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| ORIGINAL ARTICLE |
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| Year : 2020 | Volume
: 8
| Issue : 2 | Page : 102-108 |
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Tracheostomy Experience among Indian Otolaryngology-Head and Neck Surgery Residents – A Survey
Shaoni D Sanyal, Ranjan Raychowdhury
Department of ENT Head and Neck Surgery, Vivekananda Institute of Medical Sciences, Kolkata, West Bengal, India
| Date of Submission | 03-Jul-2020 |
| Date of Decision | 20-Jul-2020 |
| Date of Acceptance | 07-Sep-2020 |
| Date of Web Publication | 8-Dec-2020 |
Correspondence Address:
Shaoni D Sanyal
Department of ENT Head and Neck Surgery, Vivekananda Institute of Medical Sciences, Ramakrishna Mission Seva Pratishthan, 99 Sarat Bose Road, Kolkata - 700 026, West Bengal
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jhnps.jhnps_31_20
Background: Tracheostomy is a common surgical procedure which otolaryngology-head and neck surgery (ORL-HNS) trainees are expected to perform in both emergency and elective settings. Few papers deal specifically with resident training in this procedure. we surveyed the standard of training in the Indian context. Materials and Methods: A questionnaire-based survey was conducted among residents attending the annual national conference of the Association of Otolaryngologists of India. The results of the survey were tabulated using Microsoft Excel. Results: Ninety questionnaires were circulated among postgraduate trainees in their 1st, 2nd, or 3rd year of training (P-1, P-2, and P-3) as well as senior residents (SR). The response rate was 47%. The majority of the respondents (51%) were P-2. The distribution between elective and emergency tracheostomy was variable. The most common indication for tracheostomy in our survey was prolonged Intensive Therapy Unit (ITU) ventilation (42%). In elective tracheostomy, the primary surgeon was either an SR or P-3 (60%) and used a horizontal incision (52%). In emergencies, the primary surgeon was either an SR or P-3 and preferred a vertical incision (65%). Most trainees exposed the trachea by layer dissection; only 6% used monopolar diathermy. Entry through vertical incision and dilator was the preferred method (51%). The first tube change was performed at 72 h by 49% of the respondents. Eighty-four percent of the trainees were confident of performing emergency tracheostomies independently. Conclusions: ORL-HNS trainees should be competent in tracheostomy. The lack of supervision by faculty, variation in steps, and postoperative management all impact the outcome. A standardized technique and faculty supervision are vital for optimum training.
Keywords: Internship and residency, self-assessment, tracheostomy
How to cite this article:
Sanyal SD, Raychowdhury R. Tracheostomy Experience among Indian Otolaryngology-Head and Neck Surgery Residents – A Survey. J Head Neck Physicians Surg 2020;8:102-8 |
How to cite this URL:
Sanyal SD, Raychowdhury R. Tracheostomy Experience among Indian Otolaryngology-Head and Neck Surgery Residents – A Survey. J Head Neck Physicians Surg [serial online] 2020 [cited 2022 Jul 4];8:102-8. Available from: https://www.jhnps.org/text.asp?2020/8/2/102/302627 |
| Introduction | |  |
Tracheostomy is one of the most common surgical procedures in the field of otolaryngology-head and neck surgery (ORL-HNS). Tracheostomy is required to secure the airway in case of obstruction or for the facilitation of prolonged ventilation. ORL-HNS trainees are expected to perform surgical tracheostomy in both emergency and elective settings.
The Medical Council of India guidelines of 1997 stated that interns should have observed, assisted, and performed tracheostomy during the course of their training. It is, therefore, expected that ORL-HNS residents should be adequately trained and confident in performing tracheostomy. A search of the English scientific literature yielded very few papers dealing specifically with open tracheostomy and/or resident training in this procedure.
