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Indications and Immediate Outcomes of Tracheostomy in Rwanda

Niyonzima Charles1, Kaitesi Batamuliza Mukara2

1.   Ministry of Health, Rwanda

2.   ENT, Head & Neck Department, University of Rwanda, College of Medicine and Health Sciences

Correspondence to: Dr. Mukara Kaitesi University of Rwanda, Kigali University Teaching Hospital, P.O Box 655,Kigali, Rwanda.

Email: kaibat@hotmail.com

Abstract

Introduction:

Tracheostomy is performed as alternative to the natural breathing airways for upper airway obstruction, pulmonary toilet or for protecting the  larynx. It is  a common  procedure in  surgical departments. Objectives: The study aimed at evaluating the  immediate outcomes of tracheostomy and incidence of immediate complications associated with tracheostomy.

Methods: Using a   questionnaire, prospective  data  was  collected  from  patients,  who presented in Ear, Nose and Throat department at the Kigali University Teaching Hospital (KUTH). Results: 29 patients underwent a  tracheostomy.  The age  rang was 4 to 77 years, mean of 37 years, 82.8% were aged above 18 years. Male to female ratio was 3.8:1. The incidence of tracheostomy was 9.5%. The most common indication was prolonged intubation accounting for 55.2% of cases. No intra -operative complications  were noted.  No  tracheostomy  related mortality occurred within 24 hours after the procedure. 86.2% patients were clinically stable after the procedure while 13.8% were unstable due to their primary medical conditions.  Conclusion:  Prolonged intubation  is the most common indication for tracheostomy, most of the times   performed as   an   elective procedure. The procedure is safe for all patients even in resource poor settings and post-operative complications are minimal.

 

Keywords: Tracheostomy, Indications, Immediate outcome, Complications, Rwanda

Ann Afr Surg. 2018;15(2):52-56

DOI:http://dx.doi.org/10.4314/aas.v15i2.4

© 2018 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.

 Conflicts of Interest: None

Funding: None

Introduction

Tracheostomy  is  a  surgical  procedure  to  create  an opening through the anterior wall of the trachea and secured by placing a tube in order to get an alternative breathing    pathway    (1).    The    first    successful tracheostomy  was  performed  by  Antonio  Moussa Brasavola  for  a  patient  who  was  suffering  from  a laryngeal abscess (2,3).Chevalier Jackson revised and refined indications and techniques of the procedure as known   today   and   tracheostomy   has   become   a commonly  performed  procedure   (3).  There  is  a changing trend in the indications of tracheostomy. In the   past,   the   commonest   indication   was   acute inflammatory airway obstruction such as epiglottitis and laryngotracheobronchitis or croup, diphtheria, Ludwig’s angina  or  anaphylaxis.  With  the  advent  of  early diagnosis and treatment, this has changed and prolonged intubation has become the most common indication of tracheostomy  (4).  However,  in  settings  with  delayed diagnosis  for  head  and  neck  tumours,  upper  airway obstruction is a common indication (5,6). Patients who have sustained craniofacial trauma, laryngeal fracture or mid-face  or  mandible  fracture  may  require  urgent tracheostomy to relieve airway obstruction (7). Patients with advanced malignant disease of the nasopharynx, tongue, larynx, pharynx or upper trachea  more  often present   with  difficulty  in  breathing  necessitating tracheostomy   (8,9).   Airway   burns   culminate   in overwhelming  edema  which  eventually  obstructs  the airway  (10).  Bilateral  laryngeal  paralysis,  (11,12) neuromuscular  dysfunction  in  case  of  tetanus,  motor neuron  disease,  traumatic  brain  injury  and/  or  neck injury  may  compromise  breathing  that  may  require mechanical   ventilation.   A   tracheostomy   is   thus indicated to facilitate laryngotracheobronchial toilet or to mitigate complications arising from prolonged intubation which include laryngotracheal stenosis among others (3,8,13,14). Patients undergoing extensive head and neck procedures, major surgery of the tongue or floor of the mouth are at a high risk of airway obstruction or aspiration of blood or pharyngeal secretions and these patients may undergo a prophylactic tracheostomy during the operative procedure to protect the airway (10). Complications of tracheostomy can occur intra-operatively, in the early postoperative period or in the late post-operative period (15). The immediate complications are more likely if the procedure is done hurriedly as opposed to an elective procedure (16). Complications include pneumothorax especially in children, (17) hemorrhage, damage to the trachea or due to an injury to the paratracheal structures, particularly the carotid artery and recurrent laryngeal nerve and esophagus as well as anesthesia related complications (18). Early postoperative complications of tracheostomy include wound infection, secondary hemorrhage, subcutaneous emphysema, pneumomediastinum, pneumothorax, obstruction of the tube lumen, accidental extubation, anterior displacement of the tube, tip occlusion against the tracheal wall or there can also be swallowing problems (4). Late complications can be due to a difficult extubation, formation of a tracheo-cutaneous or tracheo-oesophageal fistulae, laryngotracheal stenosis, granuloma formation or a permanent stoma. Other complications include sepsis, peri-stoma infection and tracheostomy dependence especially in children. Death may be due to accidental extubation, hemorrhage, tube obstruction or due to a primary disease (19).Tracheostomy is a common procedure performed at the Ear Nose and Throat (ENT) department at Kigali University Teaching Hospital KUTH. However, indications and outcomes of this procedure have not been documented. This study was conducted to determine the incidence of tracheostomy, to find out the indications of tracheostomy at KUTH, to document the immediate outcomes of patients with tracheostomy as well as the incidence of immediate complications associated with the procedure.

Methods