Research

JAMA Otolaryngology–Head & Neck Surgery | Original Investigation

Tracheotomy Outcomes in Super Obese Patients

Ryan V. Marshall, MS; Patrick J. Haas, MD; John M. Schweinfurth, MD; William H. Replogle, PhD

CME Quiz at
IMPORTANCE Surgeons need to understand the expected outcomes for super obese patients jamanetworkcme.com and
CME Questions page 812
undergoing tracheotomy to appropriately counsel patients and families about likely risks and
benefits.

OBJECTIVE To determine the outcomes, complications, and mortality after tracheotomy in

super obese patients (those with a body mass index [BMI] greater than 50).

DESIGN, SETTING, AND PARTICIPANTS A retrospective review was conducted of billing records
from a tertiary care academic medical center from November 1, 2010, through June 30, 2013,
to identify patients undergoing tracheotomy. Medical records were reviewed to identify
patients with a BMI (calculated as weight in kilograms divided by height in meters squared)
greater than 50 and a control group with a BMI of 30 to 50. Patient characteristics, including
BMI, age, race/ethnicity, primary diagnosis for hospitalization, medical comorbidities, and
surgical technique, were measured.

MAIN OUTCOMES AND MEASURES The primary outcome measure was dependence on
tracheostomy at discharge. Secondary outcomes included rates of ventilator dependence,
mortality, postoperative complications, and discharge disposition.

RESULTS The super obese population included 31 patients and was predominantly African
American (20 patients [65%]) and female (21 patients [68%]). Mean BMI of super obese
patients was 64.0 (range, 50.2-95.5). The obese patient population was mainly African
American (25 patients [74%]) and female (17 patients [50%]). Twenty-five of 31 super obese
patients (81%) were discharged with a tracheotomy tube in place, compared with 16 of 34
obese patients (52%). Seven patients (23%) in the super obese group were ventilator
dependent at discharge, compared with 4 patients (13%) in the obese group. Only 2 of the
super obese patients (3%) were decannulated before discharge, compared with 15 (44%) in
the obese group. In-hospital mortality was similar for the 2 groups (super obese, 4 patients
[13%] and obese, 3 patients [9%]). The overall complication rate was 19% in the super obese
group (6 patients) compared with 6% in the obese group (2 patients). Super obese patients
were less likely to be discharged to a health care facility (17 patients [55%]) compared with
patients in the obese group (22 patients [65%]).

CONCLUSIONS AND RELEVANCE Tracheotomy in super obese patients is a safe and effective
strategy for airway management. Critically ill, super obese patients have a high likelihood of
remaining dependent on a tracheotomy or ventilator at the time of discharge.

Author Affiliations: School of

Medicine, University of Mississippi
Medical Center, Jackson (Marshall);
Department of Otolaryngology and
Communicative Sciences, University
of Mississippi Medical Center,
Jackson (Haas, Schweinfurth);
Department of Family Medicine,
University of Mississippi Medical
Center, Jackson (Replogle).
Corresponding Author: Ryan V.
Marshall, MS, School of Medicine,
University of Mississippi Medical
JAMA Otolaryngol Head Neck Surg. 2016;142(8):772-776. doi:10.1001/jamaoto.2016.1089 Center, 2500 N State St, Jackson, MS
Published online May 26, 2016. 39216 (rvmarsha@gmail.com).

