Introduction
Tracheostomies remain an essential part of care Intensive Care Units around the world.1 As of 2014, approximately 800,000 tracheostomies were performed in the United States and studies have documented a statistically significant increase in tracheostomies.2 Indications for tracheostomies are semi-elective and are determined on an individual basis while considering the patient’s future complication risk.3Although more invasive than endotracheal intubation, tracheostomies are safer, more comfortable, allow easier verbal communication, shorter intensive care unit stays, days spent on mechanical ventilation, and hospital stay lengths.4 The only absolute indication for tracheostomy placement is a difficult airway, while the most common indication is airway security following prolonged mechanical ventilation.5 An estimated 10% of mechanically ventilated patients undergo tracheostomy.2 Other common indications include catastrophic neurologic insult, copious secretions, upper airway obstructions, and severe obstructive sleep apnea.2,6
Tracheostomies are placed most often through an open surgical technique (OST) or percutaneous dilational technique (PDT). Complications significantly increase the mean cost and total charges burden on ICU patients and any attempt to mitigate complications benefits the patient as well as the healthcare system.7 Early complications include bleeding, infection, subcutaneous emphysema, tube dislodgement, posterior tracheal wall injury, and tracheostomy tube obstruction.8,9 The incidence of serious and fatal complications as well as readmission, however, is miniscule in comparison.9 While PDT and OST have similar overall complication rates, OST does have higher incidence of bleeding and infections8 and bleeding remains the most common complication in both techniques.10
Other predictors of complication incidence have been thoroughly studied. When considering overall complication incidence, several studies show that age, gender, smoking status, anatomical variants, tracheostomy size, tracheostomy type, and suture stabilization are not highly predictive of acute complications.11,12 In contrast, obesity is a highly described predictor of tracheostomy complications.13 Obesity was found to be independently associated with an increased risk of all complications, acute kidney injury, and unplanned readmission within the first 30 days of tracheal tube placement.14 Beyond obesity, factors that were also predictive of increased complications include number of comorbidities, neck pathology, tracheostomy placement in operating room vs inpatient unit, previous radiotherapy, and previous tracheotomy.11 Additionally, certain demographic groups may be associated with increased mortality in tracheostomy patients. Specifically, African American children, Hispanic adults, and adults with lower levels of education have a higher mortality rate, but the same complication rate as other groups with tracheostomy.15
The relationship between obstructive pulmonary diseases and acute post-tracheostomy complications has been incompletely studied. Chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), and asthma are some of the most common pulmonary pathologies in the United States and worldwide and are associated with high disease burdens.16-18 Mechanical ventilation, and in severe cases, tracheostomy are fundamental tools in the management of patients with COPD and asthma suffering from acute respiratory failure.19 Given the high incidence of obstructive lung diseases worldwide and the clinical utility of tracheostomies among patients with these diseases, it is important to characterize the risk of post-procedure complications.