ORIGINAL ARTICLES

TRACHEOTOMY I THE INTENSIVE CARE UNIT

LOCAL COMPLICATIONS OF ARTIFICIAL
AIRWAYS (TABLE I)
Any endotracheal intubation has certain complication risks
associated with the anatomical area through which the tube
may pass. Because of the differences in the way paediatric and
adult airways react to instrumentation, this discussion will
focus mainly on the application for adult intensive care unit
(lCD) patients.
Generally the intensivist has the following options available
with which to control the airway: (i) nasotracheal intubation;
(iz) orotracheal intubation; and (iii) tracheotomy - standard,
percutaneous and cricothyroidotomy.
Cricothyroidotomy is mentioned here for one reason only,
and that is to place it in proper perspective. Because of an
unacceptable long-term complication rate, especially regarding
subglottic stenosis, it should be reserved for dire airway
emergencies, and even then should be converted to a standard
tracheotomy as soon as possible.' It is important to realise that
the role of cricothyroidotomy is that of a life-saving procedure
and that any long-term placement of an endotracheal tube in
such close proximity to the cricoid cartilage should be
condemned.
Abrasion
Pressure
necrosis
Trachea-
oesophageal
fistula

Posterior glottic fusion
Subglottic stenosis
Arytenoid dislocation
Vocal cord palsy
Abductor failure
Table I. Local complications of intubation

Sinusitis
hygiene
Nasal ulcers
ulcers
However in the 1800s the situation started to improve, and in
1833 Armand Trousseau reported a 25% success rate for
tracheotomy performed in cases of diphtheria. This caused
such a vast improvement in the natural course of the disease
that he was awarded the prize of the Academie de Medecine in
ParisI
By 1909 Chevalier Jackson had standardised both the
technique and indications for the procedure, which at that
stage was performed mainly for upper airway obstruction." In
1943 the indications were expanded to include bronchial toilet
for patients with poliomyelitis
5
Long-term ventilation as an
indication for tracheotomy was added as a third indication
during the 1952 polio epidemic in Copenhagen.
Currently tracheotomy is a widely practised procedure with
an acceptably low morbidity and one that should have a
minimal mortality rate.
REVIEW ARTICLE
Whenever one attempts to gain an overview of a subject it is
always worth while, and usually humbling, to obtain a
historical perspective. So often in our modern arrogance we
merely succeed in reinventing the wheel.
Tracheotomy is certainly no different. The first known
descriptions of an incision into the trachea to alleviate upper
airway obstruction appeared in ancient Egypt 3 500 years ago.!
Popular legend has it that in 300 BC Alexander the Great found
one of his soldiers with a life-threatening throat injury, and
used his dagger to make an incision into the man's airway.'
UnforturJately the chronicles do not tell us whether the patient
survived; in earlier centuries terrible mortality usually
accompanied this procedure. Available records indicate that
only 28 successful tracheotomies were reported between the
years 1546 and 1815.
3
HISTORY
Airway management is a vital component of intensive care
unit treatment. Unfortunately, securing the airway poses
significant and often unrecognised risks to sensitive
structures such as the larynx. Pressure and trauma from an
artificial airway may occur anywhere in the involved
anatomical regions. There is a strong association between
duration of intubation and development of airway
complications. Long-term intubation may be associated with
some form of stenosis in up to 20% of cases. When
laryngostenosis becomes established, less than 20% of these
cases will eventually be successfully decanulated. TImeous
evaluation and early conversion to tracheotomy for patients
intubated for longer than 5 - 7 days will prevent many of
these unfortunate complications.
S Afr Med J1998; 88: 1444-1447.
SUMMARY
C R van Schalkwyk, W A Mclntosh
TRACHEOTOMY IN THE leD-
CURRENT OPINIONS
Department of Otorhinolaryngology, University of the Witwatersrand,
Johannesburg
C R van Schalkwyk, MB ChB, FCS (SA)
W A McIntosh, MB ChB, FCS (SA), FRCS (Edin), FRCS (Glasg), FACS
ovember 199 ,Vo!. ,No. 11 SAMJ
ORIGINAL ARTICLES
Oro/nasopharyngeal
Sinusitis is often mentioned as a complication of prolonged
endotracheal intubation. Opacification of maxillary sinuses
during prolonged nasotracheal intubation has been reported to
be as high as 96%; even with orotracheal intubation this figure
may be as high as 22.5%.' However, it should be pointed out
that not every opacified sinus in an reu setting is a clinically
significant sinusitis; for the diagnosis of reu sinusitis to be
confirmed, an organism cultured from the sinus under sterile
conditions should correspond with a bacteriological culture
obtained from the blood. Under these stringent conditions true
reu sinusitis is not that common'
The performance of thorough oral hygiene and mouth care is
certainly limited by the presence of a tube in the oral cavity.
