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Department of Surgery, University of Miami School of Medicine and Jackson Memorial Hospital. Dr. Meyer is a National Institutes of Health trainee

The most common postoperative sầu complications are those involving respiration, và they are especially dangerous lớn patients classified as poor risks because of age or other handicaps. Ahy vọng the 11 patients whose histories are given, some who were nearly moribund from respiratory difficulties were saved by tracheostomy; others made good recoveries from major surgery under conditions that would have sầu been hopeless without the help afforded by prophylactic tracheostomy. If this possibility is foreseen, an orderly procedure can be carried out in the operating room instead of desperate measures on the ward. Scrupulous care of the tracheostomy is essential; this includes aseptic precautions, humidification of the inhaled air or oxyren, & the systematic but gentle use of suction lớn aspirate accumulating mucus.

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The value of tracheostomy in the postoperative care of certain thoracic and neurosurgical patients has been recognized for some time,1 but there has not been widespread acceptance of this procedure as an adjunct to therapy for the critically ill general surgical patient. The present report concerns the prophylactic use of tracheostomy in a series of aged & bad risk patients. For each of these patients a major operation was deemed mandatory, but the prognosis for immediate postoperative survival was poor because of debilitation and independent pulmonary or cardiovascular disease. The objectives of tracheostomy were to allow maximum utilization of pulmonary reserve và lớn prevent postoperative sầu pulmonary complications.

The most comtháng postoperative sầu complications are related to the respiratory system.2 These complications, which may only be a source of morbidity in younger people, carry serious implications for feeble geriatric or poor risk patients. Preexisting pulmonary disease plus loss of the strength necessary for powerful coughing and ventilation have already reduced the respiratory reserve sầu. The additional factors of anesthesia and postoperative sầu pain may lead to lớn a condition in which retained secretions, atelectasis, & pneumonitis are lethal. A pulmonary complication can develop with such subtlety that its presence is not suspected.1 The resultant anoxia or hypercapnia may be manifest in altered function of the heart, brain, kidney, or other organs in this type of patient. These structures often exhibit such marked pathological changes that compensated function can continue only within a narrow margin of safety và under optimal environmental conditions. The cause of death in these circumstances is frequently designated as coronary occlusion, cerebrovascular accident, renal failure, or other cause, while actually the initiating factor was disruption of a delicately balanced homeostatic state by hypoxia.

It has been our experience with poor risk patients that pulmonary complications can be predicted with a high degree of accuracy on the basis of the preoperative sầu history & physical examination. In the past we have sầu treated these patients by standard methods of preoperative sầu và postoperative sầu bronchopulmonary nhà vệ sinh,3 only to see problems of hypoxia and/or hypercapnia develop. If a respiratory complication arises in this type of patient, treatment by any means is likely lớn be unsuccessful.

Postoperative sầu pulmonary difficulties were anticipated in the patients included in the present study. The cases were reviewed with the department of anesthesiology & the decision for prophylactic tracheostomy was usually made well in advance of the proposed operation. Tracheostomy was done in the operating room immediately after completing the primary procedure or during the first few postoperative sầu hours.

It has been our impression that tracheostomy has extended the limits of operability to lớn include certain aged và poor risk patients who could not otherwise have sầu been expected to survive sầu a major surgical procedure. The present report documents the use of this prophylactic measure in one of the general surgical charity services of the Jackson Memorial Hospital during a recent three-month period (January through March, 1958).


