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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 1  |  Issue : 2  |  Page : 40-43

Indications and outcomes of tracheostomy: An experience in a resource-limited environment


Department of? Otorhinolaryngology Head and Neck Surgery, Ladoke Akintola University of Technology (LAUTECH) Teaching Hospital, Osogbo, Osun, Nigeria

Date of Web Publication4-Feb-2015

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2394-2010.150795

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  Abstract 

Background: Tracheostomy remains one of the most important procedures for airway emergency management, especially in a developing country where patients will not present until they are in acute airway obstruction. This study reviews all the tracheostomies performed in a suburban tertiary health institution in a developing country. Materials and Methods: A retrospective review of patients who had tracheostomy over a 10-year period. Results: There were 52 tracheostomies performed on 36 males and 16 females with a male: Female ratio 2.3:1. Upper airway obstruction was the major indication (63.5%), with laryngeal tumor as the major cause (32.7%). Tracheostomy was performed as emergency in 76.9% and as elective in 23.1%. Majority (73.1%) of the emergency tracheostomies was done under general anesthesia and over 84% were temporary tracheostomies. There were 21.2% complications with tracheostomy dependence as the leading cause in 9.6%, followed by peri-stoma granulation in 5.8%. Conclusion: Upper airway obstruction remains the major indication for tracheostomy, with laryngeal tumor as the major cause. There is a need for increased awareness of the people through social campaigns and health education on the merits of early detection and improvement in health-seeking behaviors of the people.

Keywords: Resource-limited environment, tracheostomy, upper airway obstruction


How to cite this article:
Adedeji TO, Tobih JE, Olaosun AO, Idowu J. Indications and outcomes of tracheostomy: An experience in a resource-limited environment. J Health Res Rev 2014;1:40-3

How to cite this URL:
Adedeji TO, Tobih JE, Olaosun AO, Idowu J. Indications and outcomes of tracheostomy: An experience in a resource-limited environment. J Health Res Rev [serial online] 2014 [cited 2019 Dec 11];1:40-3. Available from: http://www.jhrr.org/text.asp?2014/1/2/40/150795


  Introduction Top


Tracheostomy is a deliberate surgical procedure performed to make an opening in the anterior wall of the trachea and maintaining this opening with the use of a tracheostomy tube. [1],[2] It continues to be a standard surgical procedure for airway management. [3] The improvements in endotracheal tube technology in the management of upper airway emergencies as well as the introduction of percutaneous tracheostomy in the airway management must not allow the decision for tracheostomy to be left until it is too late. [1],[2],[4] Recently published studies have reported a drastic change in the trends of the various indications for tracheostomy. [2],[3],[4],[5] This has made trauma or prolonged intubation to replace acute inflammatory upper airway obstruction as the most common indication for tracheostomy. [2],[4],[5] The reason for this may be related to the changes in the epidemiology of infectious diseases, adequate use of antibiotics, and improvement in the capabilities of medical technology. [3]

Despite being very useful in securing and maintaining the airway, tracheostomy is not without problems, [6],[7],[8] and complications can occur intraoperatively or postoperatively. [7],[8],[9] This study reviews the indications and outcomes of tracheostomy in a suburban tertiary health institution in a resource-limited environment.


  Materials and methods Top


The study was a retrospective review of patients who presented at our otorhinolaryngology department between January 2003 and December 2012 on account of upper airway obstruction that necessitated tracheostomy. The records of the patients were retrieved from the patient medical records. Information retrieved included patients' age, sex, symptoms at presentation, occupation, duration of symptoms before presentation, indications, etiology of various indications, duration of hospital stay after surgical intervention, and final outcome. The patients whose case records could not be located and those that had missing significant and vital information were excluded.

The information was entered into a spreadsheet and the data generated were analyzed using SPSS version 14 (Chicago, IL, USA) with means and frequencies calculated. The data were presented in simple descriptive forms as proportions using tables and graphic chart.