Pressure effects from endotracheal tubes may cause
ulceration of mouth corners or nasal alae.
lo
Sloughing of
inferior turbinates and even sloughing of the soft palate has
been seen.
Laryngeal trauma
The position of the larynx relative to the oropharynx and
trachea is such that any rigid structure passing through all
three will tend to impinge on the posterior surface of the larynx
and cause maximum pressure effects in this area." The rigidity
of the posterior cricoid lamina will greatly enhance these
effects. Pressure on the mucosa that exceeds capillary filling
pressure will result in ischaemia and eventually lead to
necrosis of the tissue. The end result is a laryngeal pressure
sore in the posterior glottis.
The cricoid is the only complete ring in the upper respiratory
tract above the carina, making it the most important part of the
laryngeal skeleton as far as injury is concerned." Trauma to the
cartilage often leads to resorption and constriction, which in
turn results in a subglottic stenosis. An indwelling
endotracheal tube is quite capable of causing this kind of
trauma.
Traumatic intubation may result in dislocation of an
arytenoid, most commonly the left one," the reason for this
being that the tube enters the oral cavity from the right side
and then impinges obliquely on the left side of the larynx.
Unless this is noticed and corrected immediately the chances of
ever having a normally functioning crico-arytenoid joint again
are slim indeed.
Damage to the nerve supply of the larynx is thought to occur
when an inflated cuff is situated high in the airway, causing
pressure effects on the anterior branches of the recurrent
laryngeal nerves as they pass between the cricoid and
arytenoid cartilages. This may result in a unilateral, or more
rarely a bilateral, vocal cord palsy.
The normal larynx exhibits phasic movements associated
with breathing. Loss of the transglottic airflow resistance leads
to an absence of phasic inspiratory abduction, resulting in an
effectively immobilised larynx. Once endotracheal intubation
has caused ulceration in the larynx, the patient is already in
trouble. Performing a tracheotomy may remove the insult, but
the resulting immobile, traumatised larynx with apposition of
raw surfaces is the perfect setting for a posterior glottic fusion."
Tracheal trauma
Any inflated cuff in the tracheal lumen will have an abrasive
effect on the mucosa, depending on the amount of movement
taking place.
ls
With oro- or nasotracheal tubes cuff movement
may be as much as a centimetre or more with flexion or
extension of the head. Tracheotomy tubes also have some
movement, but not of the same magnitude as the longer tubes.
As far as damage caused by cuff pressure is concerned, it is
accepted that the pressure effects of the cuffs of endotracheal
and tracheotomy tubes are for all practical intents and
purposes vi.rrually identical.
'

It is quite clear from the previous paragraphs that the effects

of endotracheal intubation may be found at all anatomical
levels of the upper airways. Tracheotomy, on the other hand,
bypasses the first two levels, which from a laryngologist's
perspective is appealing because it spares the very sensitive
and vulnerable larynx.
INTUBATION V. TRACHEOTOMY
Intubation
Advantages of intubation to the reu physician are that no
surgeon is required and no surgery is involved. The reu
physician can perform it and there is no need for ca-ordination
with any other specialty. Accessibility is good, with all the
equipment immediately available in the reu, and it is usually a
very quick procedure. Although intubation is perceived to be a
reversible procedure, it should be pointed out that if laryngeal
trauma occurs, it might not be as reversible as one would like it
to be.
Several disadvantages are associated with ora- and
nasotracheal intubation. Both oral and nasal endotracheal tubes
may be difficult to secure" and suctioning of a long thin tube is
often problematic. Oropharyngeal and nasal trauma have been
mentioned before, but certainly bear emphasising again.
