Ann Thorac Surg 1997;64:982-985
© 1997 The Society of Thoracic Surgeons
Original Article: General Thoracic
The Role of Tracheostomy in Acquired Immunodeficiency Syndrome
David R. Flum, MD,
Omar S. Bholat, MD,
Marc K. Wallack, MD
St. Vincent's Hospital and Medical Center, New York Medical College, New York, New York
Accepted for publication April 14, 1997.
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Abstract
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Background. Tracheostomy tube (TT) insertion for respiratory failure in patients with acquired immunodeficiency syndrome has been associated with an early mortality rate of 100%. We have reviewed our experience with tracheostomy to determine if there is a role for this procedure among certain subgroups.
Methods. A retrospective review was conducted of 47 patients diagnosed with acquired immunodeficiency syndrome who underwent tracheostomy from 1988 to 1995. Patients were divided into three groups based on indications for tracheostomy: group 1, Pneumocystis carinii pneumonia (PCP); group 2, non-PCP pneumonia; and group 3, others (including neurosyphilis, endocarditis, and trauma).
Results. All groups were similar with regard to demographic details and laboratory values (mean age, 38 ± 1.4 years; 95% male; CD4 count = 21.8 ± 3.6 cells/µL). In the vast majority of cases the decision to place a TT was elective. Forty-three percent of all patients had signed do not resuscitate orders before endotracheal tube intubation. The mean time from endotracheal tube to TT insertion was 14.1 ± 1.6 days. Early mortality after TT placement was dismal (91%) for group 1 patients but significantly better (47%) in group 2 patients (p = 0.04). Early mortality usually occurred within 3 weeks of TT placement (range, 1 to 54 days). The cause of pneumonia (PCP versus non-PCP) was the only statistically significant variable in predicting outcome. For those who survived to TT removal (26%), the average time to removal of TT was 67 ± 11 days. Long-term survival was noted in 8 group 2 patients (mean, 584 days) and in 2 group 1 patients (450 days).
Conclusions. Outcome after tracheostomy in patients with AIDS is generally poor. Patients with PCP should not undergo TT placement; however, patients with non-PCP pneumonia have a reasonable expected survival and should undergo the operation.
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Introduction
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See also page 985.
As the number of patients infected with human immunodeficiency virus (HIV) has increased, difficult questions regarding the usefulness of surgical interventions in this population have emerged. Only through careful scrutiny of surgical outcomes will realistic therapeutic goals be achieved. Certain surgical pathology presents so late in the clinical progression of acquired immunodeficiency syndrome (AIDS) that operation is ill-advised [1], whereas other entities may be present earlier in the course of disease and therefore are better suited to surgical intervention [2]. The challenge to the clinician is in distinguishing these two groups.
Pneumonia and respiratory failure are frequently implicated in the terminal stages of AIDS [3]. Prolonged ventilatory support requiring endotracheal tube (ETT) placement is associated with death in 50% to 85% of patients [3–5]. Tracheostomy tube (TT) insertion is periodically performed when patients with AIDS require prolonged mechanical ventilation. The short-term mortality rate after tracheostomy has been reported at 100% and has led some authors to advocate a policy of no tracheostomy for patients with AIDS [2]. Unfortunately, available data to evaluate the utility of tracheostomy describe only small groups of patients. Our clinical impression regarding tracheostomy in a large group of patients with AIDS is that this procedure has little role in the spectrum of disease. However, there does appear to be a subgroup of patients with AIDS in whom it is indicated. This retrospective review was designed to evaluate our experience and to determine the indications for TT placement, comorbid factors, and expected survival after tracheostomy. In this way realistic expectations, recommendations, and decision making can be employed by those who care for patients with AIDS.
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Material and Methods
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A retrospective review was conducted in the Department of Medical Records at St. Vincent's Hospital and Medical Center of New York City. Forty-seven consecutive patients diagnosed with AIDS and undergoing tracheostomy from January 1, 1988, to December 31, 1995, were identified. The medical records of these patients were reviewed by a team of examiners. Data obtained included demographic, clinical history, laboratory, radiologic, diagnostic, operative, postoperative, and disposition variables. At the time of data acquisition, follow-up surveys were completed through telephone contact to the patient or next available source. Follow-up questionnaires included patient disposition and further clinical or operative information. Patients were divided into three groups based on the indication for tracheostomy: group 1, Pneumocystis carinii pneumonia (PCP); group 2, non-PCP pneumonia; and group 3, other indications. Bronchoscopy was routinely used to obtain sputum for analysis when routine cultures were insufficient for microbiologic diagnosis. Short-term mortality was defined as death within 60 days of the operation.
