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.
Risk Factors for Tracheostomy Tube Malposition
There was no significant relationship among tracheostomy tube malposition, age, gender, severity of disease, etiology of respiratory failure, and time on the ventilator prior to tracheostomy (Table 3). The type of tracheostomy tube and the type of tracheostomy procedure (open vs closed) did not influence the risk of malposition (Table 4). Patients with a tracheostomy tube malposition had an increased mean (± SD) albumin level compared to patients without the complication (2.4 ± 0.6 vs 2.1 ± 0.5 mg/dL, respectively). Patients with a tracheostomy tube malposition were shorter in height (mean height, 1.68 ± 0.11 vs 1.72 ± 0.11 m, respectively). The factor most strongly associated with tracheostomy tube malposition was the subspecialty of the surgical service of the surgeon who performed the tracheostomy (p = 0.006). Compared to thoracic surgeons, general surgeons were equally likely to be associated with a tracheostomy tube malposition (odds ratio, 1.35; 95% CI, 0.50 to 3.62; p = 0.551), while other subspecialty surgeons were more likely associated with a tracheostomy tube malposition (odds ratio, 6.42; 95% CI, 1.82 to 22.68; p = 0.004). Forty-one patients underwent tracheostomies performed by nonthoracic subspecialty surgeons. These patients had a 23% risk of tracheostomy malposition. These other subspecialty surgeons were otolaryngologists (n = 1), plastic surgeons (n = 1), neurosurgeons (n = 1), transplant surgeons (n = 2), and vascular surgeons (n = 36).
Patients with a tracheostomy tube malposition had a longer duration of mechanical ventilation (median duration, 25 vs 15 days, respectively; p = 0.016), but had similar lengths of hospital stay following tracheostomy (median stay, 33 vs 26 days, respectively; p = 0.258) compared to patients without malposition (Table 5). There were no differences in ICU readmissions or the number of patients discharged to home, rehabilitation facilities, or other health-care facilities. Tracheostomy tube malposition had no significant effect on hospital mortality.
Table 1—Type of Malposition
|Type of Malposition||No. (%)*|
|Posterior tracheal wall occluding distal tip of tube||37 (92)</sp|