Abstract
Tracheostomy a lifesaving procedure done more frequently for critically ill patients for mechanical ventilation, bronchopulmonary toileting, reduce pulmonary effort has variable complications to itself. The common being secondary infection with bacteria and fungi, which in turn lead to granulation formation in stoma and on peristomal region. This prospective study was done with an aim to study, correlate and compare the microbial organisms grown in culture from tracheostomy tubes and peristomal granulation in ventilated and non-ventilated patient. We studied 210 patients out of them 100 patients satisfied the inclusion and exclusion criteria and they were included in this study. We found 89 patients staining positive for bacterial cultures and 8 patients staining positive for fungi and the granulation increases as the time taken for tube change is more than 1 month. So, we concluded it is ideal to change tracheostomy tube within a month duration and most common organism complicating infection in stoma as Pseudomonas aeruginosa followed by coagulase negative Staphylococcus aureus.
Keywords: Tracheostomy, Tracheostomy tube, Stomal granulation, Peristomal granulation, Bacterial infection, Fungal infection
Introduction
Tracheostomy a surgical procedure in which the trachea is exteriorized creating a surgical fistula between the external atmosphere to the tracheal airway bypassing the upper airway such as nose, nasopharynx, oropharynx and larynx [1]. It is one of the oldest surgical procedure on record dating back to 3000 BC in Egypt [2]. It is done to relieve upper airway obstruction, to assist in long-term ventilatory support [3]. Performing a tracheostomy procedure is an alternative way of maintaining airway in patients who are receiving prolonged endotracheal intubation, with benefits of improving patient’s airway management and thus decreasing the chances of hospital acquired infections. Multiple late complications were described such as laryngotracheal stenosis, granulation formation, trachea-esophageal fistula, pneumothorax, tracheocutaneous fistula, scar, difficult decannulation [4]. Among these granulation formations can cause bleeding, obstruction of airway and crusting. Tracheostomy tubes often harbor microbial organisms on the tube which may cause stomal infection and granulation formation.
Methods
Type of study prospective observational study.
Study location and period Department of ENT, Head & Neck surgery Tertiary Hospital located in South India from March 2016 to June 2018.
Aim To study, correlate and compare the microbial organisms grown in culture from tracheostomy tubes and peristomal granulation in ventilated and non-ventilated patient.
The cultures were obtained during regular tube changes done during the study period with inclusion criteria of all patients undergoing tube change/replacement in our institute by the department of ENT, Head & Neck surgery, all age group and both sexes were included. Tube changes done in an emergency situation and patient not willing to consent were excluded from the study. Study was conducted with ethical approval from institutional ethics committee.
Cultures were obtained from the outer aspect of the maximum curvature (for both fenestrated and non-fenestrated tube) and from the fenestra (for fenestrated tube) of the outer tube was obtained because this was the point of maximum contact with the stoma and common site of crusting and biofilm formation. For cuffed tubes the culture was taken from the cuff. The obtained culture slides were mounted on 10% KOH, Gram staining and bacterial culture. The tubes were sent to microbiology lab in a sterile container and it was studied there for presence of biofilms.
Granulation in the stoma and peristomal regions were inspected and graded as follows
Grade 1 No granulation.
Grade 2 Minimal granulation (involving less than 50% of tracheal stoma).
Grade 3 Moderate degree of granulation (involving 50–70% of tracheal stoma).
Grade 4 Severe of exuberant granulation (involving 100% of tracheal stoma).
Statistical analysis was performed using Chi square test or Fisher’s exact test and compared using One-way Anova analysis. Total of 210 tracheostomy tube changes were performed in the study period and out of these 100 patients satisfied the criteria taken and these were analyzed.
Results Most of the patient who underwent tube change were more than 40 years of age with 45 patients above 60 years (Table 1).
Table 1.
