intensive Care Unit (ICU) and needed tracheostomy during their stay were enrolled. Patients were randomly divided into two groups. SCT technique was considered for the first group and PDT for the second one. Demographic characteristics, associated and underlying diseases, type and duration of procedure, duration of receiving mechanical ventilation and ICU stay, expenses and complications of tracheostomy including bleeding, subcutaneous emphysema, pneumothorax, stomal infection and airway loss were all recorded during study and compared between both groups.
Results: There were significant differences between two groups of patients in terms of duration of receiving mechanical ventilation (P=0.04), duration of tracheostomy procedure (P=0.001) and procedure expenses (P=0.04). There was no significant difference between two groups in terms of age and gender of patients, duration of ICU stay and complications of tracheostomy including copious bleeding, stomal infection, subcutaneous emphysema and airway.
Conclusion: According to the results of our study and similar researches, it can be concluded that PDT can be considered as the preferred procedure in cautiously selected patients during their ICU stay.
doi:10.5681/jcvtr.2014.008
PMCID: PMC3992731  PMID: 24753831
Percutaneous Dilatation Tracheostomy (PDT); Surgically Created Tracheostomy (SCT); Complications; Intensive Care Unit
14.  Open Tracheostomy after Aborted Percutaneous Approach due to Tracheoscopy Revealing Occult Tracheal Wall Ulcer 
Case Reports in Anesthesiology  2013;2013:190818.
Tracheostomy is a common procedure for intensive care patients requiring prolonged mechanical ventilation. In this case report, we describe a 78-year-old female patient admitted for an aneurysm of the cerebral anterior communicating artery. Following immediate endovascular coiling, she remained ventilated and was transferred to the neurological intensive care unit. On postoperative day ten, a percutaneous tracheostomy (PCT) was requested; however, a large ulcer or possible tracheoesophageal fistula was identified on the posterior tracheal wall following bronchoscopic assessment of the trachea. Therefore, the requested PCT procedure was aborted. An open tracheostomy in the operating room was completed; however, due to the position and depth of the ulcer, a reinforced endotracheal tube (ETT) was placed via the tracheostomy. Four days later, the reinforced ETT was replaced with a Shiley distal extended tracheostomy tube to bypass the ulceration. Careful inspection and evaluation of the tracheostomy site before PCT prevented a potentially life-threatening issue in our patient.
doi:10.1155/2013/190818
PMCID: PMC3730139  PMID: 23956883
15.  Anaesthesia and airway management in mucopolysaccharidosis 
This paper provides a detailed overview and discussion of anaesthesia in patients with mucopolysaccharidosis (MPS), the evaluation of risk factors in these patients and their anaesthetic management, including emergency airway issues. MPS represents a group of rare lysosomal storage disorders associated with an array of clinical manifestations. The high prevalence of airway obstruction and restrictive pulmonary disease in combination with cardiovascular manifestations poses a high anaesthetic risk to these patients. Typical anaesthetic problems include airway obstruction after induction or extubation, intubation difficulties or failure [can’t intubate, can’t ventilate (CICV)], possible emergency tracheostomy and cardiovascular and cervical spine issues. Because of the high anaesthetic risk, the benefits of a procedure in patients with MPS should always be balanced against the associated risks. Therefore, careful evaluation of anaesthetic risk factors should be made before the procedure, involving evaluation of airways and cardiorespiratory and cervical spine problems. In addition, information on the specific type of MPS, prior history of anaesthesia, presence of cervical instability and range of motion of the temporomandibular joint are important and may be pivotal to prevent complications during anaesthesia. Knowledge of these risk factors allows the anaesthetist to anticipate potential problems that may arise during or after the procedure. Anaesthesia in MPS patients should be preferably done by an experienced (paediatric) anaesthetist, supported by a multidisciplinary team (ear, nose, throat surgeon and intensive care team), with access to all necessary equipment and support.
