Discussion
The analysis of this study highlights the relationship between
obstructive lung pathology and acute tracheostomy complications.
Obstructive pulmonary pathologies, specifically COPD, OSA, and asthma,
were more likely to endure acute post-tracheostomy complications with a
moderate statistical significance. While the statistical significance
was moderate, it does carry clinical implications. COPD is an
independent predictor of the need for tracheostomy,20and thus, any increased risk for post-tracheostomy complications impacts
this vulnerable population with an already tenuous respiratory status.
Tracheostomy has also been shown to improve the cardiovascular endpoints
of patients with OSA,21 but it is not without risk.
Considering that the chronic obstructive pulmonary patients are more
likely to require mechanical ventilation and therefore tracheostomy than
patients without these diseases,19 a higher
complication rate is a risk that should be considered when making
decisions regarding tracheostomy. Ultimately, the benefit from early
tracheostomy to avoid prolonged intubation, and its complications,
likely outweighs the potential risk of acute post-tracheostomy
complications. Therefore, electing for tracheostomy while focusing on
the prevention of common complications is warranted.
In this cohort, the overall complication rate was 9% and complication
types were consistent with prior studies with bleeding being the most
common (33%) followed by tracheitis (15%) and dislodgement (10%). The
most common early complication of tracheostomy is bleeding, and
prevention of clot descent through the distal airward is
essential.22 Tracheostomy infections are also a common
complication and maintaining a high clinical suspicion for them is
important.23 Additionally, counseling patients on
recognizing early signs of major complications as well as close follow
up and monitoring is crucial.
One of the secondary outcomes examined in this study was BMI. BMI was
not a significant predictor of acute tracheostomy complications in this
patient cohort, as shown through the bivariate analysis and
multivariable regression models. This is in direct contrast to existing
studies that show that obesity, measured by BMI, carries a higher risk
of tracheostomy complications.13,14 This could be due
to the timeline of complications assessed in different studies.
Complications such as unplanned readmissions occur further from surgery
while this study specifically looked at the first 14 days of the
post-operative period. Therefore, even though this study demonstrated no
significant correlation with acute tracheostomy complications,
clinicians should be aware of this existing association if a patient has
a high BMI, neck circumference, or skin-to-tracheostomy site distance.
The other secondary outcome measure was complication rate among patients
with chemotherapy and radiation treatment in the early post-tracheostomy
window (post-operative day 0-6). Radiation was found to have a moderate
association in multivariable analysis, and chemotherapy and radiation
were highly correlated with one another. The increased risk of early
complication likely occurred due to poor wound healing considering
chemotherapy and radiation are well described causes of poor wound
health irrespective of the surgical procedure performed. Chemotherapy
frequently slows wound healing, as some widely used chemotherapeutic
drugs directly impact cell cycle progression and new tissue deposition.
Radiation increases inflammation in local tissues, promoting cell death
and slowing wound healing.24 In head and neck cancer
patients particularly, many have received neck radiation prior to
surgery, impacting the tissues around the tracheostomy site. Slow
healing wounds have a higher incidence of infection, recurrent bleeding,
and more serious invasive processes including
osteomyelitis.25 Considering infection and bleeding
are two of the most common complications in the acute post-tracheostomy
setting, close monitoring of the tracheostomy site is warranted. It is
important to note the limitations of this study. Data collection and
medical record review may have been subject to sampling bias, as the
cohort was not randomized. Additionally, as a retrospective analysis,
there may be bias when interpreting results.