All data were evaluated for statistical relationships using a statistical analysis package (Microsoft Excel 4). Student's t testing, 
2, multivariate analysis, and Fisher exact testing were applied where appropriate. A p value less than 0.05 was considered statistically significant. All data are presented as mean ± standard error of the mean unless otherwise specified.
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Results
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Forty-seven patients (mean age, 38 ± 1.4 years; 95% male) with AIDS who underwent tracheostomy were reviewed. The patients were subdivided into three groups: group 1, PCP (22), group 2, non-PCP pneumonia (15), and group 3, other indications (10). Group 2 included patients with pneumonia caused by toxoplasmosis (3), pneumococcus (4), Mycobacterium tuberculosis (3), Klebsiella (2), Streptococcus (1), and unspecified bacteria (2). Group 3 included patients with neurosyphilis (1), endocarditis (1), small bowel lymphoma (1), head and neck operation (1), tonsillar abscess (1), aspergillosis (1), and trauma (4). All groups were similar with regard to preoperative laboratory values (CD4 count, 21.8 ± 3.6 cells/µL; albumin, 2.8 ± 1 g; white blood cells, 7.9 ± 2.1 x 103/µL; lactate dehydrogenase, 2,210 ± 243 international units/L; worst oxygen tension before intubation, 55 ± 13 mm Hg). The most commonly reported source of HIV infection was different between groups. Sixty percent of patients in group 1 were infected with HIV from sexual contact, whereas 60% of group 2 and 3 patients reported intravenous drug use as the source for HIV infection (p = 0.07). The mean time from hospitalization to ETT placement was 5.3 ± 2.7 days and the time from ETT placement to TT insertion was 14.1 ± 1.6 days.
Only a small percentage of patients undergoing TT for pneumonia had ETT placement on arrival to the emergency room (18% and 9% for groups 1 and 2, respectively). In the majority of cases the decision to place a TT was elective despite the fact that 43% of all patients had signed do not resuscitate (DNR) orders before ETT placement. Tracheostomy was performed in the setting of multiple system organ failure in more than a third of patients with pneumonia. The procedure was performed in the operating room 95% of the time and under general anesthesia in 60%. In group 3 a statistically higher rate of patients were intubated on arrival when compared with other groups. This higher rate of patients with out-of-hospital ETT placement was linked to trauma admissions and in-field resuscitation in this group. Short-term mortality (Table 1
) after TT placement was 91% in group 1 and 53% in group 2 (p = 0.04), with death occurring soon after the operation. In patients with early mortality, the time from TT insertion to death was 22 ± 6 days (median, 17 days; range, 1 to 54 days for all patients considered). Short-term mortality (median survival time) in groups 1, 2, and 3 occurred at 17, 17, and 7.5 days, respectively (not significant).
The small subset of patients in groups 1 and 2 who survived were separately evaluated to determine survival characteristics. The cause of the pneumonia (PCP versus non-PCP) was statistically linked to survival; however, CD4 count, albumin level, preoperative laboratory testing, and source of HIV were not. Among survivors after tracheostomy, differences in the length of time until TT decannulation were not statistically significant. Long-term outcome was statistically better for group 2 compared with group 1. The small number of group 1 survivors (n = 2) precluded statistical analysis in determining predictors of survival. Of the group 1 long-term survivors, 1 patient died after 450 days and the other was lost to follow-up. In group 2, long-term survival of 584 ± 65 days (median, 465 days) after tracheostomy was noted (n = 8). Two of the 8 patients were alive at the time of follow-up (average, 75 months). Follow-up was complete in 94%.