Our study aims to explore the current standard in training of Indian ORL-HNS residents.
| Materials and Methods | | |
A survey was conducted among residents attending the annual national conference of the Association of Otolaryngologists of India by means of a questionnaire [Annexure 1]. The results of the survey were tabulated using Microsoft Excel. As this was a voluntary questionnaire-based survey of opinions, no specific ethical clearance or informed consent was obtained.
| Results | | |
A total of ninety questionnaires were circulated among the residents, including postgraduate trainees in their 1st, 2nd, or 3rd year of training (P-1, P-2, and P-3) as well as senior residents (SR). The response rate of the survey was 47%.
The majority of the respondents (51%) were P-2; 16% of the respondents were SR [Figure 1].
The respondents were questioned about the frequency of tracheostomy at their institutes – 58% of the respondents had been exposed to between five and ten tracheostomies every month, whereas 19% had seen <2 tracheostomies per month [Figure 2].
The distribution between elective and emergency tracheostomy was variable. Thirty-five percent of the respondents had seen a majority of emergency tracheostomies, another 35% had seen a majority of elective tracheostomies, whereas the rest reported having seen an equal number of elective and emergency tracheostomies [Figure 3]. | Figure 3: Distribution of respondents exposed to elective versus emergency tracheostomies
Click here to view |
The most common indication for performing a tracheostomy in our survey was prolonged ITU ventilation (42%), followed by obstruction of the airway due to a growth (32%) and trauma (26%) [Figure 4]. In most cases of elective tracheostomy, the primary surgeon was either an SR or P-3 (60%) and preferred to use a horizontal incision (52%). In an emergency scenario, the primary surgeon was either an SR or P-3 (93%) and preferred to use a vertical incision (65%) [Figure 5], [Figure 6] and [Table 1].
Ninety-three percent of the trainees exposed the trachea by layer dissection and only 6% used monopolar diathermy. Entry into the trachea through vertical incision and dilator was the preferred method (51%), 32% made a rectangular window, and 4% used a Bjork flap. Only 23% of the respondents always used tracheal stay sutures, and 39% always sutured the tracheostomy tube to the skin [Table 1].
The first tube change was performed at 72 h by 49%, at 1 week by 28%, at 48 h by 19%, and at 36 h by 4%. Eleven percent of the respondents felt that percutaneous tracheostomies had decreased the number of open procedures performed by their department.
Eighty-four percent of the trainees felt that they would be able to perform emergency tracheostomies independently.
| Discussion | | |
An extensive search of the English scientific literature yielded very few papers dealing specifically with open tracheostomy and its training.
Residents training in ORL-HNS are expected to be competent in performing tracheostomies, both in elective and emergency settings. In our study, 84% of the 43 respondents felt confident of their ability to perform both elective and emergency tracheostomies independently, although only 30% were senior and 3rd year residents. We found marked variation in the operative steps. These findings are in keeping with the observations made by Muallem-Kalmovich et al. They conducted a questionnaire-based survey among 93 Israeli ORL-HNS trainees and found that 65% felt confident in performing tracheostomies despite a lack of standardization in their training and reduced exposure to surgical tracheostomies.[1]
Only 39.5% of the respondents in our survey reported the presence of faculty during elective tracheostomy, and emergency tracheostomy was generally carried out by an SR or P-3 with no faculty present. Muallem-Kalmovich et al. found that elective tracheostomy was more commonly performed, and 65%–71% of respondents reported the presence of a senior physician during the procedure, whereas Israeli residents perform eight tracheostomies a year; our survey showed that 58% of Indian trainees performed between five and ten tracheostomies per month with an equal proportion between elective and emergency tracheostomies.[1]
There are several technical scales in use to rate a surgeon’s competence. Self-assessment is not recommended. Maschuw et al. showed that novice surgical trainees with high self-assessment scores performed simulated surgical tasks faster but at the expense of less economic movements and with a greater error score than the advanced group.[2]
The Israeli study suggested a discrepancy between the high self-assessment of resident’s surgical abilities and evaluation by their senior physicians. This observation was different from the data reported by Chadwick et al., who showed that more than 90% of ORL-HNS residents in the USA thought that they were competent to perform tracheostomy at 2.55 postgraduate years (PGYs), whereas their program directors thought that they were competent to perform it earlier, at 2.41 PGYs. Our study did not collect any feedback from senior physicians regarding the competence of the trainees.[3]
