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Year : 2019  |  Volume : 9  |  Issue : 1  |  Page : 6-11

A prospective clinical study of the flora and early secondary effects after tracheostomy

1 Department of Otolaryngology Head and Neck Surgery, Karnataka Institute of Medical Sciences, Hubli, Karnataka, India
2 Department of Anaesthesiology, Karnataka Institute of Medical Sciences, Hubli, Karnataka, India

Date of Submission07-Jan-2020
Date of Acceptance13-Mar-2020
Date of Web Publication14-May-2020

Correspondence Address:
Prof. Vikram Kemmannu Bhat
Department of Otolaryngology, Head and Neck Surgery, Karnataka Institute of Medical Sciences, Vidyanagar, Hubli - 580 021, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jlv.JLV_7_19

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Introduction: Tracheostomy patients develop copious secretions from the stoma along with cough after the procedure. However, the morphology of this secretion and the pattern of the flora over a period of time are not studied. Objective: The main objectives are to study the early after-effects of tracheostomy and to study the flora of the tracheal secretion and its impact on the host. Materials and Methods: This was a cross-sectional study that was undertaken in a tertiary referral public hospital. Sixty patients were categorized into two groups of 30 each, intubated (Group A) and nonintubated (Group B), before tracheostomy. The consistency, quantity, and culture sensitivity of the tracheal secretion and its impact on the lungs were noted on day 2, 30, and 90 after the procedure. Results: The most common after-effect was copious tracheal secretion that was obvious immediately after tracheostomy which, gradually reduced to scanty. The most common organism was Pseudomonas and Klebsiella in intubated and nonintubated patients on day 2 and day 30, respectively. Conclusion: Tracheal secretion was copious and colonized in most of the patients in both the groups in the immediate post tracheostomy period which became scanty and free of colonies by the 3rd month. The organisms had no negative impact on the lower respiratory tract.

Keywords: Intensive care, intubation, tracheostomy

How to cite this article:
Bhat VK, Rajan RR, Nagachar S, Sachidananda R. A prospective clinical study of the flora and early secondary effects after tracheostomy. J Laryngol Voice 2019;9:6-11

How to cite this URL:
Bhat VK, Rajan RR, Nagachar S, Sachidananda R. A prospective clinical study of the flora and early secondary effects after tracheostomy. J Laryngol Voice [serial online] 2019 [cited 2022 Aug 12];9:6-11. Available from: https://www.laryngologyandvoice.org/text.asp?2019/9/1/6/284236

   Introduction Top

Tracheostomy plays a pivotal role in the airway management. Tracheostomy is a common life-saving procedure performed in most clinical departments. It has been noticed that almost all patients who undergo tracheostomy develop copious secretions from the stoma along with productive cough. However, it is not known whether these secretions are potentially infectious and whether they need segregation. Furthermore, it is not known after how many days these patients actually develop bacterial colonies in the tracheobronchial tree. How harmful are these organisms to the host? It has been observed that these secretions gradually reduce over a period of time. But do these colonies disappear too and if so, after what duration? This study tried to find answers to these observations.

   Materials and Methods Top

This pilot study was undertaken in patients with tracheostomy in a tertiary referral hospital over a period of 1 year and 6 months. Clearance from the institutional ethical review board was obtained (No: PGS/590/2015-16). This was a cross-sectional study, with two groups – Group A included patients who were intubated (orotracheal) (n = 30 at day 0) and on mechanical ventilation and Group B included patients who were not intubated (n = 30 at day 0). Every eligible adult (18–75 years) consecutive case that underwent tracheostomy and also fulfilled the required criteria was recruited into the study. Immunocompromised, pediatric, diabetic patients and those with tracheoesophageal fistula were excluded from the study.

