The Science Journal of the American Association for Respiratory Care

2006 OPEN FORUM Abstracts

INCIDENCE OF TRACHEOSTOMY TUBE MALPOSITION IN PATIENTS RECEIVING LONGTERM MECHANICAL VENTILATION.


Susan E. Lagambina, RRT; H. Thomas Stelfox, MD, PhD; Jean Kwo, MD; Dean R. Hess, PhD, RRT, FAARC; Elise M. Gettings, MPA, RN; Luca M. Bigatello, MD; Ulrich Schmidt, MD, PhD. Massachusetts General Hospital and Harvard Medical School, Boston, MA


Type of malposition (> 1 for some patients)
Cuff in Stoma 3%
Posterior tracheal wall occluding tube 92%
Tube too short horizontally 5%
Tube too short vertically 3%
Granuloma 15%




Background. Anecdotally, we have noted tracheostomy tube malposition, resulting in partial occlusion of the tracheostomy tube, as a barrier to successful weaning from mechanical ventilation. The purpose of this study is to determine the incidence of tracheostomy tube malposition in patients undergoing prolonged mechanical ventilation. Methods. We performed a retrospective review of all adult patients with a tracheostomy admitted to the respiratory acute care unit at the Massachusetts General Hospital which specializes in weaning from mechanical ventilation. The medical records of all patients admitted between July 1, 2002, and December 31, 2005, were reviewed. Tracheostomy tube malposition was defined as bronchoscopic evidence of >50% occlusion of the distal end of the tube. Each bronchoscopy report was reviewed independently by 2 clinicians familiar with interpretation of bronchoscopy findings. The clinical response to the tracheostomy tube malposition and the disposition of patients was also collected from the medical record. Results. The medical records of 431 patients were reviewed. We identified 39 cases of tracheal tube malpositions, an incidence of 9% (95% confidence interval 6% to 12%). Median time from tracheotomy to diagnosis of tube malposition was 12 days. The types of malposition identified are summarized in the Table. Patients with tracheostomy tube malposition were more likely to have a tube change (69% versus 35%, p < 0.001).  The length of hospital stay after tracheotomy was significantly longer in patients who had tracheostomy tube malposition (34 days versus 25 days, p = 0.03). Conclusions. The 9% incidence of tracheostomy tube malposition that we report suggests that this is not a trivial issue in long term mechanically ventilated patients. According, clinicians caring for these patients should have a high index of suspicion for this problem in patients with a tracheostomy who fail repeated weaning attempts. High ventilating pressures, high airways resistance, and auto-PEEP unexplained by the patient's underlying lung disease should prompt consideration of tracheostomy tube malposition. More study is needed to identify the risk factors associated with this complication.

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