Electronic supplementary material
The online version of this article (doi:10.1007/s10545-012-9563-1) contains supplementary material, which is available to authorized users.
doi:10.1007/s10545-012-9563-1
PMCID: PMC3590422  PMID: 23197104
16.  Early tracheostomy in intensive care trauma patients improves resource utilization: a cohort study and literature review 
Critical Care  2004;8(5):R347-R352.
Introduction
Despite the integral role played by tracheostomy in the management of trauma patients admitted to intensive care units (ICUs), its timing remains subject to considerable practice variation. The purpose of this study is to examine the impact of early tracheostomy on the duration of mechanical ventilation, ICU length of stay, and outcomes in trauma ICU patients.
Methods
The following data were obtained from a prospective ICU database containing information on all trauma patients who received tracheostomy over a 5-year period: demographics, Acute Physiology and Chronic Health Evaluation II score, Simplified Acute Physiology Score II, Glasgow Coma Scale score, Injury Severity Score, type of injuries, ICU and hospital outcomes, ICU and hospital length of stay (LOS), and the type of tracheostomy procedure (percutaneous versus surgical). Tracheostomy was considered early if it was performed by day 7 of mechanical ventilation. We compared the duration of mechanical ventilation, ICU LOS and outcome between early and late tracheostomy patients. Multivariate analysis was performed to assess the impact of tracheostomy timing on ICU stay.
Results
Of 653 trauma ICU patients, 136 (21%) required tracheostomies, 29 of whom were early and 107 were late. Age, sex, Acute Physiology and Chronic Health Evaluation II score, Simplified Acute Physiology Score II and Injury Severity Score were not different between the two groups. Patients with early tracheostomy were more likely to have maxillofacial injuries and to have lower Glasgow Coma Scale score. Duration of mechanical ventilation was significantly shorter with early tracheostomy (mean ± standard error: 9.6 ± 1.2 days versus 18.7 ± 1.3 days; P < 0.0001). Similarly, ICU LOS was significantly shorter (10.9 ± 1.2 days versus 21.0 ± 1.3 days; P < 0.0001). Following tracheostomy, patients were discharged from the ICU after comparable periods in both groups (4.9 ± 1.2 days versus 4.9 ± 1.1 days; not significant). ICU and hospital mortality rates were similar. Using multivariate analysis, late tracheostomy was an independent predictor of prolonged ICU stay (>14 days).
Conclusion
Early tracheostomy in trauma ICU patients is associated with shorter duration of mechanical ventilation and ICU LOS, without affecting ICU or hospital outcome. Adopting a standardized strategy of early tracheostomy in appropriately selected patients may help in reducing unnecessary resource utilization.
doi:10.1186/cc2924
PMCID: PMC1065024  PMID: 15469579
intensive care; mechanical ventilation; resource utilization; Saudi Arabia; trauma; tracheostomy; weaning
17.  Submental intubation: A journey over the last 25 years 
Airway management in patients with faciomaxillary injuries is challenging due to disruption of components of upper airway. The anesthesiologist has to share the airway with the surgeons. Oral and nasal routes for intubation are often not feasible. Most patients have associated nasal fractures, which precludes use of nasal route of intubation. Intermittent intraoperative dental occlusion is needed to check alignment of the fracture fragments, which contraindicates the use of orotracheal intubation. Tracheostomy in such situations is conventional and time-tested; however, it has life-threatening complications, it needs special postoperative care, lengthens hospital stay, and adds to expenses. Retromolar intubation may be an option, But the retromolar space may not be adequate in all adult patients. Submental intubation provides intraoperative airway control, avoids use of oral and nasal route, with minimal complications. Submental intubation allows intraoperative dental occlusion and is an acceptable option, especially when long-term postoperative ventilation is not planned. This technique has minimal complications and has better patients’ and surgeons’ acceptability. There have been several modifications of this technique with an expectation of an improved outcome. The limitations are longer time for preparation, inability to maintain long-term postoperative ventilation and unfamiliarity of the technique itself. The technique is an acceptable alternative to tracheostomy for the good per-operative airway access.
doi:10.4103/0970-9185.98320
PMCID: PMC3409936  PMID: 22869933
Adult; intubation; intratracheal methods; maxillofacial injuries/surgery; oral/methods; surgery
18.  New Therapeutics in Promoting and Modulating Mandibular Growth in Cases with Mandibular Hypoplasia 
BioMed Research International  2013;2013:789679.