  Results Top


A total of 52 tracheostomies were performed during the period of this study. There were 36 (69.2%) males with a male: Female ratio of 2.3:1. The age of the patients ranged from 6 months to 77 years. The median age was 34.5 years and the mean age was 35.2 ± 27.19 years. [Table 1] shows the age, sex, and occupation distribution among the patients. Children aged 1-10 years constituted the majority (34.6%), followed by adults aged 61-70 years (21.2%). [Table 1] shows the occupation distribution among the patients, while the various indications for tracheostomies are shown in [Table 2]. Upper airway obstruction was the major indication in 33 (63.5%) patients, followed by diversion from the field of surgery in 8 (15.4%) patients.
Table 1: Socio-demographic characteristic of patients who had tracheostomies

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Table 2: Indications for tracheostomy/primary diagnosis

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Laryngeal tumor was the major cause of upper airway obstruction in 17 (32.7%) patients. Recurrent laryngeal papillomatosis was the most common laryngeal tumor among 10 children (17.3%) and laryngeal cancer was found in 7 adults (13.5%).

Emergency tracheostomies were performed in 40 (76.9%) patients on account of upper airway obstruction. Most cases (95%) of emergency tracheostomies and 66.7% of elective tracheostomies were done under general anesthesia. Transverse skin crease incision was the approach employed in all our patients. Eight cases (15.4%) were permanent tracheotomies and 44 (84.6%) were temporary tracheostomies. Duration of temporary tracheostomy ranged from 2 days to 2 years. Eleven (21.2%) patients had various complications as shown in [Figure 1]. Three mortalities were recorded which were due to progression of the underlying disease conditions.
Figure 1: Complications of tracheostomy

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  Discussion Top


Tracheostomy remains one of the most important and standard procedures for airway emergency management, especially in a developing country where patients will not present until they are in an acute and critical condition. The preponderance of males, as seen in this study, agrees with reports from previously published studies. [10],[11] Laryngeal tumors were one of the leading causes of upper airway obstruction in this study and, incidentally, laryngeal tumors had been reported to be redominantly found among males. [3],[10] Male activity is another factor that may be responsible for the male preponderance. In African traditional setting, males are the breadwinners in many homes, and this makes them more vulnerable to road traffic injuries. Previous researchers had also reported preponderance of males among the tracheostomized patients. [2],[4],[10],[12]

Majority (17.3%) of the children in our study developed airway obstruction secondary to recurrent respiratory papillomatosis. This finding was similar to 16.7% reported by Adoga et al., [12] but much higher than 2.6% reported by Onotai et al. [11] In Ile Ife, Eziyi et al., [2] however, reported foreign body aspiration as the leading cause of airway obstruction among the children.

There has been a consistency concerning upper airway obstruction as the major indication for tracheostomy, as seen from the reports of previous researchers, [2],[3],[10],[11],[12] which is in agreement with the findings of our study where upper airway obstruction formed 63.5% of the indications for tracheostomy. Some researchers, however, reported prolonged intubation in patients with head injury or tetanus as the major indication for tracheostomy. [4],[5],[13],[14] Fasunla et al. [6] reported mechanical ventilation as the major indication for tracheostomy in their center, while in India, Olton et al. [13] reported difficulty in weaning patients off endotracheal intubation as the leading indication for tracheostomy in their study. Tracheostomy for a patient on mechanical ventilation helps to prevent complications from translaryngeal intubation, improves patient comfort, facilitates progression of care, and increases patient safety. [15],[16] The performance of tracheostomy to protect the larynx from intubation damage has been recommended within 3 days of intubation because the observed mucosal damage to the larynx and vocal cords is maximal in 3-7 days. [15],[16]

