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.