191 / 412
open group were for surgical scar revision. The other major
complications observed in our PT patients included loss of
airway, bleeding, and tracheo-innominate artery fistula, all
well-known risks of PT.
As we did not find the route of tracheostomy formation
to influence the incidence of tracheal stenosis, we attemp-
ted to identify factors that may have contributed to stenosis
formation. Numerous and variable risk factors for tracheal
stenosis following intubation have been suggested in the
literature and include trauma and inflammation at the
endotracheal tube cuff site, excess granulation tissue
around the tracheal stoma site or over a fractured cartilage,
high tracheostomy site, prolonged intubation, traumatic
intubation, or previous intubation or tracheostomy.
1
Both
groups in this study received tracheostomy within 7 days
of admission as per American College of Surgeons recom-
mendations. Our study demonstrated that patients who
developed tracheal stenosis tended to have longer mechan-
ical ventilator requirements (26.7 vs 16.1 days,
P
5
.055),
with patients developing stenosis being on the ventilator on
average 11 additional days. It could be hypothesized that
additional ventilator days meant more time with an inflated
tracheal cuff causing tracheal ischemia and stenosis. We did
identify that younger age and longer length of ICU stay
were associated with increased rate of tracheal stenosis;
however, the reason for these findings is unclear and these
findings were not observed in similar studies.
There are several limitations to our study. It is retro-
spective in nature with a relatively small sample size. Also,
the study time frame included the widespread introduction
of the percutaneous technique at our institution. The
associated learning curve for a new procedure may have
influenced the results or influenced which technique was
used to create the tracheostomy in specific patients. Also,
the percentage of patients seen after dismissal from the
hospital was unknown.
Common shortcomings of other investigations into this
topic are length and reliability of follow-up, thereby
calling into question the accuracy of the reported inci-
dence of tracheal stenosis. We have a unique practice
environment in which there are 2 level-1 trauma centers
serving the entire population center with extremely rural
surroundings. This leads to an isolated trauma population
for study. These centers inform each other of any
complications or admissions from each other’s population.
Additionally, the next closest trauma center for follow-up
for tracheal symptoms is 200 miles away. Because of this,
we do not believe that any patients were lost to follow-up
or transferred to the other trauma center with a compli-
cation of tracheal stenosis. Also, in our city, if a patient
presented to one of the other large multispecialty groups,
then that patient would be redirected to our clinic.
Evidence for this rests in the fact that 5 of the 9 tracheal
stenosis patients presented to our clinic in a delayed
fashion well after hospital discharge. These factors help
distinguish our follow-up results as compared with other
studies. This said, there still exists the possibility that late
occurring and/or subclinical tracheal stenoses may have
Table 3
Comparison of demographics, injury severity, mechanism of injury, hospitalization details, disposition, and death for patients
with tracheal stenosis versus patients without tracheal stenosis
Parameter
Tracheal stenosis
No tracheal stenosis
P
value
Value
Value
No. of subjects
9 (1.5%)
607 (98.5%)
Age (years)
*
29.8
6
11.8
45.2
6
20.6
.021
Sex (male)
6 (66.7%)
452 (74.5%)
.701
Injury severity score
†
30.0 (19.5, 37.0)
25.0 (17.0, 33.0)
.175
Glasgow coma scale score
†
3.0 (3.0, 13.0)
5.0 (3.0, 14.0)
.659
Mechanism of injury
1.000
Blunt
9 (100.0%)
572 (94.2%)
Penetrating
0 (.0%)
31 (5.1%)
Drowning
0 (.0%)
2 (.3%)
Burn
0 (.0%)
2 (.3%)
Admission to tracheostomy interval (days)
9.3
6
7.9
7.0
6
4.9
.175
Intensive care unit days
*
28.3
6
18.8
18.9
6
13.3
.036
Mechanical ventilation days
*
26.7
6
21.7
16.1
6
11.7
.055
Hospital length of stay (days)
*
40.0
6
21.7
26.9
6
25.6
.127
Disposition
.604
Home/home with home health care/jail/mental health facility
2 (22.2%)
77 (12.7%)
Rehabilitation center/select specialty hospital acute care/
other acute hospitals
7 (77.8%)
42 (69.4%)
Skilled nursing unit/nursing home
0 (.0%)
28 (4.6%)
Hospice/death
0 (.0%)
80 (13.2%)
Death
0 (.0%)
75 (12.4%)
.610
*Mean
6
standard deviation.
†
Median (25th and 75th percentile).
W.W. Kettunen et al. Tracheostomy complications in trauma
171