Sinusitis is probably less common than previously thought, but
most authors agree that removal of a nasal tube is indicated if
the diagnosis is suspected. By far the most important
disadvantage of endotracheal intubation is the trauma inflicted
on the larynx and the resultant impairment of its dynamic
functions.
Tracheotomy
A tracheotomy tube is easier to suction and secure than oral or
nasal tubes and certainly simplifies airway care." Although
there is a reduction of ventilatory dead space in the order of
50%, it is rarely considered to be of Significant clinical
advantage.
tO
Tracheotomy is much more comfortable for the
ORIGINAL ARTICLES
_._----
===:::::::::>- ITracheotomy I
mm
I
I
patient who is conscious and aware, and because there is less
movement of the cuff than with the endotracheal tubes, there is
less mucosal abrasion.
l7
However by far the most important
advantage of a tracheotomy is the fact that the larynx is
bypassed.
Surgical complications are some of the most often-quoted
disadvantages of tracheotomies. However operative morbidity
overall is less than 6%, even for tracheotomies performed in the
ICU.'8 Mortality directly attributable to the procedure is rare.
l9
The presence of a purulent-appearing discharge from a
tracheotomy site in the early postoperative phase is quite a
common finding. It is, however, unusual for this to be a sign of
true stoma sepsis. Much has been written about the
psychological impact of having a tracheotomy.l7 When one
looks at the overall psycholOgical implications for the patient
requiring ICU admission, however, the tracheotomy
contribution per se pales into relative insignificance. Because a
tracheotomy bypasses the transglottic airflow, causing loss of
the adductor reflex, an unexpected exacerbation of aspiration
might occur.'"
TIMING OF TRACHEOTOMY
The timing of an elective tracheotomy remains controversial.
The plethora of opinions on the subject is evidence of the fact
that no clear answer exists. Rather an opinion should be
formulated based upon an understanding of the
pathophysiological factors involved.
In 1984 Whited pointed out the association between duration
of intubation and the occurrence of post-intubation
laryngostenosis." Patients intubated for less than 5 days did
not demonstrate any laryngostenosis, whereas the incidence
rose to 14% for patients intubated for longer than 10 days. It is
accepted that long-term intubation may be associated with
some form of stenosis in up to 20% of cases.
In 1992 Feinstein
22
looked at patients with established
laryngeal trauma and compared intubation with non-
intubation trauma. In the group with non-intubation trauma
there was a 91% resolution rate, as opposed to the intubation
group, where less than 20% of patients had resolution of their
symptoms more than 2 years after onset. To be fair, the figures
do not compare apples with apples, because the non-intubation
group was treated correctly, whereas in our opinion the
intubation group was not. It does, however, highlight the
implications of laryngeal trauma that is not recognised and
managed adequately.
Opponents of early tracheotomy for possible long-term
intubation point out that less than 20% of patients develop
intubation-related complications and that therefore 80% of
tracheotomies would have been performed unnecessarily. On
the other hand, four out of five patients who do develop
laryngeal fibrosis will end up being permanent laryngeal
cripples with long-term tracheotornies.
22
To place the situation in numerical perspective, if 100
patients were intubated for longer than 10 days, 20 would be at
risk of developing some form of laryngostenosis." Of these 20
patients, 16 run a serious risk of being permanent laryngeal
cripples." If, on the other hand, the 100 patients had all
undergone early tracheotomy, less than 5 would have
developed an associated major or minor complication.
l9
In certain instances it is possible to individualise the decision
'regarding when the correct time would be to perform an
elective tracheotomy. A patient who is unlikely to survive does
not require an elective tracheotomy; on the other hand, a
patient who at the time of admission to the lCV is expected to
require ventilation for longer than 7 days should have an
elective tracheotomy performed as soon as possible.