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Comment
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Pulmonary disease is frequently encountered by clinicians caring for patients with AIDS. However, it is in the complications of pulmonary disorders, such as pneumothorax, empyema, and tracheostomy, that surgeons are actively involved in patient management [2]. Although thoracotomy and thoracoscopy may have a role in patients with AIDS, early reports have indicated that tracheostomy may not have a favorable impact on the natural course of AIDS. Respiratory failure requiring ETT placement and mechanical ventilation is associated with a mortality rate approaching 85% [3–5]. Although improved outcome has been noted by some groups [4, 5], TT has been avoided in patients with AIDS. It has been suggested that mechanical ventilation and tracheostomy should not be considered in patients with AIDS [2, 3]. Despite the presumption that tracheostomy is not indicated in patients with AIDS, there is a limited body of available data regarding the role of this procedure (Table 2). In one report [8] of 120 surgical procedures performed in patients with AIDS, TT placement was performed in 7. Of all the operative procedures described in this report, tracheostomy was the singular exception to the rule that operation in patients with AIDS prolongs the length and quality of life. In another review [6] of 110 operations in patients with AIDS, 6 tracheostomies were performed. No follow-up of this group was provided.
In this large review of outcome after tracheostomy in patients with AIDS, patients with PCP had the most dismal outcomes of all (91% mortality). A subset of patients with AIDS has been recognized, however, who undergo TT placement for non-PCP pneumonia and have a reasonable expectation (>50%) of survival. A last group of patients with AIDS who require TT placement for trauma, head and neck operation, or respiratory insufficiency caused by other sources also has a good expectation of survival to TT removal. In light of the dismal survival statistics in patients with PCP, we do not advocate TT placement in this group. Although other studies have reported a 100% mortality rate after TT placement in patients with PCP, our series noted a 9% survival rate. This relative improvement in survival identified in the group with PCP may be linked to misdiagnoses or mixing of pathology. Of the small number of patients with PCP who survived, this study failed to identify variables or features that were linked to survival. Until better predictors of outcome can be determined among this group, it is unlikely that TT placement will benefit enough patients to warrant the poor outcomes in others.
Several disturbing issues regarding the decision for TT placement were noted in this review. The bulk of patients were not intubated on arrival to the hospital, and theoretically this intervening period should have allowed time for discussions regarding the level of aggressiveness of care desired by the patients and their families. Interestingly, DNR orders had been completed by more than 40% of patients before intubation. Do not resuscitate orders often represent a patient's perspective regarding the desired "level of aggressiveness of care." It may be that other factors (including family wishes, medico-legal considerations, or physician perspectives) contributed to the decision to place a TT in these patients despite the preexisting DNR order. The decision to place a TT is even more alarming because of the poor outcomes after TT placement in this subgroup. Aside from representing a futile form of care, the procedure is associated with considerable expense and questions of patient discomfort. The issue of patient discomfort during the procedure should be balanced by whether continued orotracheal intubation is more or less comfortable than TT placement and maintenance. Other issues to consider in delivering what may be considered futile therapy are the financial burden to society associated with the procedure and the risk to hospital personnel during invasive procedures. Finally, it should be considered that new medications that may improve the survival of patients with AIDS should temper our assessments of surgical outcomes. Continued research will be necessary to determine if improved medical therapy has had any impact on the surgical outcomes noted in this review.
This review supports the contention that patients with AIDS who require TT placement have poor outcomes. Placement of a TT in patients with PCP is almost universally associated with death within 3 weeks of the procedure. Patients with non-PCP pulmonary processes and other indications for TT placement are a subgroup that should be offered operation. In these patients (groups 2 and 3) successful outcomes can be predicted for a reasonable percentage and removal of TT can be expected in the same. Placement of a TT should be considered in these groups but discouraged in patients with respiratory failure secondary to PCP. Once a decision has been made to use a TT in a patient with AIDS, the timing of the operation remains the same as that for patients without AIDS. Only by evaluating specific surgical procedures in patients with AIDS can we determine who will and will not benefit from an operation. This study should serve to clarify the current role of tracheostomy in patients with AIDS.
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Acknowledgments
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We acknowledge the attending staff at St Vincent's Hospital and Medical Center, New York Medical College, who managed the care of this complex group of patients: Thanks to Drs Marshall Kramer, Enrique A. Bonfils-Roberts, Jesse Blumenthal, Timothy Melester, Christopher Mills, Jose Corvalon, Vincent Scarpinato, Albert Burchell, Jack Yee, Steven Wong, Jack Slattery, James Pacholka, and Marc K. Wallack.
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Footnotes
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Address reprint requests to Dr Flum, PO Box 67, Indian Health Service, Chinle, AZ 86503.
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References
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Invited Commentary
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Ann. Thorac. Surg. 1997 64: 985.
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Abstract
Introduction