In our survey, 84% of the trainees felt confident in performing tracheostomy – both elective and emergency. This compares well with the Israeli study where 65% of trainees were confident of performing open tracheostomy. This contrasts with the findings of among anesthesia trainees – 58% of core trainees and 33% of specialist trainees were not confident in handling tracheostomy patients, including performing percutaneous tracheostomy and changing the tube.[4]
Although tracheostomy is a commonly performed procedure, there is a great variation in the surgical steps, which impacts the outcome. While in training, residents require a standardized and simplified surgical procedure. This can reduce the complications during surgery.[5]
The type of incision preferred is usually a horizontal incision in pediatric as well as adult patients.[5],[6],[7] Kremer et al. recommend both horizontal and vertical skin incisions in pediatric tracheostomy.[8] The vertical incision allowed for an improved anatomic orientation, but caused more unsightly scars. In emergency situations, a vertical incision was preferred by Campisi and Forte as it provided easier access.[6] A vertical incision can be safely extended inferiorly without injuring the great vessels. In our survey, 65% of the respondents preferred to use the vertical incision.
Most studies preferred to split the strap muscles and divide the thyroid isthmus with cautery.[5],[6],[8] This is similar to the findings in our survey where most trainees (93%) preferred to split and retract the strap muscles instead of using monopolar diathermy.
Opening the trachea may be done by different methods such as fenestration with an inferior stalked cartilage flap (Bjork 1955), horizontal or vertical incision. Traditionally, the vertical incision was preferred in pediatric tracheostomy.[9]
Fry et al. in their animal-based model found that the vertical incision was superior to the horizontal H-shaped tracheal incisions and inferior-based tracheal flaps with regard to the development of tracheal stenosis and suprastomal collapse. Any incision on the trachea may lead to the development of cicatricial “A” frame deformity, tracheal stenosis, or tracheomalacia.[10]
Biesalski et al. recommended a small oval window centered on the trachea.[11]
This method of tracheal fenestration was also supported in a recent study by Syed et al. The advantage of this method was that injury or incision of the tracheal wall was restricted to the size of the tube, whereas a traditional tracheostomy potentially injures at least four tracheal rings.[7]
Waki et al. recommended the Bjork flap. It facilitated the placement of the cannula and decreases the risk of a pneumomediastinum. The method of fenestration of the trachea is not related to the frequency of complications as long as it is performed in such a way so as to avoid injury to the cricoid cartilage.[12] Although a Björk flap reduced the danger of a tracheostomal collapse during cannula exchange or during an accidental decannulation, it increased the risk of tracheal stenosis.[8]
In our study, the vertical incision was favored by nearly half the respondents (51%) whereas Björk flap was rarely used (4%).
Most studies recommend maturation and stay sutures in pediatric tracheostomy.[7],[13] Our survey showed that these were used routinely only by 23% and 39.5%, respectively.
An important part of ward management is the first tube change. Our study showed much variation in this. The first tube change was performed at 72 h by 49%, at 1 week by 28%, at 48 h by 19%, and at 36 h by 4%. A study by Tabaee et al. conducted in New York reported that the first tube change was performed after a mean of 5.3 days (range, 3–7) posttracheostomy to allow the formation of a tract between the skin and trachea and to identify infection at the surgical site.[14]
The UK National Confidential Enquiry into Patient Outcome and Death (2014) stated that the most serious complications in patients during and after tracheostomy insertion in both critical care and the ward were accidental tube displacement, obstruction, pneumothorax, and hemorrhage.[15]
The Indian Society of Critical Care Medicine recommends that any intensivist, proficient in airway management, can perform percutaneous tracheostomy independently once they have performed 10 cases under supervision; surgical tracheostomies should be performed by ORL HNS surgeons. In their study, most tracheostomies were performed by intensivists (53.8%), followed by surgeons (17%), followed by trainees who were mainly anesthesiologists posted in the ICU (13.8%) and then interventional pulmonologists (0.8%).[16] In our survey, 11% felt that the advent of percutaneous tracheostomies has reduced opportunities for ORL-HNS trainees.