As a general rule of thumb a decision between continued
intubation and conversion to tracheotomy should be made by
day 5 - 7 for adult patients. Ideally this decision should be
based on a thorough endoscopic assessment of the larynx.13 If a
patient is too unstable at this stage for endoscopy to be
performed safely and still cannot be extubated, then a
tracheotomy is indicated. If endoscopy is successful and
trauma is found to be limited to oedema of the cords,
superficial mucosal ulceration, or a small amount of
granulation tissue, then intubation can probably be continued
for another 48 - 72 hours before reassessment. If, however, deep
ulceration has occurred with exposed perichondrium or
cartilage, the patient should be extubated as soon as possible or
.converted to a tracheotomy to prevent any further damage (see
algorithm).13 The dilemma faced is that if the decision to
perform a tracheotomy is postponed until evidence of
laryngeal trauma is found, then that patient is already at
I Day '-2 Intubation for >7days? I
/,
~ ~
U
IDay 5-7 Intubation for >7days? I
====:::>>- ITracheotomy I
I Assess larynx I= IUnable I :>- ITracheotomy I
, . - - , - - - - ~ - ,----
Superficial trauma I I Deep trauma I
IExtubatable? I
/\
~ ~ ---(> ITracheotomy I
Intubation tracheotomy algorithm.
o\'ember 199 ,Vol. , No. 11 SAMJ
ORIGINAL ARTICLES
significant risk of developing laryngostenosis. The key to
success is to prevent damage in the first place.
The argument has also been raised that the most pressure
effects in the airway are found at the level of the cuff and that
these are the same for both endotracheal and tracheotomy
tubes. Although this is true, it should be seen in perspective.
Firstly, the trachea is not a dynamic structure; secondly,
because it is not a circumferentially rigid structure, it is not as
sensitive to pressure effects as the larynx; and thirdly, tracheal
stenosis is much more amenable to surgical correction than
laryngostenosis.
CONCLUSION
In an ideal world no tube would ever pass through any larynx.
Unfortunately we do not live in an ideal world, which is one of
the reasons why we have ICUs and potential for long-term
intubation. A significant amount of time, energy and money is
spent on prevention of bedsores. Patients are placed on ripple
mattresses, turned regularly and rubbed with alcohol. Our plea
is that the state of 'laryngeal bedsores' be similarly recognised,
its implications realised, and its prevention vigorously
pursued.
References
1. Van Heum LWE. Brink PRG, Kootstra G. De gesc.hiedenis van de tracheotomie. Ned Tijdschr
Gmmkd 1995; 139, 2674-2678.
2. Alberti PW. Tracheotomy versus intubation. A 19th century controversy. Ann Otol Rhino
LAryngoI1984; 93, 333-337.
3. Goodal1 EW. The story of tracheotomy. British Journal of Childrm's Diseases 1934; 31: 167-176.
.;. Jackson c. Tracheotomy. LAryngoscope 1909; 19, 285-290.
5. Galloway TC Tracheotomy in bulbar poliomyelitis. JAMA 194-3; 123: 1096-1097.
6. Lassen HCA. A preliminary report on the 1952 epidemic of poliomyelitis in Copenhagen
with special reference to the treatment of acute respiratory insufficiency. LAncet 1953; 1: 37-
.;!.
7. Boyd AD, Romita MC, Conlan AA, Fink 50, Spencer Fe A clinical evaluation of
cricothyroidotOffi}'- Surg Gyllecol Obstet 1979; 149: 365-368.
8. Rouby jJ, Laurent P, Gosnach ~ , t , et al. Risk factors and clinical relevance of nosocomial
maxillary sinusitis in the critically ill. Am JRespir Crit Care Med Im; 150: 776-783.
9. Weymuller EA jun, Rice OH. Surgical management of infectious and inflammatory disease.
In, Cummings CW, Fredrickson ~ I , Harker LA, Krause Cj, 5chuller DE, eds. Otolo'Yngology
- Head and Neck Surgery. 2nd ed. St Louis, Mosby-Year Book, 1993, 9- 960.
10. Da\-is NJ. Endotracheal intubation and tracheostomy. In: Oh TE, ed. Intensive Core M!lnll.al.
Sydney: Buttenvorths, 1990: 150-153.
11. Heffner JE. TlID.ing of tracheotomy in mechanically ventilated patients. Am Rev Respir Dis
1993; 147, 768-771.
12. Cotton RT, Myer CM. Contemporary surgical management of laryngeal stenosis in children.
AmJOtoloryngoI1984; 5, 360-368.
13. Benjamin B. Laryngeal trauma from intubation: Endoscopic evaluation and classification. In:
Cummings CW, Fredrickson JM, Harker L-'\, Krause Cj, 5chuller OE, eds. Otolaryngology-
Head and Nrck Surgery. 2nd ed. St Louis' "Iosby-Year Book, 1894-1895.