Children with mandibular growth deficiency may develop airway obstruction. The standard treatment of severe airway obstruction involves invasive procedures such as tracheostomy. Mandibular distraction osteogenesis has been proposed in neonates with mandibular deficiency as a treatment option to avoid tracheostomy procedure later in life. Both tracheostomy and distraction osteogenesis procedures suffer from substantial shortcomings including scarring, unpredictability, and surgical complications. Forward jaw positioning appliances have been also used to enhance mandible growth. However, the effectiveness of these appliances is limited and lacks predictability. Current and future approaches to enhance mandibular growth, both experimental and clinical trials, and their effectiveness are presented and discussed.
doi:10.1155/2013/789679
PMCID: PMC3681221  PMID: 23819121
19.  A novel technique for securing tracheal blood supply in salvage anterior mediastinal tracheostomy 
Highlights
•This is the first report of the novel surgical procedure to maintain the tracheal blood supply in anterior mediastinal tracheostomy.•The longer tracheal stump makes easier to create a tracheostomy, but has a disadvantage for its blood supply.•The unaffected-sided tracheal sheath was preserved in a state of connecting with the ipsilateral lobe of the thyroid gland and the tracheal stump.•The trachea was cut diagonally, leaving the unaffected tracheal wall longer.•This technique enables to secure the blood supply of the tracheal stump and to prevent postoperative fatal complications.
Introduction
The only way for complete cure of advanced esophageal cancer with invasion to the mid-trachea is anterior mediastinal tracheostomy (AMT), which has a significantly high risk of fatal complications. The shorter tracheal stump is beneficial for good blood supply, but complicates to create a tracheostomy.
Presentation of case
A 71-year-old patient with a history of advanced cervical esophageal cancer who was treated with definitive chemoradiotherapy 3 years earlier had local recurrence on the left side of the trachea despite salvage lymphadenectomy for solitary left paratracheal lymph node recurrence 1 year earlier. AMT involving a resection of nearly the whole trachea was needded for complete resection. However, the recurrenced tumor was localized on the tracheal left side. We designed the new surgical procedure to preserve a longer segment of the unaffected right tracheal wall by diagonal cut (3.6 cm longer than on the left side) while maintaining adequate blood flow by preserving the right lateral vascular pedicle in a state of connecting with the right lobe of the thyroid gland and the right tracheal stump. The postoperative course was uneventful, and at 1 year postoperatively, no tumor recurrence has been detected.
Discussion
Preservation of the lateral vascular pedicle enables a longer tracheal stump by securing sufficient blood supply and a longer tracheal stump in AMT, even when unilateral, enables to create tracheostomy more surely, preventing fatal complications.
Conclusion
This novel procedure should be considered in cases with tumor invasion extending into the lower mid-trachea that is limited to one side.
doi:10.1016/j.ijscr.2015.07.020
PMCID: PMC4573604  PMID: 26263449
Anterior mediastinal tracheostomy; Tracheal blood supply; Esophageal cancer; Lateral longitudinal anastomosis; Salvage surgery
20.  Tracheostomy. 
Archives of Disease in Childhood  1990;65(1):123-126.
The records of all children who had a tracheostomy performed over a 10 year period from January 1979 were reviewed. Altogether 142 patients aged 1 day to 24.8 years received a tracheostomy, 70 in the first year of life. The conditions necessitating tracheostomy were trauma (n = 21), acquired subglottic stenosis (n = 21), subglottic haemangioma (n = 16), Guillain-Barré syndrome (n = 14), Pierre Robin syndrome (n = 9), craniofacial disorders (n = 9), micrognathia (n = 5), and others in 47. In patients successfully decannulated the median period of tracheostomy was 104 days (range 3 days to 9.0 years) and in 25 patients the tracheostomy is still in situ. Eighty four patients (60%) were discharged from hospital with their tracheostomy in situ and no patient was kept in hospital because of a tracheostomy beyond four weeks. There were two tracheostomy related deaths in hospital. Both patients had severe acquired subglottic stenosis secondary to ventilation for lung disease of prematurity. There were no tracheostomy related deaths at home; complications included tracheal granulomas and polyps (n = 19). After removal of the tracheostomy 13 children had a fistula requiring surgical closure and four required revision of the tracheostomy scar. Tracheostomy is well tolerated in small children, with few complications and can be managed safely in the home by the family.