Case 1

This moribund 65-year-old woman was admitted on Jan. 6, 1958, after six days of abdominal pain, vomiting, & distention. Examination showed wet lungs & peritonitis with abdominal distention. X-rays showed bilateral basilar atelectasis, massive sầu pneumoperitoneum, & distention of the small intestine. At celiotomy, a perforated sigmoid diverticulum was found, with fecal peritonitis and adhesive obstruction of the ileum. Treatment consisted of closure of the perforation, transverse colostomy, decompression of the small intestine, lysis of adhesions, abdominal drainage, and gastrostomy. Digitalization was necessary during surgery. Tracheostomy was performed after wound closure. Postoperatively the patient improved steadily for six days, & then had an exsanguinating gastric hemorrhage necessitating rapid replacement with 2,500 cc. of blood & 1,000 cc. of plasma expander. She was reexplored, và a bleeding prepyloric ulcer was found và suture-ligated. Anesthesia was induced through the tracheostomy. Tracheobronchial care, including management of aspirated blood, was facilitated by the tracheostomy. She recovered slowly until bleeding recurred four days later, requiring a transfusion of 3,000 cc. of blood, at which time she was returned khổng lồ surgery for gastrectomy. Anesthesia was again induced through the tracheostomy & bronchoscopy was performed at the conclusion of the procedure. Her recovery was slow but without further complication. On Feb. 3, radiography showed that the atelectasis which was present at the admission had cleared. The cannula was removed 32 days after admission. She was discharged on Feb. 17 and has remained well since.


Comment

This critically ill patient would probably not have survived any one of the three procedures without a carefully managed tracheostomy. At the time of gastric hemorrhage, blood aspiration was so overwhelming that no other measure would have sầu allowed the consistent maintenance of a patent airway.


Case 2

This 57-year-old man, with an incompletely obstructing carcinoma of the rectum, was admitted with chills, fever, dyspnea, & diarrhea & had lost 40 lb. (18.1 kilogam.), His chest was emphysematous with diffuse rales bilaterally. Chest x-ray revealed chronic interstitial fibrosis. He was treated for bronchopneumonia with clinical improvement but without striking change in the x-ray findings. On Feb. 7, 1958, an abdominoperineal resection was done, followed by a prophylactic tracheostomy. The patient’s early convalescence was uncomplicated và the tracheostomy was removed on the sixth postoperative day. He developed obstruction of the small intestine eight days after surgery which was unresponsive to intestinal intubation. Lysis of adhesions was carried out three days later và the tracheostomy cannula was replaced through the original incision. Seven days after reexploration he resumed a full diet và the cannula was again removed. He was discharged on March 10 và has been well since.


Comment

In this case tracheostomy was indicated by chronic disabling lung disease with a recent superimposed acute-infection.


Case 3

This 74year-old man was admitted with a four-month history of pain in the right upper quadrant & had lost 40 lb. (18.1 kilogam.). There was a palpable mass in the right upper quadrant. For the preceding nine years he had had progressive sầu dyspnea and severe asthma. Examination revealed an emphysematous chest with widespread inspiratory & expiratory wheezes. Chest fluoroscopy showed diffuse air trapping, enlargement of the pulmonary artery, & fired diaphragms. Electrocardiogram findings suggested coronary insufficiency. At operation on Feb. 7, 1958, he was found to lớn have sầu empyema of the gallbladder and a walled-off subhepatic abscess which contained many stones. The gallbladder & abscess were excised, the comtháng ducts explored, a T-tube was inserted, and tracheostomy was performed. During convalescence the tracheostomy was supplied with room air which had been pumped through Alevaire (sterile aqueous solution of Superinone in combination with glycerin & sodium bicarbonate). The use of bronchodilators, which had started a week before surgery, was continued. Postoperative tracheobronchial care was not a problem, even though the patient was disoriented and irrational during the first four days. On the sixth day after surgery the cannula was removed. He was discharged on the 13th day after operation and subsequently has had the T-tube removed in the clinic.


Comment

Prophylactic tracheostomy was done because this patient was a pulmonary cripple. In patients with emphysema the use of pure oxyren should be avoided because of the danger of inducing hypercapnia.