14. Asher VA, 5asaki cr, Gracco Le Laryngeal physiology. In, Fried MP. The LArynx. A
Multidisdplinary Approach. 2nd ed. St Louis' Mosby-Year Book, 1996, 51-53.
15. Zalzal GH. Cotton RT. Glottic and subglottic stenosis. In: Cum.mings CW, Fredrickson IM,
Harker LA, Krause Cl, 5chuller DE, e<!s. Otolaryngology - Head and Neck Surgery. 2nd ed. St
Louis, Mosby-Year Book, 1993, 198-1.
16. Coppolo Dr. May JJ. 5elf-extubatioos. A 12-month experience. Chest 1990; 98, 165-169.
17. Astrachan 01, Kirchner JC, Goodwin WJ jun. Prolonged intubation vs tracheotomy:
Complications, practical and psychological considerations. Laryngoscope 19 ': 98: 1165-1169.
18. Pogue MD, Pecaro BC. Safety and efficiency of elective tracheostomy performed in the
intensive care unit. / Oral MDXilloJac Surg 1995: 53: 895-897.
19. Stock MC, Woodward CG, Shapiro BA, Cane RD, Lewis V, Pecaro B. Perioperative
complications of elective tracheostomy in aitically ill patients. Crit Care Med 1986; 14: 861-
863.
20. Sasaki cr, Suzuki M, Horiuchi M, Kirchner JA. The effect of tracheostomy on the laryngeal
closure reflex. LAryngoscope 1977; 87, 1428-1433.
21. Whited RE. A prospective study of laryngotracheal sequelae in long-term intubation.
LAryngoscope 198-l; 94, 367-377.
22. Feinstein JH. A four year retrospective analysis of laryngeal trauma at the Johannesburg
HospitaL MNted (OrI) thesis, University of the Wit\vatersrand, Johnannesburg. 1992..
OUTCOME OF MECHANICAL
VENTILATION IN CHILDREN
INFECTED WITH THE HUMAN
IMMUNODEFICIENCY VIRUS
L Rudo Mathivha, David K Luyt, Hubert Hon, Melanie
Dance, Menachem Litmanovitch
ABSTRACT
Objective. To evaluate and compare the outcome of HIV-
positive (HIV+) and negative (HIV-) paediatric patients
presenting with severe community-acquired pneumonia and
requiring mechanical ventilation for respiratory failure.
Design. Prospective descriptive analysis.
Setting. Multidisciplinary intensive care unit (lCD) in a
tertiary care university-based referral hospital, staffed by
paediatric intensivists and anaesthetists.
Patients. All 110 paediatric patients admitted to the ICD with
severe community-acquired pneumonia requiring mechanical
ventilation during the 2 years 1992 through 1993. No patient
had any defined clinical manifestations of acquired
immunodeficiency syndrome on admission to the lCU.
Methods. HIV infective status was determined by p24 antigen
detection. Age, nutritional status, predicted mortality,
ventilatory requirements, oxygenation indices, other organ
dysfunction and mortality were compared between the 17
HIV+ and 93 HIV- patients.
Results. The patient groups did not differ significantly with
regard to age or nutritional status. The ventilatory
requirement measurements, positive end-expiratory pressure
time product, fraction of inspired oxygen (FiO,) time product,
and measurements of oxygenation were significantly worse
in HIV+ patients_ IDV+ patients had a mean predicted
mortality of 40_1% compared with 22.2% in HIV- patients on
admission. Mortality was dose to predicted in the HIV-
group at 31% (29/93), while in the HIV+ patients mortality at
88% (15/17) was significantly worse than predicted. All
deaths in the HIV+ group were due to severe respiratory
failure.
Intensive Care Uni/, Department of Anaesthesia and Intensive Care, Chris Hani
Baragwanath Hospital and University of the Witwatersrand, Johannesburg
L Rudo Mathivha, FCPaed (SA), FCCrit Care
David K Luyt, FCPaed (SA), FCCrit Care
Hubert Hon, FCPaed(SA)
Melanie Dance, FCPaed (SA), FCCrit Care
Menachem Litmanovitch, MD