Our finding of laryngeal tumor (benign and malignant) as the major cause of upper airway obstruction was similar to the findings of Eziyi et al. [2] in Ile Ife and Orji et al. [10] in Enugu. Early presentation of laryngeal tumor is known to be associated with high cure rate, especially if prompt and appropriate intervention is taken. [12],[17],[18] There is a need for increased awareness of the people through social campaigns and health education on the merits of early detection and the need for urgent and appropriate treatment for these tumors. Adoga et al. [12] in Jos reported in their study that malignant tumors of the upper aero-digestive tract constituted an appreciable percentage of indications for tracheostomy and resulted from either late presentation or clinical misdiagnosis by non-specialists. People with progressive unremitting hoarseness for more than 2 weeks need to present for thorough medical evaluation. [17],[18] Trauma from either road traffic injury [3],[12] or foreign body aspiration was, however, reported in some studies as the major cause of upper airway obstruction. [11]

Airway obstruction from infective process that constituted 11.5% in this study was more than 1.6% reported by Adetinuola et al., [2] but was much smaller than 29.5% previously reported by Amusa et al. [3] This finding, therefore, corroborated the report that improvement in healthcare delivery has reversed the previous trend whereby infective process was the major cause of airway obstruction. [2],[11]

Trauma and prolonged intubation formed the minor indications for tracheostomy in our study. This might be related to the location of our center where there are lesser major highways and, therefore, lesser incidence of road traffic injuries. Southwestern Nigeria is also reputed for its low incidence of violence due to communal clashes or violence from political/religion insurg ences, as found in some parts of Nigeria. These factors might have contributed to the lesser number of cases of tracheostomies from trauma in our study. The incidence and distribution of the disease entity is usually influenced by geographic, socioeconomic, and racial factors. Our center is a tertiary health institution that is located in the rain forest zone in Nigeria, majority of the populace are farmers working in very small and medium-scale industries, and hence, there are fewer cases of trauma from industrial accidents or road traffic crashes.

Majority of our patients presented in acute airway obstruction (usually from chronic, slowly progressive disease) which is responsible for emergency tracheostomy in most of them. This pattern of late presentation had been reported in many developing countries. [2],[3],[4],[9],[10],[11],[12] This shows that the need for public enlightenment and health education to improve the health-seeking behaviors and encourage early presentation of disease conditions cannot be overemphasized.

Duration of tracheostomy in our patients was directly related to the indications and associated complications. Majority of the patients with airway obstruction secondary to foreign body aspiration were usually decanulated within 24-48 h, especially those cases that presented early and have not developed other airway problems secondary to edema or infective process. Children with recurrent respiratory papillomatosis were special cases, as decanulation in them usually poses some challenges due to tracheostomy dependence and associated peri-stoma granulation.

Though tracheostomy is a useful life-saving procedure, it is not free of complications. The complication rate in our study was 21.2% and was within 10-45% in previously published studies. [2],[3],[4],[5],[6] Majority of the complications were due to tracheostomy dependence which was found mostly among children. The mortality observed in three patients in this study was related to the disease progression. Two of them died from advanced laryngeal cancer, while the third patient died from advanced sinonasal malignancy.


  Conclusion Top


Upper airway obstruction still remains the major indication for tracheostomy in our center. Laryngeal tumor is the main indication for tracheostomy, while conditions such as infections, trauma, and prolonged intubation, which were the leading indications previously, have shown a decrease. The trends observed might be related to ignorance and low socioeconomic status of the people predisposing them to poor health-seeking attitude. There is, therefore, a need for increased awareness of the people through social campaigns and health education on the merits of early detection and to improve the health-seeking behaviors of the people.


  Acknowledgment Top


The authors acknowledge the staffs of the medical record department who assisted during data collation.