Patients belonging to Group A were those patients admitted in either the medical or surgical intensive care unit (ICU). These patients were intubated for a variable period of time (7–21 days) and had undergone tracheostomy in the view of prolonged ventilator support. Patients belonging to Group B were those patients admitted in the ear, nose, and throat or surgical department. These patients had respiratory distress with or without stridor and had undergone tracheostomy on an elective or emergency basis [Table 1] and [Figure 1].
Table 1: Source of patients in the two groups

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Figure 1: Flow chart of the study

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Patients of both groups were followed up on the 2nd day after tracheostomy and then at 1st month and at 3rd month. The tracheal secretion was collected under aseptic precautions. A sputum trap was applied to a sterile catheter, and the suction catheter was advanced into the tracheostomy tube until resistance was encountered. Then, suction was applied until secretion was collected in sputum trap. Care was taken to see that the suction catheter did not touch the wall of tracheostomy tube. The tip where the secretion was present was cut and preserved in a sterile bottle. These were sent for culture and sensitivity and Ziehl–Neelsen staining to rule out tuberculosis. The tip was inoculated for culture on chocolate agar and MacConkey agar at 37°C aerobically for 48 h. The antibiogram of each bacterial isolate was performed by Kirby–Bauer disc diffusion technique.

The consistency of tracheal secretion was documented as mucoid, mucopurulent, or watery. The quantity of the tracheal secretion was assessed by the examiner and by the history provided by the patient and caretakers as follows:

  1. Profuse when the secretion was plenty and second hourly suctioning was required
  2. Moderate when the frequency of suctioning was less about 3 or 4 times a day to clear the airway
  3. Minimal when frequency of suctioning was reduced to <2 times a day
  4. Scanty when there was no need for suctioning and sputum was only seen when the patient coughed.

The main indications for suctioning were:

  1. Blocked tube or respiratory distress
  2. Desaturation on pulse oximeter
  3. Inability to clear the tube by coughing
  4. Request by the patient.

Complications during and after surgery were documented. Radiography of chest and lateral neck was done in all. Patients of Group A and Group B who required only a temporary tracheostomy underwent decannulation and closure. All patients were humidified with standard tracheostomy humidifiers after tracheostomy.

Statistical analysis

Statistical analysis was done using Stata student's edition version 12. Continuous variables were summarized as mean and standard deviation and categorical variables as proportions.

Comparison of proportions between Group A and Group B was done using the Chi-square test or Fisher's exact test depending upon the expected cell counts. To compare the microorganism growth patterns between the two groups, Z-test for proportions was applied.

Comparison of continuous variables in the two groups was done using independent samples t-test. All statistical analyses were considered significant if P < 0.05.

   Results Top

Age and gender distribution in present study

Mean age distribution for Group A was 38.43 ± 15.9 years. Mean age distribution for Group B cases was 61.77 ± 12.1 years. In Group A, 63.3% were male and 36.7% were female. In Group B, 76.7% were male and 23.3% were female.

Source of patients and need for tracheostomy in the two groups

[Table 1] shows the source of patients and [Table 2] shows the need for tracheostomy in both the groups. The intracranial causes were seen only in Group A and included intracranial hemorrhage, hypoxic-ischemic encephalopathy following hanging and cerebral infarction. Other causes included Guillain–Barre syndrome, myasthenia gravis, vocal cord palsy, oropharyngeal lymphoma, and retropharyngeal abscess in Group A and Group B.
Table 2: Indications for tracheostomy among the study participants

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Status of patients after tracheostomy

[Figure 1] shows the status of the patient following tracheostomy in the two groups. In Group A, 50% underwent decannulation during the 3rd-month follow-up, while ten patients (33.3%) expired. Of the expired patients of Group A, three had no flora and seven had flora in the secretion after culture. The death was, however, due to medical causes that existed before intubation and tracheostomy. In Group B, 70% had permanent tracheostomy and six patients (20%) expired during follow-up. Of the expired patients of Group B, one had no flora and five had flora in the secretion. The most common cause of death in this group turned out to be terminal malignancy of the larynx. The most common after-effect was an immediate increase in the amount of tracheal secretion. The follow-up findings of the two groups with regard to the most common organism, quality of secretion, and lung findings are summed up in [Table 3].
Table 3: Comparison of the cases in the two groups during follow-up (n=30)

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Microbiology of the tracheal secretion

[Table 4] shows the organism detected in the tracheal secretion on day 2 following tracheostomy. Other Gram-negative bacteria (GNB) detected were Citrobacter freundii and Escherichia coli.
Table 4: Microbiological growth pattern of tracheal secretions on day 2 of follow-up

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[Table 5] shows the pattern of the organisms of tracheal secretion during the follow-up on day 30. Z-test of two proportions was used for analysis (P = 0.63).
Table 5: Microbiological growth pattern of tracheal secretions on day 30 of follow-up

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At the end of 3rd month, five patients of Group A and 21 of Group B were assessed; all of them had no flora in the culture.