PMCID: PMC1792410  PMID: 2301974
21.  Broken tracheostomy tube: A fractured mandate 
Tracheostomy is a common airway procedure for life support. This procedure is safe, although occasional early and late complications are known to occur. Fracture and hence aspiration of a tracheostomy tube in the tracheobronchial tree is a rare late complication, which can be potentially life threatening. Published reports of a fractured tracheostomy tube presenting as a foreign body in the tracheobronchial tree are few. The most common dislodged sites reported were the trachea and the right main bronchus, the inner flange in our patient was lodged in the trachea and the left main bronchus. Foreign-body aspiration is a serious medical emergency demanding timely recognition and prompt action as was successfully done in our patient. Therapeutic rigid bronchoscopic removal is the mainstay of treatment. A periodic review of the techniques of tracheostomy care including timely check-ups for signs of wear and tear can possibly eliminate such avoidable late complications.
doi:10.4103/0974-2700.93098
PMCID: PMC3299168  PMID: 22416168
Broken tracheostomy tube; complications; tracheostomy care
22.  Acute Airway Obstruction Secondary to Vocal Fold Heterotopic Ossification 
Head and Neck Pathology  2014;9(1):96-99.
A 29-year old man of Eritrean origin presented with acute stridor and respiratory distress on a background 1 year history of progressive breathing difficulty and worsening inspiratory stridor. Fibreoptic laryngoscopy revealed an indeterminate swelling of the left vocal fold leaving no clear airway visible. The patient refused surgical tracheostomy. Microlaryngoscopy revealed a hard, calcified mass arising from the left cord preventing intubation. Histological analysis after excision revealed features consistent with heterotopic ossification. At 4 months repeat microlaryngoscopy was performed revealing normal appearance of the larynx and subglottis. Heterotopic ossification in the larynx is a very rare condition that presents a diagnostic and therapeutic challenge. In the first documented case in the larynx, we describe how the disease caused life threatening airway obstruction, but was managed in a way that led to preservation of laryngeal function and complete resolution of the condition.
doi:10.1007/s12105-014-0539-3
PMCID: PMC4382488  PMID: 24682868
Airway obstruction; Heterotopic ossification; Larynx; Myositis ossificans; Tuberculosis; Osteoma
23.  Impact of real-time ultrasound guidance on complications of percutaneous dilatational tracheostomy: a propensity score analysis 
Critical Care  2015;19(1):198.
Introduction
Recent studies have demonstrated the feasibility of real-time ultrasound guidance during percutaneous dilatational tracheostomy, including in patients with risk factors such as coagulopathy, cervical spine immobilization and morbid obesity. Use of real-time ultrasound guidance has been shown to improve the technical accuracy of percutaneous dilatational tracheostomy; however, it is unclear if there is an associated reduction in complications. Our objective was to determine whether the peri-procedural use of real-time ultrasound guidance is associated with a reduction in complications of percutaneous dilatational tracheostomy using a propensity score analysis.