Age distribution of patient
| Age of the patients (in years) | No. of patients |
|---|---|
| < 20 | 3 |
| 21–40 | 9 |
| 41–60 | 43 |
| > 61 | 45 |
Gender distribution was M:F 53:47. Fifty seven patients were with uncuffed tube and 43 patients were having cuffed tracheostomy tube. In these 38 patients were under ventilatory support and the remaining 62 patients were without ventilator support. Thirty two culture yields gram positive organism and 40 yielded gram negative cultures. Seventeen patient had both gram positive and gram negative and 11 cultures showed no growth (Table 2).
Table 2.
Gram staining of cultures
| Gram staining | No of patients |
|---|---|
| Gram positive | 32 |
| Gram negative | 40 |
| Both | 17 |
| No organism | 11 |
Positive bacterial cultures where obtained in 89 patients, most common isolate was Pseudomonas aeruginosa (28%) followed by coagulase negative Staphylococcus aureus. The bacterial culture obtained is shown in Table 3.
Table 3.
Bacterial culture isolated
| Bacteria isolated | No of cultures (in %) |
|---|---|
| Pseudomonas aeruginosa | 28 |
| Coagulase-negative Staphylococcus aureus | 27 |
| Streptococcus sp. | 26 |
| Escherichia coli | 14 |
| Klebsiella pneumoniae | 3 |
| Acinetobacter baumannii | 1 |
| Citrobacter sp. | 1 |
Granulation in stomal and peristomal regions were assessed and we found all patients who had tracheostomy tube insitu had some amount of granulation present with maximum number patients having a Grade 1 granulation at 835 followed by Grade 2 in 12%, Grade 3 in 3% and Grade 4 in 2%. Out of the tube changes done during the study period 62% of patients was non ventilated or not on ventilatory support while change of tube was done and 38% patients were with ventilatory support.
Gram staining was done in all 100 patients and out of that 89 patients’ swabs were stained (both Gram positive and Gram negative) and the remaining 11 patients showed no organism on gram stain and culture. On comparison of gram stain with granulation patient cultures who had gram negative stain had more (40%) granulations than with patient harboring gram positive (32%) (Table 4). The comparison of granulation and gram staining (Gram positive and Gram negative) is statistically insignificant.
Table 4.
Comparison of Gram stain with the granulation
| Peristomal granulation (grade) | Total | ||||
|---|---|---|---|---|---|
| 1 | 2 | 3 | 4 | ||
| Gram stain | |||||
| Gram positive | 26 (31.3%) | 5 (41.7%) | 0 | 1 (50%) | 40 |
| Gram negative | 34 (41%) | 5 (41.7%) | 1 (33.3%) | 0 | 32 |
| Both | 12 (14.5%) | 2 (16.7%) | 2 (66.7%) | 1 (50%) | 17 |
| No growth | 11 (13.3%) | 0 | 0 | 0 | 11 |
| Total | 83 (100%) | 12 (100%) | 3 (100%) | 2 (100%) | 100 |
We observed statistically significant difference on comparing Gram stains between single and double lumen tube. When comparing the single and double lumen tracheostomy tubes with the gram stain 24 patients on single lumen tube had shown bacterial growth and 65 patients with double lumen tube had yielded bacteria. Eleven patients had no growth in culture and staining. This is shown in Table 5. The comparison of the outcomes of Gram stain obtained from the tracheostomy tube of single and double lumen tracheostomy tubes is statistically significant with both organisms visualized in the tracheostomy tube with p value of 0.001.
Table 5.
Comparison of organism with tracheostomy tube type
| Tube type | Total | ||
|---|---|---|---|
| Single lumen | Double lumen | ||
| Gram stain | |||
| Gram positive | 12 (37.5%) | 20 (29.4%) | 40 |
| Gram negative | 12 (37.5%) | 28 (41.2%) | 32 |
| Both | 0 | 17 (25%) | 17 |
| No growth | 8 (25%) | 3 (4.4%) | 11 |
| Total | 32 (100%) | 68 (100%) | 100 |
Out of the 100 patients studied 8 patients stained positive for fungal smear and out of these patients one patient was on ventilatory support. Granulation was present in all patient. Though statistically not significant 6 patients had Grade 1 granulations and Grade 2 was on 2 patients (Table 6).