Case 4

This 79-year-old man was admitted for treatment for carcinoma of the stomach. He had been followed in the medical clinic for two years with intractable heart failure. On admission he suffered from decompensation, with edema, bilateral massive sầu pleural effusion, rapid atrial fibrillation, và uremia. An abdominal aortic aneurysm was present with peripheral vascular insufficiency (no pulses below the femoral arteries). A radical subtotal gastrectomy was performed on Feb. 7, 1958, after extensive preparation. Prophylactic tracheostomy was done at this time. His immediate postoperative condition was satisfactory, but two days after surgery he developed evidence of cerebral và femoral emboli. A left iliofemoral embolectomy was carried out. Several toes became gangrenous & on Feb. 13 a mid-thigh amputation was done. His condition gradually deteriorated & he developed giant decubiti. Despite the tracheostomy, tracheobronchial care became progressively more difficult. He died one month after surgery, on March 7, 1958. Autopsy findings included extensive sầu old infarct of the left ventricle, recent mural thrombus of the left atrium, multiple renal infarcts, severe generalized arteriosclerosis, bilateral bronchopneumonia, and various pathological signs of cardiac decompensation.


Comment

This was the only patient in the series in whom a pulmonary complication arose after tracheostomy. The development of severe terminal bronchopneumonia must be explained by inadequate tracheostomy care.


Case 5

This 83-year-old man was admitted on Feb. 7, 1958. He had been followed for five sầu years in the outpatient department because of hypertension và periodic heart failure. He had been known to have sầu complete left bundle-branch bloông chồng for this period. Chest x-ray on admission showed bilateral pulmonary congestion. On the day of admission cholecystectomy was performed for gangrene of the gallbladder. Prophylactic tracheostomy was considered at the time of surgery but was not done. Although he recovered promptly from anesthesia, during the next 10 hours he became moribund with irrational and irritable behavior, tachycardia, & wet lungs. Endotracheal suction gave sầu only temporary relief. Tracheostomy was done at this time. Improvement was rapid và after a few days recovery seemed assured. He subsequently developed a subhepatic abscess, which was drained with the patient under local anesthesia. Massive sầu hemorrhage occurred from the depths of the abscess during the third, fourth, & fifth postoperative weeks, necessitating transfusions of 6,000 cc. He developed intractable heart failure và died on March 18, 1958. During his last week of life he required repeated thoracenteses for a right pleural effusion. Serial chest x-rays during the five-week postoperative period showed no evidence of intrapulmonary complication except for atelectasis at the right base of the right lung, which was thought lớn be secondary to the subhepatic abscess. Permission khổng lồ perform autopsy was not granted.


Comment

This patient served as his own control in evaluating the role of tracheostomy in the determination of immediate postoperative sầu survival. Prophylactic tracheostomy was considered at the time of surgery and rejected. As a result of this error in judgment the tracheostomy became an urgent measure several hours later, after his condition had deteriorated badly.


Case 6

This 85-year-old man was admitted for the treatment of a large carcinoma of the gastric antrum. He had been receiving digitalis since a myocardial infarction 15 years prior to lớn admission, & for one year heart failure had been increasingly difficult lớn control despite constant bed rest. Physical examination revealed an emphysematous chest with distant breath sounds. He was a very feeble old man. Chest x-ray showed emphysema and slight cardiomegaly. An electrocardiogram revealed a complete left bundle-branch blochồng. On Feb. 18 radical gastrectomy was performed, with removal of 85% of the stomach, và a prophylactic tracheostomy. The tracheostomy was postoperatively supplied with oxygene which had been passed through Alevaire. Although he aroused promptly after anesthesia, he was alternately confused and comatose until the fourth postoperative day, but subsequently improved rapidly. The cannula was removed on the sixth postoperative sầu day và the patient was discharged 13 days after surgery. He has continued khổng lồ vì chưng well và is now living at a convalescent trang chính.

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Comment

This octogenarian had not been able khổng lồ leave bed for one year prior to admission due to lớn severe heart disease complicated by emphysema. The prevention of anoxia during a difficult convalescence was facilitated by the tracheostomy.


Case 7

This 75-year-old man was admitted on Feb. 21, 1958, with abdominal pain and jaundice. Chest x-ray revealed bilateral basilar atelectasis. His condition deteriorated rapidly & within four days he developed anuria, hyperpyrexia, và hypotension. On the fifth day after admission, common duct drainage and tracheostomy were performed with the patient under local anesthesia. The patient’s temperature then returned to normal, & kidney function was restored. The jaundice deepened, however, và the patient died 26 days after surgery. At autopsy the basilar atelectasis was found khổng lồ have cleared và the only pulmonary abnormality was congestion of the lungs. Autopsy also revealed far-advanced biliary cirrhosis with multiple intrahepatic stones in both the right và left hepatic ducts.


