Emergency Tracheostomy in a Tertiary Level Hospital in Bangladesh: Indications and Complications

Objective: To see the common indications, pattern of complications (during and post operative) of emergency tracheostomy in the tertiary level hospital in Bangladesh. It also gives the idea for minimizing the complications. Methods: This cross sectional study was carried out in the Department of Otolaryngology & HeadNeck surgery of Dhaka Medical College Hospital, Dhaka, from 14 April 2015 to 14 October 2015. This study includes all emergency patients irrespective of age and sex whose tracheostomy was done in emergency operation theatre of ENT department of Dhaka Medical College and Hospital. Results: The study reveals that the commonest indications of emergency tracheostomy were diagnosed case of carcinoma of larynx & base of tongue (30%) followed by post-irradiated carcinoma larynx (24%). Next common indications were stridor in undiagnosed case (18%), difficulty in intubation during surgery (10%), history of road traffic accident (6%), cut throat injury (6%), foreign body in throat (2%), laryngeal edema and blunt trauma in neck (2%) respectively. Commonest complications during the procedure were apnoea (12%), haemorrhage (18%), injury to surrounding structure (10%), cardiac arrest (4%) & respiratory arrest (2%). Common complications in early post operative period were surgical emphysema (10%), crusting or blockage (4%), tube dislodgement (4%), &stomal infection (2%). Late post operative complications were stomal granulation tissue (4%), pneumonia (2%), stomal infection (2%), tracheocutaneous fistula (2%), & tracheomalasia (2%).


Introduction
Tracheostomy is used to describe as the creation of a stoma at the skin surface which leads into the trachea. 1 The word tracheostomy comes from two Greek words: the root tom-meaning 'to cut' and the word trachea means wind pipe. 2 Despite being one of the most common surgical procedures tracheostomy can be one of the most challenging because of the medical complexities presented by many patients. Tracheostomy was first described nearly 3500 years ago.
The first successful tracheostomy is attributed to Antonio Musa Brasaralo, who published his account of procedure in 1546 AD. Chevalier Jackson's description of his modifications to the procedure, published in 1909, improved its efficiency and safety and reduced the mortality of tracheostomy from 25% to 2%. 3 The procedure has been given several different names, including pharyngotomy, laryngotomy, bronchotomy, tracheotomy and tracheostomy. Tracheostomy has many advantages and some disadvantages. Among the advantages it may act as a bypass in case of upper airway obstruction, reduce 50% (100 ml) of anatomical dead space, reduce airflow resistance, helps in toileting of tracheobronchial tree and protect against aspiration. Some disadvantages like normal function of nasal cavity and normal voice are lost, elimination of glottic stop and increased risk of pulmonary infection.
Commonest indications of tracheostomy are carcinoma of larynx, cut throat injury, ludwig's angina, acute epiglotitis and after total thyroidectomy if both recurrent laryngeal nerves are injured.
Depending upon the urgency, there are mainly two types of tracheostomy. 1. Emergency, 2. Elective. Patient suffering from severe stridor or respiratory distress need emergency tracheostomy in the emergency operation theatre aseptically after taking proper informed consent. All the procedures are carried out in the operation theatre using standard technique. Skilful surgeon, assistants and nurses are required during the procedure, while trained ward staff carry out post-operative tracheostomy care. Emergency tracheostomy has also been found to lead to life threatening complications like hypoxia, cardiac arrest, injury to structures immediately to the trachea, pneumothorax, haemothorax and even death.
After doing the procedure patient must be monitored carefully to avoid post-operative complications. In 1 st 24 hours risk is proportionate to time then it reduces. Securing the tube to skin to prevent dislodgement, putting wet gauze over the tube, inflation (with short period of deflation) of the cuff of tracheostomy tube for the 1 st 12 hours, repeated suctions of the secretions as needed. Instillation of normal saline to soften the crusts is needed. A piece of clean gauze need to place around the tube to prevent soiling of the wound and maceration of the skin.
Many critically ill patient's families have been denied in authorizing tracheostomy because of cosmetic issues and speech problem. 4,5 Methods This was a cross-sectional study done at the Department of Otolaryngology and Head-Neck surgery of Dhaka Medical College Hospital, Dhaka for six months, from 14 th April 2015 to 14 th October 2015. This study included all emergency patients irrespective of age & sex, whose tracheostomy was done in emergency operation theatre of Dhaka Medical College and Hospital. A total of 50 patients who met the inclusion criteria were selected for this study. Data were collected in a prescribed data collection sheet. All data were compiled and analyzed.             The commonest indication showing laryngeal carcinoma or carcinoma of base of tongue (15%), which is followed by post irradiated carcinoma larynx with stridor, (12%). History of radiotherapy may damage small blood vessels result in endarteritis obliterans and consequent local ischaemic damage also causes larynx necrosis. 9 Next common indication is stridor in undiagnosed case about 9%. Then proper evaluation of the disease is done after doing the life-saving procedure. 10% cases belonged to difficulty in intubation during surgery. Next common indications are history of road traffic accident (6%), cut throat injury (6%), laryngeal oedema (1%), blunt trauma in neck (1%) & foreign body in throat (1%).

Results
Published rates of tracheostomy related complications vary greatly (5-65%) and depends on study designs, length of follow up and definition of complications. Among the complications during the procedure haemorrhage occurs in 10% cases. Most commonly haemorrhage results from injury to the anterior jugular vein early in the dissection, specially during the emergency procedures or to the thyroid isthmus later in the dissection during attempts to mobilize it. 10 11,12,13,14 In this study 2 patients died because of terminal stage of malignancy not related to tracheostomy.

Conclusion
In this study of 50 cases of tracheostomy have been analysed in the department of Otolaryngology & Head-Neck surgery of Dhaka Medical College Hospital. It is an ancient procedure in the surgical field and is a life saving procedure. In this study there were few complications. Most of the complications were preventable & could have been avoided by careful operative technique and meticulous post operative management.
Most of the patients lost to follow up. So that it is difficult to study any late complications of the cases. Probably it happens due to their lack of awareness and lack of communication.