TABLE I.
Qualitative Results Based on Free-Text Descriptions.
| Result | No. |
|---|---|
| No. of respondents | 253 |
| No. of events described | 405 |
| Location/timing of event | |
| Intraoperative* | 19 |
| Postoperative: inpatient/long-term care (8 of these occurred in the first postoperative week) | 101 |
| Postoperative: inpatient location inferred | 40 |
| Postoperative: home | 30 |
| Nonspecified | 215 |
| Total | 405 |
| Specific events that led to catastrophe (no.) | |
| Decannulation | 139 |
| Accidental decannulation, loss of airway (88) | |
| Accidental decannulation, false passage (34) | |
| Planned tracheotomy change, loss of airway (5) | |
| Planned tracheotomy change, false passage (12) | |
| Bleeding (no.) | 128 |
| TIF/carotid artery erosion (91) | |
| Volume bleed, source unknown (37) | |
| Tube occlusion/mucous plug | 57 |
| Tracheoesophageal fistula | 33 |
| Airway obstruction/stenosis | 18 |
| Pneumothorax/subcutaneous emphysema | 5 |
| Nonspecified | 6 |
| Other† | 19 |
| Total | 405 |
| Outcome of event | |
| Death | 177 |
| Major disability | 38 |
| Transient morbidity | 16 |
| Nonspecified | 174 |
| Total | 405 |
| Associated/contributing factors | |
| Patient and disease factors | |
| Cancer or radiotherapy | 29 |
| Pediatric | 28 |
| Obese | 26 |
| Trauma: burns, laryngeal fracture, foreign body | 6 |
| Obstructive sleep apnea | 6 |
| Clotting defect/anticoagulation | 3 |
| Infection | 3 |
| Other significant illness‡ | 9 |
| Total | 110 |
| Tracheotomy-care issues | |
| Tracheotomy change | 24 |
| Patient transfer/repositioning | 15 |
| Poor tracheotomy care/education | 14 |
| Nursing care | 11 |
| Junior care | 10 |
| Ties too loose | 6 |
| Excess cuff pressure | 5 |
| Equipment/staff did not arrive in time | 3 |
| Total | 88 |
| Tracheotomy-insertion issues | |
| Percutaneous tracheotomy | 12 |
| Tracheotomy placed too low | 1 |
| Total | 13 |
See Results section for details.
Because the responses were completely free-text, and these elements shown in the table were not specifically asked for, it is likely that the true number of patients with each of these characteristics was higher.
Intraoperative events included tracheoinnominate artery fistula, tracheoesophageal fistula, airway fire, tracheotomy change—false passage, bleeding, pneumothorax, tracheal tear, laryngomalacia.
Tracheomalacia, necrotizing fasciitis, airway fire, tracheal tear, pneumonia, infection, foreign body, inability to cannulate stoma, downsized too early.
Guillain-Barre syndrome, immunocompromise, diabetes, muscular dystrophy, Down syndrome.
TIF = tracheoinnominate artery fistula.