Comment

Like several other patients in this series this man went inlớn surgery with a previously established respiratory complication. The pulmonary status improved with tracheostomy despite deterioration of his general condition.


Case 8

This 49-year-old man had an 11-year history of progressive muscular dystrophy involving both legs and both arms as well as the accessory muscles of respiration. He had one-bloông chồng exercise tolerance và after prolonged conversation became dyspneic. On Feb. 28, 1958, he underwent cholecystectomy & common duct exploration. Because of his neurological disability a prophylactic tracheostomy was done. Because of feeble respiratory efforts và excessively thiông xã mucus there was great difficulty in keeping the tracheobronchial tree clean postoperatively. He was disoriented for the first two days after surgery và on the second day he aspirated gastric contents và nearly became asphyxiated. Suction was applied immediately & bronchial wash carried out with saline solution. He showed improvement after this, but a chest x-ray on the fourth postoperative sầu day showed disk atelectasis at both bases. His chest gradually cleared and the tracheostomy cannula was removed 10 days after surgery. He was discharged trang chủ two days later.


Comment

Extensive neurological disability made postoperative tracheostomy mandatory in this case. Death from aspiration of gastric contents in the early postoperative sầu period would probably have sầu resulted without this precaution.


Case 9

On March 5, 1958, this 74-year-old woman was brought lớn the emergency room in shoông xã after having been struông chồng by an autodi động. She had multiple injuries, including a traumatic amputation of the left leg, extensive sầu soft tissue injury of the right leg, hemothorax, and fractures of the left second to eighth ribs, left scapula, and right superior và inferior pubic ramày. After transfusion of 4,000 cc. of blood and plasma she was taken to the operating room for a left supracondylar amputation and débridement of other wounds. Tracheostomy was not done. Fifteen hours after surgery she was irrational, dyspneic, ashen, and clammy. Tracheostomy was performed with immediate benefit. Her condition was critical for many days but improvement was steady. The hemothorax was evacuated with repeated thoracenteses. Despite the serious chest wall injury neither atelectasis nor pneumonitis developed. The tracheostomy tube was removed on the eighth postoperative sầu day. The patient was discharged in good condition on the 22nd postoperative sầu day, and has subsequently returned khổng lồ her home in New Jersey.


Comment

This is the type of crushed-chest injury for which Carter4 recommended early tracheostomy. The unnecessary delay in this case nearly cost the patient her life.


Case 10

This 71-year-old man had had dyspnea on exertion & severe nocturnal asthma for several years. Chest x-ray & electrocardiogram were normal. The present admission was for unremitting obstructive jaundice. On March 10, 1958, a pancreaticoduodenal resection was performed. Prophylactic tracheostomy was considered because of the patient’s history of asthma but was not done. For the first few hours after surgery there were no pulmonary difficulties but after this the patient’s condition deteriorated rapidly despite the use of bronchodilators, forced coughing, & endotracheal suction. He developed extreme dyspnea, carphology, hallucinations, tachycardia, & bilateral diffuse rales. His condition was grave 18 hours after surgery. Tracheostomy was performed with removal of profuse thiông chồng secretions và the patient showed immediate improvement. Subsequently he developed persistent fever và nine days postoperatively a subhepatic abscess was drained. His condition again improved but on March 28 he developed high intestinal obstruction. He was reexplored on April 2, và jejunal obstruction was found in the wall of the subhepatic abscess. A gastrojejunostomy và feeding jejunostomy were done below this point, after which he gradually & steadily improved. The tracheostomy tube was removed on April 10, one month after the pancreaticoduodenectomy, and the patient was finally discharged on May 8, 1958. Despite his postoperative experiences there was never any evidence of pneumonitis or atelectasis on serial x-rays.