Table 6.
Comparison of fungal smear with the granulation
| Peristomal granulations (grade) | Total | ||||
|---|---|---|---|---|---|
| 1 | 2 | 3 | 4 | ||
| Fungal smear | |||||
| Positive | 6 (7.2%) | 2 (16.7%) | 0 | 0 | 8 |
| Negative | 77 (92.8%) | 10 (83.3%) | 3 (100%) | 2 (100%) | 92 |
| Total | 83 (100%) | 12 (100%) | 3 (100%) | 2 (100%) | 100 |
We observed a statistically significant difference in fungal smear stain when compared between single and double lumen tracheostomy tubes with double lumen tube smears stain positive in 8 patients and single lumen smears did not stain positive any of the smears studies.
Tube change was done on average of 13 days in ventilatory support patients and on average of 88 days in non-ventilated patients. Patients who had undergone tracheostomy tube change after 1 month had higher grading of granulation and percentage of patients with granulations was more for patients who had undergone tube change after a month. Patients who were ventilated, single lumen tube had undergone tube change on average of 13 days. The difference though it is insignificant statistically the patients who had undergone tube change often or within 1 month had lesser granulations than patients having tube change after this period.
Discussion
Tracheostomy considered as one of the life saving procedure for patients who is on prolonged endotracheal intubation [5]. However, tracheostomy has serious complications that need to be addressed ranging from recurrent lower respiratory tract infection to life threatening sepsis [6]. Enteric gram-negative bacilli are the common organism responsible for the nosocomial infections in tracheostomy patients [7]. Microorganisms produce extracellular polysaccharides which binds to implants or external surfaces which results in formation of biofilm [8]. Usually gram-negative organisms bind to surfaces. It results in increased resistance to antimicrobials. It has a potential to cause infections in tracheostomy tubes [9].
In a study conducted by Acharya et al. [10] studied on respiratory infection due to colonization of microorganisms from tracheostomy tubes in hospital to identify the common pathogen causing LRTI in their study the found that Pseudomonas aeruginosa to be the most common organism and Acinetobacter being the second most common. Similarly in other studies conducted by Ferreira [11] on cultures from endotracheal tubes found Pseudomonas to be the most common organism to be isolated and Gotsman et al. [12] found Staphylococcus to be most common organism causing respiratory infection due to contamination from tracheostomy tube. In our study we found Pseudomonas aeruginosa to be the most common isolate from the tracheostomy tube followed by Coagulase negative Staphylococcus aureus, Streptococcus sp. It is noted that chronically and critically ill are known to be more vulnerable for colonization and subsequent infection of the airway. Neiderman et al. [7] in a study found that gram negative organism colonize and form biofilms more in upper airway than the lower airway and in patients with tracheostomy. Similarly we found evidence of gram negative organism being grown more than gram positive organism even though the difference is not statistically significant.
We found fungal stains to be positive in patients on long term tracheostomy. We could not find a similar study in published literature about isolation of fungi on different variable related to tracheostomy tubes. We found all fungal positive stain from double lumen tube with more being fenestrated. Fenestra in double lumen tubes can harbor fungi in tracheostomy which are changed after a month duration.
Yaremchuk investigated on prevention of stomal granulations on regular tracheostomy tube change as persistence of granulation can cause delayed decannulation and interference with the function of the tracheostomy tube. According to the study Staphylococcus species have been frequently isolated from the stomal sites. They have emphasized on the importance of regular tube change. In our study also we found as the time interval between the tube change increases the grading of peristomal granulation increases. As the study states tracheostomy tubes to be changed every month to avoid granulation formation, bacterial colonization and biofilm formation [13].