| Conclusion | | |
Tracheostomy is an essential, life-saving surgery. ORL-HNS trainees should be competent in performing tracheostomies. The lack of supervision by faculty, variation in procedural steps, and postoperative management all impact the outcome. The increasing trend of percutaneous tracheostomies has also reduced the training opportunities for ORL-HNS surgeons. Thus, in the current scenario, a standardized technique and faculty supervision are vital for optimum training of ORL-HNS surgeons.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Disclosure
This material has never been published and is not currently under evaluation in any other peer reviewed publication.
Ethical approval
The permission was taken from Institutional Ethics Committee prior to starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent
Informed consent was obtained from all individual participants included in the study.
| Annexure | | |
| Annexure 1: National Survey on Training in Tracheostomy | | |
Please circle the appropriate answer or tick in as required:
For the purpose of this survey, any tracheostomy not performed on a regular ENT theater list should be considered as an emergency.
- What is your training status?
DLO 1st year 2nd year
MS 1st year 2nd year 3rd year
DNB 1st year 2nd year 3rd year
SR
- Name and location of your institute (optional)
- On average, in your unit, how many tracheostomies are performed each month?
2 or less □
Between 2 and 5 □
Between 5 and 10 □
- How many of these are emergencies and how many are elective?
50% elective, 50% emergency □
More than 75% elective □
More than 75% emergency □
- Who is the main surgeon (S1) in the elective tracheostomies?
Professor □
Associate professor/reader □
Assistant professor/lecturer □
RMO/clinical tutor □
Senior resident □
Final year resident □
- Who is the main surgeon in emergency tracheostomies?
RMO/clinical tutor □
Senior resident □
Final year resident □
- What is the main source of emergency tracheostomy referrals?
Road traffic accidents □
ITU/ICCU prolonged ventilation □
Obstructing laryngeal growths □
- What incision is used for elective tracheostomy in your unit?
Always horizontal □
Always vertical □
No fixed incision □
- What incision is used for emergency tracheostomy in your unit?
Always horizontal □
Always vertical □
No fixed incision □
- How do you expose the trachea?
Layer by layer dissection □
Monopolar diathermy □
Bipolar diathermy □
- What tracheostomy tube is initially inserted?
Metallic tube (single) □
Metallic tube (double) □
Cuffed plastic tube (single) □
Cuffed plastic tube (double) □
Uncuffed plastic tube (single) □
Uncuffed plastic tube (double) □
- How do you enter the trachea?
Vertical incision + dilator □
Inclined incision + dilator □
Rectangular window □
Bjork flap □
- Do you insert stay sutures in the trachea?
Always □
Sometimes □
- Do you suture the tube to the skin?
Always □
Sometimes □
- Do you suture the incision?
Always □
Sometimes □
- When is the tube changed for the first time?
After 48 h □
After 36 h □
After 72 h □
After 1 week □
- Have percutaneous tracheostomies reduced the number of open tracheostomies in your institute?
Yes □
No □
Not done in institute □
- At the end of PG attachment, how will your tracheostomy training be?
Able to perform both emergency and elective independently □
Able to perform both with senior assistance □
Not confident of performing emergency without senior □
Thank you for filling in this questionnaire.
