Thorax: first published as 10.1136/thx.20.1.87 on 1 January 1965. Downloaded from Thorax (1965), 20, 87 Tracheostomy in a thoracic surgical unit D. B. CLARKE' From Harefield Hospital, Harefield, Middlesex The first authenticated instance in which tracheo- (Nelson, 1958; Head, 1961; Meade, 1961; Watts, stomy was performed was in 1546 when 1963). Brasavola (Guthrie, 1944) relieved respiratory The patients referred by physicians had gross obstruction in a patient who was probably destruction of lung tissue resulting from chronic suffering from Ludwig's angina. From then until bronchitis and emphysema or tuberculosis, and as the second world war obstruction of the upper a result of superadded infection or spontaneous respiratory passages remained the sole indication pneumothorax they had progressed to a state of for this operation. It was a procedure regarded respiratory failure with carbon dioxide retention. with distrust, being in fact referred to as 'the Four tracheostomies were performed for less scandal of surgery', but in recent years its indica- precisely defined conditions which included tions have been extended, its potentialities more myasthenia gravis, the rupture of an empyema precisely defined, and its limitations more critically into the bronchial tree, and in two cases malignant appraised. In this study an analysis has been cachexia (Table I). made of the tracheostomies performed during the The indications for tracheostomy are retention past five years in a thoracic surgical unit. This of sputum because of an ineffective cough, unit consists of 87 beds which also serve general inadequate ventilation of the lungs, obstruction of copyright. medical and chest wards. the airway above the tracheal level, and after cardiac surgery (Table II). Bjork and Engstrom CLINICAL MATERIAL (1955) suggest that an arterial Pco2 above 70 mm. Hg is a strong indication for tracheostomy, INDICATION FOR TRACHEOSTOMY A total of 69 but in this series we have been guided by the http://thorax.bmj.com/ tracheostomies were performed in five years. Of clinical signs of hypercapnia, i.e., shallow respira- these, 52 % followed lung resections; the tion, stupor, a hot flushed skin with an elevated remainder were carried out after cardiac and blood pressure, and a bounding pulse. In a patient oesophageal surgery, in patients with respiratory who showed signs of sputum retention, tracheo- failure who had been referred from the medical stomy was usually deferred until physiotherapy wards, for respiratory obstruction, chest injury, had been given an adequate trial or bronchoscopic and in unconscious patients who were incapable of aspiration of secretions had failed to provide more coughing (Table I). In other series the most than temporary relief. The timing of the operation on September 30, 2021 by guest. Protected frequent indications have been head and chest is important. There is little to be gained from injuries and paralysis of the muscles of respiration persisting with physiotherapy when it becomes obvious that nothing is being achieved other than TABLE I the exhaustion of the patient. There is a large CONDITIONS IN WHICH TRACHEOSTOMY WAS PER- measure of truth in the adage that the right time FORMED, WITH MORTALITY to perform tracheostomy is when the likelihood of its being necessary is first suggested. of Condition No. TotalT of Deaths Total Intermittent positive pressure ventilation using Pulmonary resections .. 36 52 16 55 a mechanical respirator was used in 218% of Respiratory failure .. .. 9 13 4 13-8 Cardiac surgery .. .. 7 10-3 4 13-8 cases. The conditions in which tracheostomy was Airway obstruction .. .. 6 8-7 0 0 performed are detailed in Table I and the indica- Oesophageal surgery .. 3 4-3 1 3-4 Chest injuries .. .. 2 2-9 1 3-4 tions for tracheostomy in these conditions are Unconsciousness .. .. 2 2-9 1 3-4 Miscellaneous 4 5*8 2 6-8 given in Table II. Total .69 29 42 TRACHEOSTOMY IN LUNG RESECTIONS An analysis of the 36 lung resections shows that 50% of the 1Present address: The United Birminsham Hospitals tracheostomies in this group followed left 87 G Thorax: first published as 10.1136/thx.20.1.87 on 1 January 1965. Downloaded from 88 D. B. Clarke TABLE II INDICATIONS FOR TRACHEOSTOMY Resections - Indication Left Right Left Left Right Right Rteray Cardiac Obstruc- pagealsTrauma Miscel- Total Pneumo- Pneumo- Lower Upper Middle Upper Failure Surgery tion Surgery l aneous nectomy nectomy Lobe Lobe Lobe Lobe Respiratory_ _ insufficiency 4 I 0 0 0 9 I 0 2 8 Sputum retention 9 5 1 1 2 1 0 1 0 21 Elective Poor respira- tory function 3 i3 Cardiac ..4 4 Paradoxl Unconsciousness 1 3 Bronchial fistula I 1 Airway obstruc- tion .6 6 Cardiac failure 213 pneumonectomy (Table III). In nearly half of these to take some of the strain from a doubtful there was evidence of damage to the left recurrent bronchial suture line after pneumonectomy. It may laryngeal nerve which must have