Double lumen tracheostomy tubes found to harbor all fungal and more polymicrobial organisms this maybe due to greater surface area of tubes and the space between the outer and inner cannula could lay a path for the secretions to accumulate and act as a medium for the microbials to grow.
Conclusion
Most common organism to be cultured from the tracheostomy tube was Pseudomonas aeruginosa followed by coagulase negative Staphylococcus aureus. Fungal growth was common on double lumen tube left insitu for more than a month than single lumen tracheostomy tubes. Most significant factor for granulation formation is the duration of tracheostomy tube left insitu. We recommend tracheostomy tube to be changed every month to avoid serious infections associated with tracheostomy tubes.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Engels PT, Bagshaw SM, Meier M, Brindley PG. Tracheostomy: from insertion to decannulation. Can J Surg. 2009;52(5):427–433. [PMC free article] [PubMed] [Google Scholar]
- 2.Blomstedt P. Tracheostomy in ancient Egypt. J Laryngol Otol. 2014;128(8):665–668. doi: 10.1017/S0022215114001327. [DOI] [PubMed] [Google Scholar]
- 3.Andriolo BN, Andriolo RB, Saconato H, Atallah ÁN, Valente O. Early versus late tracheostomy for critically ill patients. Cochrane Database Syst Rev. 2015;1(1):CD007271. doi: 10.1002/14651858.CD007271.pub3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Sankari NV, Mohan J, Simon P, Sivakumar I, Subamanium Y. A new and simple method of fabrication of tracheostomal prosthesis. J Indian Prosthodont Soc. 2015;15(1):76–82. doi: 10.4103/0972-4052.155047. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Alabi BS, Afolabi OA, Dunmade AD, et al. Indications and outcome of tracheostomy in Ilorin, North Central Nigeria: 10 years review. Ann Afr Med. 2018;17(1):1–6. doi: 10.4103/aam.aam_130_16. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Moar JJ, Lello GE, Miller SD. Stomal sepsis and fatal haemorrhage following tracheostomy. Int J Maxillofac Surg. 1986;15(3):339–341. doi: 10.1016/S0300-9785(86)80097-7. [DOI] [PubMed] [Google Scholar]
- 7.Neiderman 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(1):39–44. doi: 10.1378/chest.85.1.39. [DOI] [PubMed] [Google Scholar]
- 8.Limoli DH, Jones CJ, Wozniak DJ. Bacterial extracellular polysaccharides in Biofilm formation and function. Microbiol Spectr. 2015;3(3):1–19. doi: 10.1128/microbiolspec.MB-0011-2014. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Diaconu O, Siriopol I, Poloşanu LI, Grigoraş I. Endotracheal tube biofilm and its impact on the pathogenesis of ventilator-associated pneumonia. J Crit Care Med (Targu Mures) 2018;4(2):50–55. doi: 10.2478/jccm-2018-0011. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Acharya R, Wakode PT, Bhandary S, Khanal B, Khatiwada S. Colonization and infection in tracheostomized patients at tertiary care hospital in Eastern Nepal. Health Renaiss. 2014;12(2):68–73. doi: 10.3126/hren.v12i2.14102. [DOI] [Google Scholar]
- 11.Ferreira TO, Koto RY, Leite GFC, Klautau GB, Nigro S, Silva CB, Souza APIF, Mimica MJ, Cesar RG, Salles MJC. Microbial investigation of biofilms recovered from endotracheal tubes using sonication in intensive care unit pediatric patients. Braz J Infect Dis. 2016;20(5):468–475. doi: 10.1016/j.bjid.2016.07.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Gotsman MS, Whitby JL. Respiratory Infection following Tracheostomy. Thorax. 1964;19(1):89–96. doi: 10.1136/thx.19.1.89. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Yaremchuk K. Regular tracheostomy tube changes to prevent formation of granulation tissue. Laryngoscope. 2003;113(1):1–10. doi: 10.1097/00005537-200301000-00001. [DOI] [PubMed] [Google Scholar]