It has been difficult at any time to establish the incidence of lesions that follow tracheal intubation. In 1967, 17% of a vulnerable population from a respiratory care unit at the Massachusetts General Hospital developed clinical evidence of upper airway obstruction. This selected population consisted of survivors of relatively prolonged treatments of the most severe respiratory failures and the study occurred in the era preceding the development of low-pressure cuffs. Large numbers of patients who had received respiratory support for lesser problems, often through an endotracheal tube, were not included. The figure compared quite closely with the range then described from other institutions: 20% from the Toronto General Hospital with a similar population, 12% of a group of cardiac surgical patients from Mount Sinai Hospital in New York, and 16% of a group of 50 patients from Australia. Harley attempted to establish the incidence of laryngotracheal stenosis following tracheostomy and assisted ventilation, by analyzing reported series.20 The range was from 0 to 22%, with an average of 3.27% for 3,793 tracheostomies.

Introduction of low-pressure cuffs of varying efficacy and closer attention to avoidance of stomal erosion greatly diminished the occurrence of injury in succeeding years. Following introduction of our prototype of the low-pressure latex cuff, cuff stenosis vanished at Massachusetts General Hospital. Careful attention to the use of currently available plastic large-volume, low-pressure cuffs has continued this record. Stomal strictures were reduced to well under 1% (see "Prevention of Postintubation Lesions" below). In recent years, further attention to tube support has eliminated these lesions as well. Unfortu-

figure 11-15 Obstructing granuloma in a child, caused by erosion by the tip of a tra-cheostomy tube. The angle of many adult tubes is inappropriate for pediatric use. Broncho-scopic removal of the granuloma sufficed.

nately, this is not universally true, for reasons described later. Postintubation lesions of all types continue to be produced worldwide, and they continue to be the leading indication for tracheal surgery.

Tracheoesophageal fistula (TEF) and tracheo-innominate arterial fistula resulting from intubation and ventilation are described in Chapter 12, "Acquired Tracheoesophageal and Bronchoesophageal Fistula," and Chapter 13, "Tracheal Fistula to Brachiocephalic Artery."

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