Comment

There will not be unanimity of opinion about the need for prophylactic tracheostomy in some patients. Because of a reluctance to employ tracheostomy unless specifically required, we have allowed a postoperative sầu trial period, in borderline cases, during which the patient is closely observed for evidence of pulmonary difficulty. If the slighkiểm tra complication develops, tracheostomy should be done without delay.


Case 11

This 65-year-old man was referred from another hospital for treatment of a large chondrosarcoma of the left shoulder. He had had pulmonary tuberculosis in his youth, và 17 years previously had undergone nephrectomy for tuberculous pyelonephritis. He took digitalis daily & had been in heart failure recently. He had dyspneic for 10 years và had needed convalescent home page care for the past 2 years. Examination showed cyanosis, kyphosis, markedly emphysematous chest, và diffuse wheezes over both lung fields. Chest x-rays showed bilateral apical scarring and emphysema. Electrocardiogram disclosed complete right bundle-branch block. Maximum breathing capađô thị was 27 liters per minute. Vital capathành phố was 2,700 cc. Timed vital capacity showed a 31%, 42%, and 52% expiration in 1, 2, và 3 seconds. The diagnoses were advanced pulmonary emphysema and cor pulmonale. Bronchodilators were used preoperatively và the patient was given positive pressure breathing exercises. On March 19, 1958, left interscapulothoracic amputation and tracheostomy were done. Room air pumped through Alevaire was used postoperatively to lớn supply the tracheostomy cup. Convalescence was uncomplicated and the cannula was removed on the fifth day after surgery. He was discharged on the 12th postoperative sầu day.


Comment

This patient was referred from an outlying hospital for consideration of radiotherapy, since it was thought that his condition precluded extirpative therapy. The use of prophylactic tracheostomy was probably a critical factor in permitting reversal of this decision.


Comment

Until the last two decades the indication for tracheostomy was rigidly defined as mechanical upper airway obstruction. The broader utility of this procedure in the treatment of secretional airway obstruction was not realized until Galloway’s report 5 on the use of tracheostomy in the treatment of bulbar poliomyelitis. Tracheostomy has subsequently become accepted treatment in a variety of clinical conditions in which mechanical obstruction is not a major factor, including coma from any cause, tetanus, respiratory burns, tracheobronchitis, traumatic chest injuries, và the postoperative sầu state after major thoracic & neurosurgical procedures.1

In describing the management of crushed-chest injuries Carter 4 defined the following benefits to be derived from the use of tracheostomy: reduction in the respiratory dead space, decrease in the resistance khổng lồ air flow, & increase in the ease of management of tracheobronchial secretions in patients who cannot or will not cough. In addition, by diminishing the effort necessary for ventilation, pain is relieved. The advantages of tracheostomy are applicable to the care of geriatric và poor risk patients who have had major abdominal surgery. These people have sầu a respiratory reserve sầu so limited that maximum utilization of pulmonary function is necessary for their postoperative survival. They are handicapped by an increase in bronchopulmonary dead space,6 by an emphysematous & fixed chest, & by muscular weakness. The problem is further aggravated by incisional pain with splinting, suppression of coughing, và the consequent accumulation of tracheobronchial secretions. These unfavorable conditions are all at least partially alleviated by tracheostomy. The dead space is reduced, decreasing the tidal volume necessary for the same alveolar ventilation; the elimination of upper airway resistance diminishes the muscular energy expended for respiration and the more effortless ventilation can be performed with less pain; & the management of tracheal secretions is brought under moment-to-moment control. The value of tracheostomy under these circumstances was realized by Baronofsky,7 who, in addition lớn having advocated the procedure for crushed-chest injuries prior to lớn Carter’s report, has alluded to the systematic use of tracheostomy in aged and debilitated general surgical patients.

If recovery from surgery is uncomplicated, the total period of hospitalization is not significantly increased by the presence of the tracheostomy. After a trial period of occlusion the cannula can usually be withdrawn within the first postoperative week và the patient can be discharged a few days later (cases 3, 6, 9, and 11). When nonrespiratory complications have occurred we have found the presence of the tracheostomy khổng lồ be a factor on which survival (cases 1, 2, 8, and 10) has often depended.

