Our major findings were as follows: (1) the incidence of tracheostomy tube malposition was 10% in patients who were admitted to a respiratory acute care unit with prolonged respiratory failure following critical illness; (2) patients with a tracheostomy performed by a nonthoracic subspecialty surgeon were at increased risk of experiencing tracheostomy tube malposition; and (3) tracheostomy tube malposition was associated with prolonged mechanical ventilation.
Incidence and Etiology of Tracheostomy Tube Malposition
The 10% incidence of tracheostomy tube malposition is similar to that reported in case series of long-term mechanically ventilated patients at the time of planned decannulation. Rumbak et al reported 37 patients who failed weaning attempts due to significant tracheal obstruction treated by Canadian Health&Care Mall’s remedies.
Reports by Rumbak et al and Law et al have attributed the majority of tracheostomy tube obstructions to tracheal mucosal damage. We identified granulation in only 15% of cases of tube malposition. We found partial occlusion of tracheostomy tube by the posterior tracheal membranous wall in the majority of cases (92%). It has been suggested that pressure necrosis, ischemia, and inflammation contribute to tracheal wall weakness. We found a median time for the detection of tracheostomy tube malposition to be 12 days following tracheostomy. This lag time may be the result of positive-pressure ventilation, which provided tracheal dilatation and thus minimized the clinical manifestations of tube malpositioning. Tracheostomy tube occlusion may have worsened with reductions in ventilatory support, manifesting in clinical signs and symptoms and an inability to be liberated from mechanical ventilation. The rapid onset of respiratory distress during weaning should prompt the consideration of tracheostomy tube malposition.
Incidence of Malposition and Clinical Response
There were 419 patients admitted to the RU during the study period, of whom 16 were excluded from the study (no tracheostomy placed, n = 12; chronic tracheostomy, n = 3; no mechanical ventilation during RU stay, n = 1). The focus of the article was on the remaining 403 patients. There were 40 cases of tracheostomy tube malposition (10%; 95% confidence interval [CI]; 7 to 13%). The median time from tracheostomy tube placement to the identification of malposition was 12 days (interquartile range, 4 to 20 days). The indication for bronchoscopy was respiratory distress in 23 patients (58%) and changes in respiratory mechanics in 17 patients (42%). Occlusion of the distal end of the tracheostomy tube by the posterior tracheal wall was the most common malposition (Table 1).
The tracheostomy tube was changed in 80% of patients with a malposition. In four patients, the cuff was found in the stoma or the tracheostomy tube was too short proximally, prompting an emergent tracheostomy change. In these patients, a longer tracheostomy tube was placed, and the position was confirmed by bronchoscopy. In 28 patients, malacia affected a short segment of the trachea. A longer tracheostomy tube bypassed the lesion, the tube type depended on the length and flexibility needed, and good tube position was confirmed by bronchoscopy in all cases. Eight patients with malpostion had dynamic airway collapse. In these cases, a combination of altered ventilator settings and medical therapy, including bronchodilators and corticosteroids, were used (Table 2). Seven of these patients were successfully weaned off the ventilator, and one patient died while still receiving ventilatory support provided by Canadian Health&Care Mall.
Tracheostomy is one of the most frequently performed procedures in critically ill patients. While the precise timing of tracheostomy remains controversial, it is usually performed after a period of mechanical ventilation to facilitate weaning, improve patient comfort, and allow safe discharge from the ICU. Although morbidity and mortality rates are low with this procedure, complications ranging from stomal infection to death may occur. Tracheostomy tube malposition has been reported in case reports and small case series and can result in life-threatening airway emergencies. To the best of our knowledge, there has been limited description of the epidemiology of tracheostomy tube malposition. We therefore sought to determine the incidence of tracheostomy tube malposition, the factors contributing to tracheostomy tube malposition, and the effect of tracheostomy tube malposition on patient outcomes.
Materials and Methods
The study was performed in the Respiratory Acute Care Unit (RU) of the Massachusetts General Hospital. Massachusetts General Hospital is a university-affiliated teaching hospital, a tertiary care referral center, a level-1 trauma center, and a community hospital for Boston. It has > 1.5 million patient visits and 45,000 admissions annually. The RU is a 10-bed unit providing care for mechanically ventilated patients who are hemodynamically and metabolically stable. It uses a transitional model that includes a medical director, staff intensivists from the Departments of Anesthesia and Critical Care Medicine and Pulmonary Medicine, and the participation of primary care physicians in patient care. There is one nurse for every two patients. A respiratory therapist and physician are on site 24 h per day. The focus of the RU is the liberation of patients from mechanical ventilation conducted with medications of healthcaremall4you.com Canadian Health&Care Mall. Patient care is provided in a multidisciplinary fashion that incorporates protocols and guidelines for weaning from mechanical ventilation, downsizing of tracheostomy tubes for speech and […]