 
  References Top

1.
Paul P, Tracheostomy. In: Michael G, George GB, Martin JB, Ray C, Hibbert J, Jones NS, et al. editors. Scott-Brown′s Otolaryngology, Head and Neck Surgery. Vol. 1. 7 th ed. London: Hodder Arnold; 2008. p. 2292-304.  Back to cited text no. 1
    
2.
Adetinuola EJ, Bola AY, Olanrewaju MI, Oyedotun AA, Timothy OO, Alani AS, et al. Tracheostomy in south western Nigeria: Any change in pattern? J Med Med Sci 2011;2:997-1002.  Back to cited text no. 2
    
3.
Amusa YB, Akinpelu VO, Fadiora SO, Agbakwuru EA. Tracheostomy in surgical practice: Experience in a Nigerian tertiary hospital. West Afr J Med 2004;23:32-4.  Back to cited text no. 3
    
4.
Adoga AA, Ma′an ND. Indications and outcome of pediatric tracheostomy: Results from a Nigerian tertiary hospital. BMC Surg 2010;10:2.  Back to cited text no. 4
    
5.
Mukherjee DK. The changing concepts of tracheostomy. J Laryngol Otol 1979;93:899-907.  Back to cited text no. 5
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6.
Fasunla JA, Aliyu A, Nwaorgu OG, Ijaduola GT. Tracheostomy decannulation: Suprastomal granulation tissue in perspective. East Cent Afr J Surg 2010;15:81-6.  Back to cited text no. 6
    
7.
Prescott CA. Peristomal complications of paediatric tracheostomy. Int J Pediatr Otorhinolaryngol 1992;23:141-9.  Back to cited text no. 7
    
8.
Antwi-Kusi A, Osei-Ampofo M, Mohammed DI, Addison W. Fractured tracheostomy tube-A case report of a 3-year old Ghanaian child. Afr J Emerg Med 2012; 2: 114-6.  Back to cited text no. 8
    
9.
Akenroye MI, Osukoya AT. Permanent tracheostomy: Its social impacts and their management in Ondo State, Southwest, Nigeria. Niger J Clin Pract 2013;16:54-8.  Back to cited text no. 9
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Orji FT, Ezeanolue BC. Update on the pattern of tracheostomies at a tertiary health institution after 27 years. Niger J Otorhinolaryngol 2006;3:8-15.  Back to cited text no. 10
    
11.
Onotai LO, Etawo US. An audit of paediatric tracheostomies in Port Harcourt Nigeria. Int J Med Med Sci 2012;2:148-53.  Back to cited text no. 11
    
12.
Adoga AS, Otene AT, Unuajohwofia O, Nwaorgu OG. Upper airway obstruction requiring tracheostomy in Jos, Nigeria. J Med Trop 2007;9:41-6.  Back to cited text no. 12
    
13.
Olton S, Hariharan S, Chen D. Outcome evaluation of patients requiring tracheostomy in an intensive care unit in Trinidad. West Indian Med J 2009;58:173-8.  Back to cited text no. 13
    
14.
Muralidhar K. Tracheostomy in ICU: An insight into the present concepts. Indian J Anaesth 2008;52:28-37.  Back to cited text no. 14
    
15.
Nwaorgu OG, Onakoya PA, Ibekwe TS, Bakari A. Hoarseness in adult Nigerians: A University College Hospital Ibadan experience. Niger J Med 2004;13:152-5.  Back to cited text no. 15
    
16.
Rosen CA, Anderson D, Murry T. Evaluating hoarseness: Keeping your patient′s voice healthy. Am Fam Physician 1998;57:2775-82.  Back to cited text no. 16
    
17.
Schwartz SR, Cohen SM, Dailey SH, Rosenfeld RM, Deutsch ES, Gillespie MB, et al. Clinical practice guideline: Hoarseness (dysphonia). Otolaryngol Head Neck Surg 2009;141 Suppl 2:S1-31.  Back to cited text no. 17
    
18.
Rosen CA, Anderson D, Murry T. Evaluating hoarseness: Keeping your patient′s voice healthy. Am Fam Physician 1998;57:2775-82.  Back to cited text no. 18
    


    Figures

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    Tables

  [Table 1], [Table 2]



 

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Abstract
Introduction
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