Please note, all responses will be kept anonymous – if you wish to write your name it will not be revealed to anyone.
| References | | |
| 1. | Muallem-Kalmovich L, Pitaro J, Asaly A, Kessler A, Eviatar E, Shteiner M, et al. Open tracheostomy training: A nationwide survey among otolaryngology-head and neck surgery residents. Eur Arch Otorhinolaryngol 2017;274:4035-42.  |
| 2. | Maschuw K, Osei-Agyemang T, Weyers P, Danila R, Bin Dayne K, Rothmund M, et al. The impact of self-belief on laparoscopic performance of novices and experienced surgeons. World J Surg 2008;32:1911-6. |
| 3. | Chadwick KA, Dodson KM, Wan W, Reiter ER. Attainment of surgical competence in otolaryngology training. Laryngoscope 2015;125:331-6. |
| 4. | Taylor C, Barrass L, Drewery H. Training for tracheostomy. Br J Anaesth 2013;111:842-3. |
| 5. | Salgarelli AC, Collini M, Bellini P, Capparè P. Tracheostomy in maxillofacial surgery: A simple and safe technique for residents in training. J Craniofac Surg 2011;22:243-6. |
| 6. | Campisi P, Forte V. Pediatric tracheostomy. In: Seminars in Pediatric Surgery. Vol. 25. WB Saunders; 2016. p. 191-5. |
| 7. | Syed KA, Naina P, Pokharel A, John M, Varghese AM. Paediatric tracheostomy: A modified technique and its outcomes, results from a South Indian tertiary care. Int J Pediatr Otorhinolaryngol 2019;118:6-10. |
| 8. | Kremer B, Botos-Kremer AI, Eckel HE, Schlöndorff G. Indications, complications, and surgical techniques for pediatric tracheostomies-an update. J Pediatr Surg 2002;37:1556-62. |
| 9. | Björk VO, Engström CG. The treatment of ventilatory insuffficiency after pulmonary resection with tracheostomy and prolonged artificial respiration. J Thorac Surg 1955;30:356-67. |
| 10. | Fry-an update. J Pediatr Surg 2002;37:1556-62. |
| 11. | Björk VO, Engström CG. The treatment of ventilatory insuffficiency after pulmonary resection with tracheostomy and prolonged artificial respiration. J Thorac Surg 1955;30:356-67. |
| 12. | Fry TL, Jones RO, Fischer ND, Pillsbury HC. Comparisons of tracheostomy incisions in a pediatric model. Ann Otol Rhinol Laryngol 1985;94:450-3. |
| 13. | Biesalski P. Tracheotomie. In: Berendes J, Link R, Zollner F, editors. Hals-Nasen-und Ohrenheilkunde. Stuttgart, Germany: Thieme-Verlag; 1964. |
| 14. | Waki EY, Madgy DN, Zablocki H, Belenky WM, Hotaling AJ. An analysis of the inferior based tracheal flap for pediatric tracheotomy. Int J Pediatr Otorhinolaryngol 1993;27:47-54. |
| 15. | Woods R, Geyer L, Mehanna R, Russell J. Pediatric tracheostomy first tube change: When is it safe? Int J Pediatr Otorhinolaryngol 2019;120:78-81. |
| 16. | Tabaee A, Lando T, Rickert S, Stewart MG, Kuhel WI. Practice patterns, safety, and rationale for tracheostomy tube changes: A survey of otolaryngology training programs. Laryngoscope 2007;117:573-6. |
| 17. | McGrath BA, Lynch J, Bonvento B, et al. Evaluating the quality improvement impact of the Global Tracheostomy Collaborative in four diverse NHS hospitals. BMJ Qual Improv Rep 2017;6:bmjqir.u220636.w7996. |
| 18. | Gupta S, Dixit S, Choudhry D, Govil D, Mishra RC, Samavedam S, et al. Tracheostomy in adult intensive care unit: An ISCCM expert panel practice recommendations. Indian J Crit Care Med 2020;24:S31-42. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1]
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