been sustained be indicated for the same reasons after sleeve when the sub-aortic lymph nodes were excised. resection, with the added incentive that marginal Right pneumonectomy accounted for 25% of the respiratory function may well have been an indica- total, and lobectomies for the remaining 25% tion for such a procedure and that the residual (Table III). lung on the side operated upon is peculiarly liablecopyright. to sputum retention. The development of a TABLE 111 bronchopleural fistula with spill-over into the ANALYSIS OF TRACHEOSTOMIES IN PULMONARY RESECTION contralateral lung has been a further indication in two instances in this series. of Type of Resection No. % Deathst of Total Total Resections http://thorax.bmj.com/ TRACHEOSTOMY IN OTHER CONDITIONS The value L. pneumonectomy 18 50 8 50 R. pneumoniectomy 9 25 3 1875 of early tracheostomy in major chest injuries has L. lower lobectomy 2 5 5 () L. upper lobectomy 2-8 1 6-25 been established. R. middle-lower lobec- I 6-25 There are only two cases in this series because tomy .. 2 5 5 t , 625 R. upper lobectomy 4 I1-l 3 18-25 this hospital is not served by a casualty depart- movement the Total .. .. 36 16 55 ment. Both had paradoxical of chest wall, and in each the mere performance of tracheostomy reduced the paradox to such a de- Sputum retention was the commonest indication. gree that positive pressure respiration was on September 30, 2021 by guest. Protected In these cases an inadequate cough resulted from unnecessary. general weakness, pain or paralysis of one vocal The six cases of airway obstruction were due to. cord. Ventilatory inadequacy, the next commonest malignancy at laryngeal level, Ludwig's angina, cause, resulted from poor function of the residual and laryngeal oedema. lung, shallow respiration because of pain or weak- Tracheostomy is of value in respiratory failure ness, and from paradoxical movement either of in patients with gross diminution of pulmonary the chest wall, when part of this had been excised, function for three reasons: by reducing the dead or of the diaphragm when the phrenic nerve had space by approximately 100 ml. the alveolar been damaged at operation (Bjork and Engstrom, ventilation is nearly doubled; when carbon dioxide 1955;. Minnis and Griffin, 1961). When pre-opera- retention is established, assisted ventilation with tive lung function studies indicated a marginal a mechanical respirator not only washes out excess respiratory reserve elective tracheostomy was CO2 but also corrects anoxia; the excessive carried out at the time of operation in three bronchial secretion usually found in these patients instances. can be effectively sucked out. By preventing the build-up of intra-bronchial Tracheostomy combined with intermittent pressure before explosive decompression in the acl positive pressure respiration may assist patients of coughing, tracheostomy may be used electively subjected to cardiac surgery in several ways. It- Thorax: first published as 10.1136/thx.20.1.87 on 1 January 1965. Downloaded from Tracheostomy in a thoracic surgical uinit 89 ensures adequate oxygenation at all times in a cultured from the trachea was in no case the same group of patients in whom anoxia can be critical as those present in the sputum before tracheo- or even fatal. In the resting subject, about 25% stomy; 11 were infections with penicillin- of work done by the heart is expended in the resistant staphylococci and five were due to mechanical work of respiration. In mitral valve Pseudomonas pyocanea. Their studies showed disease this figure may be more than doubled. It that these organisms were derived from the follows therefore that by taking over respiration hospital environment. They must have been with a ventilator this burden is largely removed introduced into the trachea either by the suction from the heart. Further, the increase in gas catheter or from the patients' own skin. In two tension in the alveoli produced by I.P.P.R. tends cases, death resulted from bronchopleural fistula to counteract those forces which produce and in four from respiratory failure. Six patients pulmonary oedema. It has been the practice in this had tracheostomy performed after having unit of late to carry out an elective tracheostomy sustained an injury to the- recurrent laryngeal nerve in patients with mitral incompetence who have at left pneumonectomy; five of these died. There a high left atrial pressure after surgery, and were no immediate deaths in the group which had routinely after total correction of Fallot's airway obstruction above tracheal level. The fact tetralogy. that five out of nine patients who would inevitably have died from respiratory failure due to MORTALITY On first inspection, an overall degenerative lung disease with superadded infec- mortality of 42% is alarming and liable to obscure tion were saved is sufficient proof of the efficacy the very real value of tracheostomy.