[Table 6] shows the pattern of microbiological organisms during the follow-up on day 2, day 30, and day 90 in Group A and Group B patients.
Table 6: Comparison of proportion of patients with microbial growth on day 2, day 30, and day 90 in Group A and Group B patients

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Relation between the granulation around the stoma and growth in tracheal secretion

The relationship between the growth in tracheal secretion and the development of granulation around the stoma site was studied. Nine out of 10 patients with granulation tissue around the stoma had growth in their tracheal secretion. The risk ratio of 1.188 showed a marginally increased risk of granulation in the presence of flora in tracheal secretion. However, these granulations did not obstruct the trachea.

   Discussion Top

Tracheostomy is one of the most frequently performed surgical procedures in ICU patients and is also a lifesaving procedure performed to relieve airway obstruction.

Normally, the lower respiratory system, especially the trachea is protected from any bacterial colonization; hence, the trachea of healthy individuals is always sterile and free from bacterial colonization.[1] Cough and swallow are highly coordinated reflex behaviors whose collective purpose is to protect the airway. Tracheostomy reduces the effectiveness of the cough reflex. It also affects the glottis closure mechanism, and this results in aspiration and colonization of the trachea with bacteria in the patients with tracheostomies.[2]

To the best of our knowledge, there are no studies of similar kind reported from a developing country on the after-effects of tracheostomy.

Our study highlights the flora of the tracheal secretion of patients with tracheostomy in both intubated and nonintubated cases. Furthermore, this study concentrates on the pattern of the flora over a period of 3 months. On the 2nd day of tracheostomy, the tracheal secretion of eight patients (26.7%) yielded Pseudomonas species in Group A and 16 patients (53.3%) in Group B yielded Klebsiella species. In nine patients (30%) of Group A and two patients (6.7%) of Group B yielded other GNBs such as Citrobacter and Escherichia. This data is in agreement with previous investigators who found more GNB in tracheal mucosa than buccal mucosa.[1],[3] In a study by Pignatti et al.[4] in the microbiological analysis performed on tracheal aspirates, Pseudomonas aeruginosa was the most predominant bacteria identified. Guimbellot et al.[5] similarly noted increased growth of GNB predominantly Pseudomonas in children who underwent tracheostomy. Sakurai et al.[6] studied 15 patients with long-term tracheostomies and noted persistent colonization with Pseudomonas in them. Matt et al. too found tracheal granulation tissue to be rich in organisms including Pseudomonas.[7] Kramp et al. found that the heat and moisture exchanger did not endanger these patients as an additional source of pathogenic microorganisms.[8]

These so-called pathogens in our study could be nosocomial or derived from the patient himself. However, none of the patients seem to have been affected by any disease of the lower respiratory tract due to these organisms. This precarious relationship between the host and the organism gives an impression of commensalism where they colonized the secretionin vivo and did not endanger the host. The infections of the lower respiratory tract could have been prevented by the use of higher anti-infective agents in the ICU setup. However, in both the groups, the choice of these agents was mostly not guided by the bacteriological report of the secretion. The gradual disappearance of these organisms from the secretion over a period of time needs to be investigated further. No patient in this study expired due to the procedure of tracheostomy itself or its complications.

As shown in the study, 90% of the patients showed colonization of the tracheal secretion irrespective of their intubation status prior to tracheostomy. This is in agreement with the study done by Solomon et al.[9] But in due course of time, the tracheal secretion became free of colonies. All our patients had no colonies in the tracheal secretion by the end of 3rd month. The disappearance of these organisms could be related to the decrease in the quantity of the secretion which was supposedly their medium of growth.

