Management of patients who underwent classical and percutaneous tracheostomy in intensive care units

Abstract

Objectives. The article summarizes the indications for surgical tracheostomy (STS) and puncture dilatation tracheostomy (PDT) in patients who underwent mechanical ventilation in the intensive care units (ICU). Based on analysis of 502 case histories, the advantages and disadvantages of different types of tracheostomies were determined. The microbiota of the tracheobronchial tree of 40 patients after PDT was studied, the algorithm of postoperative management of patients who underwent tracheostomy in the ICU was described. We also reviewed endoscopic diagnostic and treatment methods for postintubation changes in the larynx and trachea and the main aspects of postoperative care. The revised approach to decannulation of patients allowed to reduce the duration of hospital stay.Results: Among patients after PDT (group 1; n = 164), 25 complications (15.2 %) were observed. Intraoperative complications (n = 4, 16 %): 3 technically difficult cases (12 %), when PDT had to be continued as an open surgical procedure; 1 case (4 %) of subcutaneous emphysema. Postoperative complications (n = 21, 84 %): 4 cases (16 %) of tracheoesophageal fistulas (TEF), 2 cases (8 %) of tracheomediastinal fistulas(TMF), 2 cases (8 %) of bleeding, 2 cases (8 %) of bilateral paresis of the larynx and 2 cases (8 %) of grade III ulcerative tracheitis, 6 cases (24 %) of a granulation process in the cervical trachea; 3 patients (12 %) required retracheostomy in the late postoperative period. According to the microbiological study, Klebsiella pneumoniae and Pseudomonas aeruginosa prevailed on days 1–3, Proteus mirabilis and Acinotobacter sp. on days 5–7, and Candida sp. was noted on day 10. Among patients after STS (group 2; n = 338), complications were noted in 20 (5.9 %), including 3 (15 %) intraoperative: 1 case (5 %) of pneumothorax, 2 cases (10 %) of damage to the membranous wall of the trachea with thedevelopment of TMF. Postoperative complications were observed in 17 cases (85 %), including 4 cases (20 %) of tracheal stenosis, 2 cases (10 %) of retracheostomy; 2 cases (10 %) of TMF; 3 cases (15 %) of a granulation process in the tracheostomy area, 1 case of bilateral paresis of the larynx (5 %), 3 cases (15 %) of grade III ulcerative tracheitis; 1 case (5 %) of mucosal pressure ulcer of the upper third of the posterior wall of the trachea, 1 case (5 %) of TEF.