Methods
This study reviewed all percutaneous dilatational tracheostomies performed in an 8-year period in a neurocritical care unit. Percutaneous dilatational tracheostomies were typically performed by trainees under guidance of the attending intensivist. Bronchoscopic guidance was used for all procedures with addition of real-time ultrasound guidance at the discretion of the attending physician. Real-time ultrasound guidance was used to guide endotracheal tube withdrawal, guide tracheal puncture, identify guidewire entry level and confirm bilateral lung sliding. The primary outcome was a composite of previously defined complications including (among others) bleeding, infection, loss of airway, inability to complete procedure, need for revision, granuloma and early dislodgement. Propensity score analysis was used to ensure that the relationship of not using real-time ultrasound guidance with the probability of an adverse outcome was examined within groups of patients having similar covariate profiles. Covariates included were age, gender, body mass index, diagnosis, Acute Physiology and Chronic Health Evaluation II score, timing of tracheostomy, positive end-expiratory pressure and presence of risk factors including coagulopathy, cervical spine immobilization and prior tracheostomy.
Results
A total of 200 patients underwent percutaneous dilatational tracheostomy during the specified period, and 107 received real-time ultrasound guidance. Risk factors for percutaneous dilatational tracheostomy were present in 63 (32%). There were nine complications in the group without real-time ultrasound guidance: bleeding (n = 4), need for revision related to inability to ventilate or dislodgement (n = 3) and symptomatic granuloma (n = 2). There was one complication in the real-time ultrasound guidance group (early dislodgement). The odds of having an adverse outcome for patients receiving real-time ultrasound guidance were significantly lower (odds ratio = 0.08; 95% confidence interval, 0.009 to 0.811; P = 0.032) than for those receiving a standard technique while holding the propensity score quartile fixed.
Conclusions
The use of real-time ultrasound guidance during percutaneous dilatational tracheostomy was associated with a significant reduction in procedure-related complications.
doi:10.1186/s13054-015-0924-7
PMCID: PMC4438345  PMID: 25925262
24.  Subglottic stenosis following percutaneous tracheostomy: a single centre report as a descriptive study 
SUMMARY
Tracheal stenosis is a potential complication of tracheostomy. The present study aimed to describe the epidemiologic profile of subglottic stenosis in a referral medical centre. During a 4-year period, all patients who had been admitted in an Intensive Care Unit of Imam Khomeini Hospital (affiliated to Tehran University of Medical Sciences) and had undergone percutaneous tracheostomy during 7-10 days after endotracheal intubation were enrolled in the study. After removing the tracheostomy tube, patients were evaluated regarding development of tracheal stenosis using fiberoptic bronchoscopy and multi-slice computed tomography scan. During the study period, percutaneous tracheostomy was performed in 140 patients with a mean age of 38 years. Overall 54 patients died due to the severity of the disorder during hospitalization. In the remaining 86 patients, 54 cases needed permanent or long-term mechanical ventilation and were excluded from the study. Twelve patients died during the first 3 months and 20 patients were left for final assessment. Multi-slice computed tomography scan imaging showed subglottic stenosis in 17 cases (85%). Of these, 9 patients (52%) had tracheal stenosis of < 50%. Tracheal stenosis of 25- 40% was found in 5 cases (25%). Patients in whom the tracheostomy tube had been removed in the first 3 weeks after tracheostomy did not present tracheal stenosis (n = 3, 15%). The present study revealed that subglottic stenosis is frequent in patients who have undergone percutaneous tracheostomy in the Intensive Care unit setting. However, the stenosis is generally mild and is not associated with serious and/ or life-threatening clinical manifestations.
PMCID: PMC3203718  PMID: 22065821
Percutaneous tracheostomy; Intensive Care Unit; Subglottic stenosis
25.  A review of the management of 140 elective tracheostomies following open-heart surgery 
Thorax  1969;24(1):78-83.
A retrospective survey of 140 cases of elective tracheostomy following open-heart surgery has been undertaken. All the tracheostomies were performed by surgeons of the Cardiac Unit using a standard technique during the years 1962 to 1966 inclusive. The indications during this period are discussed and possible reasons for the high incidence of tracheostomy are considered. The complications have been carefully assessed. The results indicate that, although there is room for improvement, a reduction in the number and severity of complications has been achieved. In particular there have been few late sequelae, which is attributed to good surgical technique and the adoption of the Björk operation. In 60% of the patients there were no complications; one death was directly attributable to tracheostomy.
Images
PMCID: PMC471925  PMID: 4884175

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