Influência da traqueostomia longitudinal e da traqueostomia de ressecção sobre a estenose traqueal

Abstract

Resumo: A influência exercida pelo tipo de traqueostomia sobre a formação da estenose traqueal (ET) pós-traqueostomia permanece controversa. Os objetivos deste estudo foram determinar: a influência do tipo de traqueostomia sobre a ET, as diferenças entre as duas técnicas em relação aos fatores predisponentes, desencadeantes e agravantes e os fatores predisponentes, desencadeantes ou agravantes que influenciam a ET ou por ela são influenciados. Estudaram-se, prospectivamente, 354 pacientes internados na Unidade de Tratamento Intensivo e na Unidade Coronariana do Hospital Universitário Cajuru da Pontifícia Universidade Católica do Paraná submetidos a intubação traqueal seguida de traqueostomia de ressecção (TR) ou traqueostomia longitudinal (TL) no sexto dia. Os pacientes foram submetidos a fibrolaringotraqueobroncoscopia (FL TB) nos 7. 0 , 14.0 , 21. 0 , 28. 0 e a cada 30 dias, até que se completasse um ano se ainda canulados, e no 30° e 180° dia após a decanulação. Após cumprirem os critérios de exclusão, foram selecionados 117 pacientes, sendo 86 (73,5%) do sexo masculino e 31(26,5%) do sexo feminino. A idade variou dos 9 aos 76 anos, com média de 33,1 anos. Foram realizadas 986 FLTB, sendo 794(80,52%) do protocolo, 148(15,07%) para broncoaspiração, 42 (4,25%) para diagnóstico e 2{0,20%) terapêutica. Resultados: 36(30,8%) apresentaram ET, sendo 13(26%) dos pacientes submetidos a TL e 23 (34,3%) submetidos a TR sem diferença estatística. Vinte e sete(23, 1 %) pacientes apresentaram estenose traqueal estornai, sendo 18 isoladas, seis associadas a infraestornai do terço médio, uma associada a infra-estornai do terço inferior e duas associadas a supra-estornai. Destas, oito (16%) eram de TL e 19 (28,3%) de TR. Oito(6,8%) apresentaram estenose traqueal infra-estornai isolada, sendo quatro (8%) dos de TL e quatro (6%) dos de TR. Um (0,9%) paciente apresentou estenose traqueal supra-estornai isolada, representando 2% dos pacientes com TL. ET grau leve foi encontrada em seis (16,7%) dos pacientes, ET grau moderado em 17 (47,2%) e ET grau severo em13 (36,1%). A extensão da ET variou de 11 a 32 mm, com média de 18,4mm. Após proceder-se à análise comparativa dos pacientes com ET x pacientes sem ET; pacientes de TL x pacientes de TR e pacientes de TL com ET x pacientes de TR com ET, encontrou-se diferença estatística para: idade mais avançada e pacientes com ET, pacientes com TR e ET e TR; sexo masculino e TR; Tempo de Traqueostomia e ET e ET e Tempo de Fechamento do Estoma. Estado final dos pacientes com ET: 22 (61, 1%) foram decanulados sendo sete (53,8%) daqueles com ET e TL e 15 (65,2%) com ET e TR; seis (16,7%) dos pacientes permaneceram com cânula sendo três (23, 1%) dos com ET e TL e três (13,1%) dos com ET e TR, um {2,8%) paciente de TL desenvolveu fístula traqueocutânea e sete (19,4%) foram submetidos a traqueoplastia, sendo três (23,1%) dos pacientes comETe TL e quatro (17,4%) dos comETe TR. Conclusão: a formação da ET não foi influenciada pelo tipo de traqueostomia; os pacientes submetidos a TR tinham idade acima da média, maior ocorrência de ET nos acima da média e permaneceram maior tempo internados; houve ocorrência maior de ET nos pacientes do sexo masculino, mais idosos e com maior Tempo de Traqueostomia e a ET determinou prolongamento do Tempo de Fechamento do Estoma.

Abstract: There still is much controversy about the influence exerted by the type of tracheostomy over the tracheal stenosis (TS) post-tracheostomy. This study aims at determining the influence of the tracheostomy type on TS, the differences between the two techniques in relation to predisposing, triggering and aggravating factors as well as the predisposing, triggering and aggravating factors which influence TS or are influenced by it. Were studied prospectively 354 patients from the lntensive Care Unit and from the Coronary Unit of the Cajuru Hospital of the Catholic University of Paraná who underwent tracheal intubation, followed by resection tracheostomy (RT) or longitudinal tracheostomy (L T) on the sixth day. The patients underwent a fibrolaryngo- tracheobronchoscopy (FL TB) on the 7th, 14th, 21st 28th days and every 30 days, until the first year if they still had the tube in place, and on the 30th and 180th days after having had the tube taken out. After having satisfied the exclusion criteria, 117 patients were selected, from whom 86 were male (73,5%) and 31 female (26,5%). Their age ranged from 9 to 76, with an average of 33,1 years of age. 986 FL TB were carried out. From these, 794 (80,52%) for protocol purposes, 148 (15,07%) for bronchoaspiration, 42 (4,25%) for diagnosis and 2 (0,20%) for therapeutic purposes. Results: 36 (30,8%) presented ST, 13 (26%) of the patients underwent LT and 23 (34,3%) underwent RT with no statistical differences. Twentyseven patients had stomal tracheal stenosis, being 18 isolated, six associated with the infrastomal of the midle third, one associated with the infrastomal of the lower third and two associated with suprastomal stenosis. From these, eight (16%) were of the LT type and 19 (28,3%) were of the RT type. Eight (6,8%) had infrastomal isolated tracheal stenosis, from or 4 (8%) were of the L T type and 4 (6%) of the RT type. One patient (0,9%) had isolated suprastomal tracheal stenosis, representing 2% o f the patients with L T. A to a low degree ST was found in six ( 16,7%) o f the patients, a moderate degree was found in 17 (47,2%) and an ST to a serious degree in 13 (36, 1%). Th ST length ST varied between 11 and 32 mm, with an average of 18,4 mm. After proceeding with the comparative analysis of TS patients x patients without TS; LT patients x RT patients and LT patients displaying ST x TR patients with ST, a statistical difference was found for: elderly and ST patients, RT and ST patients and RT; male patients and RT; tracheostomy length and ST and ST and Stoma closure period. Final state of ST patients: 22 (61, 1 %) had the tube removed, among whom 7 ST and LT (53,8%) and 15 ST and RT (65,2%); six (61,1%) of the patients were kept with the tube in, among of three (23,1%) ST and LT and three (13,1%) ofwhom ST and RT, one (2,8%) LT patient developed a tracheocutaneous fistula and seven had to undergo tracheoplasty, of whom three (23, 1%) ST and L T patients and four (17,4%) ST and RT. Conclusion: ST rate was not influenced by the tracheostomy type; the patients who underwent RT were older, in the older the index of the ST was greater and they were hospitalised longer. There was a greater occurence of ST on male, older patients and with the longest time of Tracheostomy I and the ST determined the extension of the Stoma Closure Duration.