There was no significant difference in both the groups with respect to the quantity and consistency of tracheal secretion. During the 2nd day of tracheostomy, all patients irrespective of prior intubation status showed profuse tracheal secretion that needed regular suctioning. During the 1st month of follow-up, the tracheal secretion was minimal in amount and finally scanty by the 3rd month. This could probably be due to the acclimatization of the tracheobronchial tree to the change in the quality of the inspired air.[10]

Tracheostomy bypasses the upper airway mechanism of warming, humidification, and filtering of the inspired air that reaches the trachea and the lungs.[10],[11] This disadvantage leads to the drying up of the tracheal and bronchial epithelium. The epithelium responds by increasing the production of mucus. The increased secretion could also be in response to a foreign body (the tube) within the trachea.

Research on tracheostomy presents special problems because of the critical nature of the patient and the conditions that warrant the surgery, lack of compliance of the patient for long-term follow-up. Many a times, the survival of these critically ill patients is not certain. Hence, many patients expire before the completion of the follow-up period.

   Conclusion Top

Increased tracheal secretion was the most common after-effect of tracheostomy. Secretions were colonized in more than 85% of the patients in the immediate posttracheostomy period which gradually became scanty and free of colonies by 3 months. The most common organisms were Pseudomonas and Klebsiella in intubated and nonintubated patients, respectively, posttracheostomy on day 2. This calls for segregation of all tracheostomized cases from the nontracheostomized ones, in order to prevent contamination and dissemination of these organisms. However, these organisms did not endanger the host by any negative impact on the lower respiratory tract in both the groups of patients. There was a marginal increase in the risk of developing granulation tissue around the stomal site when the tracheal secretion yielded growth. Irrespective of the intubation status, most of the early after-effects and early complications of tracheostomy remained the same.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Bartlett JG, Faling LJ, Willey S. Quantitative tracheal bacteriologic and cytological studies in patients with long-term tracheostomies. CHEST 1978;74:635-39.  Back to cited text no. 1
Kamath PM, Shenoy SV, Mukundan A, Shreedharan S. Antibacterial sensitivity of bacterial flora of lower respiratory tract after a week of tracheostomy. Indian J Appl Res 2015;5:319-22.  Back to cited text no. 2
Niederman MS, Ferranti RD, Zeigler A, Merrill WW, Reynolds HY. Respiratory infection complicating long-term tracheostomy. The implication of persistent gram-negative tracheobronchial colonization. Chest 1984;85:39-44.  Back to cited text no. 3
Pignatti P, Balestrino A, Herr C, Bals R, Moretto D, Corradi M, et al. Tracheostomy and related host-pathogen interaction are associated with airway inflammation as characterized by tracheal aspirate analysis. Respir Med 2009;103:201-8.  Back to cited text no. 4
Guimbellot JS, Reilly CA, Kerr A, Gilligan PH, Muhlebach MM, Esther CR. Increase in Pseudomonas infection In children undergoing tracheotomy. Am J Resp Crit Care Med 2014;189:A46-86.  Back to cited text no. 5
Sakurai S, Ono T, Amanai T, Shinohara H, Toya S, Tanaka A et al. Detection of Pseudomonas aeruginosa following tracheostomy. Oral Ther Pharmacol 2005;24:7-12.  Back to cited text no. 6
Matt BH, Myer CM 3rd, Harrison CJ, Reising SF, Cotton RT. Tracheal granulation tissue. A study of bacteriology. Arch Otolaryngol Head Neck Surg 1991;117:538-41.  Back to cited text no. 7
Kramp B, Donat M, Dommerich S, Pau HW, Podbielski A. Prospective controlled study of microbial colonization of the trachea in tracheotomized and laryngectomized patients with HME (heat and moisture exchanger). Acta Otolaryngol 2009;129:1136-44.  Back to cited text no. 8
Solomon DH, Wobb J, Buttaro BA, Truant A, Soliman AM. Characterization of bacterial biofilms on tracheostomy tubes. Laryngoscope 2009;119:1633-8.  Back to cited text no. 9
Lewarski JS. Long-term care of the patient with a tracheostomy. Respir Care 2005;50:534-7.  Back to cited text no. 10
Gonzalez I, Jimenez P, Valdivia J, Esquinas A. Effectiveness of humidification with heat and moisture exchanger-booster in tracheostomized patients. Indian J Crit Care Med 2017;21:528-30.  Back to cited text no. 11
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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