The necessity for scrupulous care of the tracheostomy is universally recognized but so important as khổng lồ justify reiteration here. Exclusion of the larynx from the airway has deprived the patient of whatever power he possessed to lớn cough explosively, & he is now at the mercy of those entrusted with the hygiene of his tracheobronchial tree. If suction is not applied at regular intervals he will be in a more indefensible state than if tracheostomy had never been done. It is taught at most nursing centers that the tip of the suction tube should not pass beyond the inner extent of the cannula, but if this practice is carried out secretions will pool beyond the over of the tracheostomy. Nursing personnel must be taught khổng lồ apply suction deeply, but with frequent rest intervals,8 with a Y-tube to lớn avoid traumatizing the mucosa. For most of the patients reported here oxygene was furnished lớn a plastic tracheostomy cup, & for those with severe emphysema compressed air was employed. Humidification was obtained by passage of the gas through a wetting agent (Alevaire). Aseptic precautions must be employed in tracheostomy care, for severe tracheobronchitis can be precipitated by careless handling of the suction catheters.

In the present series an effort was made to lớn anticipate the need for tracheostomy on the basis of preoperative evaluation. Tracheostomy was done in this series only on a group of patients who might otherwise not have been able to undergo major surgery. In three cases elective sầu tracheostomy was considered & rejected, & in these instances what could have sầu been an orderly procedure in the operating room became a desperate measure on the ward. Experiences lượt thích these have sầu tended to lớn lower our originally stringent criteria for the performance of prophylactic tracheostomy.


Summary

Prophylactic tracheostomy was used postoperatively for aged and debilitated general surgical patients. The objectives were to lớn allow maximum utilization of pulmonary reserve and to prsự kiện postoperative sầu pulmonary complications. In a recent three-month period in one of the general surgical services at Jackson Memorial Hospital, 11 patients underwent this procedure after various major operations. These people constitute a group for which it was thought that extensive sầu surgery would uniformly have been fatal without the postoperative sầu use of tracheostomy. Eight of the patients were completely rehabilitated. The remaining three died of late complications of the primary disease & in only one case did a pulmonary complication materially contribute khổng lồ death. On the basis of this experience it is suggested that the judicious use of tracheostomy is a means of extending the limits of operability khổng lồ include certain aged & poor risk patients who might not otherwise be expected lớn survive sầu a major surgical procedure.


1. Nelson TG. Tracheotomy: Clinical & Experimental Study, Part I. Am Surg. 1957 July;23:662–694. 1957 Aug;23:750–784. Part II, ibid.
2. Fotháng JJ. Prevention of Postoperative Pulmonary Complications. Am J Surg. 1957 Oct;94:611–614.
3. Haight C. Intratracheal Suction in Management of Postoperative Pulmonary Complications. Ann Surg. 1938 Feb;107:218–228.
4. Carter BN, Giuseffi J. Use of Tracheotomy in Treatment of Crushing Injuries of Chest. Surg Gynec & Obst. 1953 Jan;96:55–64.
5. Galloway TC. Tracheotomy in Bulbar Poliomyelitis. J A M, A. 1943 Dec 25;123:1096–1097.
6. Tenney SM, Miller RM. Dead Space Ventilation in Old Age. J Appl Physiol. 1956 Nov;9:321–327.
7. Baronofsky ID, Dickman RW, Vanderhoof ES. Treatment of Axinh tươi Chest Injuries, with Especial Reference khổng lồ Tracheotomy. Minnesota Med. 1950 Jan;33:49–53. Baronofsky ID, Briggs JF. Use of Tracheotomy in Critically Ill Patient. J Am Geriatrics Soc. 1954 May;2:321–323.
8. Brattsström S. Fatal Unrecognized Respiratory & Hemodynamic Sequels of Tracheostomy & Endobronchial Aspiration in Postoperative sầu and Markedly Debilitated States. Acta chir scandinav. 1954;108:170–178.