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 Tracheotomy Outcomes in Super Obese Patients
O
besity rates continue to rise in the United States, with
Mississippi at the forefront of this epidemic. The
prevalence of individuals with a body mass index
(BMI) (calculated as weight in kilograms divided by height in
meters squared) greater than 50, commonly referred to as su-
per obesity in the literature, has grown 3 times as fast as the
prevalence of those with a BMI greater than 30.1 Increasing cer-
vical and submental adipose tissue decreases visualization and
surgical access to the airway.2 Standard-size tracheotomy tubes
have been shown to fit poorly in the airways of obese and su-
per obese patients owing to the increased distance from the
skin to the tracheal wall.3 Logistical factors, such as transfer-
ring patients to a standard operating table, can also prove to
be very difficult. As airway experts, otolaryngologists are typi-
cally called on to handle patients with the most difficult neck
anatomy, including that due to severe obesity.
When considering ambulatory surgical procedures, su-
per obese patients have more frequent postoperative compli-
cations and poorer outcomes compared with those with a lower
BMI.3,4 Super obese patients have significantly increased re-
spiratory resistance, increased peak inspiratory pressure, and
a decrease in dynamic respiratory compliance during bariat-
ric surgery.5 Systolic and diastolic blood pressure and mean ar-
terial pressure were also found to be reduced intraopera-
tively in super obese patients.5 These factors result in less
respiratory reserve and at least a theoretical increased risk with
airway surgery. The literature is divided on whether obese and
morbidly obese patients show a greater risk of complications
or mortality when undergoing tracheotomy.2,6-12
Outcomes after tracheotomy in patients with a BMI greater
than 50 have not been reported in the English-language lit-
erature, to our knowledge. It is important to understand the
expected outcomes for these patients so that surgeons can ap-
propriately counsel patients and families about likely risks, ben-
efits, and the necessary care that will be required once the pa-
tient is discharged from the hospital. Analyzing complications
also gives surgeons the opportunity to identify potential
sources of complications so they can be avoided, thus improv-
ing the safety of this procedure. Understanding complica-
tions gives the patient, family, and surgeon more information
with which to make a decision regarding care.
Our goal was to determine the primary outcome of tra-
cheostomy status at the time of discharge in super obese (BMI
>50) vs obese (BMI of 30-50) patients. Furthermore, we in-
vestigated outcomes related to mortality, ventilator depen-
dence, disposition, and complication rate. We hypothesize that
the super obese patient population undergoing tracheoto-
mies at our institution as inpatients are more likely to have com-
plications related to the procedure that will affect the course
of their hospital stay when compared with an obese patient
population undergoing the same procedure.
Methods
Inpatient hospital billing records from November 1, 2010,
through June 30, 2013, at a tertiary care medical center in
Jackson, Mississippi, were searched for the Current Procedural
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Original Investigation Research
Key Points
Question What are the outcomes, complications, and mortality
after tracheotomy in super obese patients?
Findings This retrospective medical record review of 65 patients
(31 super obese and 34 obese) undergoing tracheotomies found
that super obese patients were more likely to have a tracheotomy
tube at discharge, be dependent on a ventilator at discharge, and
be discharged to health care facilities. The overall complication
rate was slightly higher in the super obese patient population.
Meaning Tracheotomy in super obese patients is a safe and
effective strategy for airway management.
Terminology codes pertaining to adult tracheotomy (codes 31600
and 31601) to identify patients who had undergone tracheotomy.
The University of Mississippi Institutional Review Board ap-
proved this study and waived the requirement for patient con-
sent. Medical records were initially analyzed for data on height,
weight, and BMI. Patients with a BMI greater than 50 were fur-
ther analyzed, along with a comparable control group consist-
ing of patients with a BMI of 30 to 50. Inpatient billing records
revealed 811 patients who underwent tracheotomy. After review
of these patients’ medical records, 31 patients with a BMI greater
than 50 and 34 patients with a BMI of 30 to 50 were identified.
Detailed information was collected about each patient in-
cluding weight, height, BMI, year of surgery, race/ethnicity, age,
sex, health insurance status at the time of hospitalization, pri-
mary diagnosis for hospitalization, medical history, hospital
length of stay, length of time receiving ventilator assistance,
number of failed extubations, fraction of inspired oxygen be-
fore tracheotomy, service performing the tracheotomy, method
of tracheotomy, details of the surgical technique, trache-
otomy size, amount of blood loss, and presence of postopera-
tive complications. Race/ethnicity was determined by the in-
formation obtained in the patient’s medical record and was
used as a descriptive statistic. Medical comorbidities, includ-
ing type 2 diabetes, hypertension, congestive heart failure,
chronic heart disease, pulmonary hypertension, lung dis-
ease, chronic renal insufficiency, and obstructive sleep ap-
nea, were recorded based on documentation of these condi-
tions in the medical record during the patient’s hospitalization.
The use of different surgical techniques, including cervi-
cal defatting and Bjork flap, were recorded. Patients’ medical
records were searched for documentation of postoperative
complications, including pneumothorax, bleeding, acciden-
tal decannulation, death within 30 days of the procedure, and
tracheal vascular fistulas.
Statistical Analysis
We tested the association between BMI categories and nomi-
nal and interval study outcomes and comorbidities with the χ2
and t test, respectively. We calculated the relative risk of signifi-
cant predictors of outcomes. To study the independent effect
of BMI on tracheotomy status at discharge, we entered each of
the 8 comorbidities individually in 8 logistic regression mod-
els with BMI status as the other predictor variable and trache-
otomy status at discharge as the outcome variable. For measures
773
 Research Original Investigation Tracheotomy Outcomes in Super Obese Patients

Table 1. Patient Demographics Table 2. Patient Comorbidities

Valuea No. (%)

Super Obese Obese Super Obese Obese
Demographic (n = 31) (n = 34) P Value Comorbidity (n = 31) (n = 34) P Value
Age, mean (SD), y 50.0 (13.5) 52.0 (14.6) .41 Type 2 diabetes 19 (61) 13 (38) .06
BMI, mean (SD) 64.0 (12.6) 36.0 (4.2) <.001 Hypertension 26 (84) 23 (68) .13
African American 20 (65) 25 (74) .38 Congestive heart failure 9 (29) 4 (12) .08
Female 21 (68) 17 (50) .14 Chronic heart disease 10 (32) 3 (9) .02
Admitting diagnosis Pulmonary hypertension 6 (19) 0 .007
Neurologic 4 (13) 18 (53) <.001 Lung disease 14 (45) 2 (6) <.001
Infectious 7 (23) 0 .005 Chronic renal insufficiency 8 (26) 0 .002
Trauma 2 (7) 6 (18) .26 Obstructive sleep apnea 18 (58) 1 (3) <.001
Other 18 (58) 10 (29) .08

Abbreviation: BMI, body mass index (calculated as weight in kilograms divided
by height in meters squared).
a
Data are presented as number (percentage) of patients unless otherwise
indicated.
of effect size, we used odds ratios (ORs) and 95% CIs for logis-
tic regressions, risk differences (RDs) and 95% CIs for difference
in proportions, and Cohen d for interval scaled differences,
based on recommendations by Ellis.13 P = .05 was considered
statistically significant. The study was powered using a β of 0.20
to detect a difference in the primary study outcome variable of
tracheotomy status at discharge of 35% (ie, 50% vs 85%).
Results
Demographics
The super obese patient population was predominantly Afri-
can American (20 [65%]) and female (21 [68%]) (Table 1). Mean
BMI of super obese patients was 64.0 (range, 50.2-95.5). The
obese patient population was mainly African American (25
[74%]) and female (17 [50%]). Comparison of age, race, and sex
within the studied population and control group failed to re-
veal a statistically significant difference between the 2 groups.
For the primary study outcome, there was a significant as-
sociation between BMI status and tracheotomy status at dis-
charge. Patients in the super obese group were 80% more likely
to have a tracheotomy at discharge (relative risk, 1.80; 95% CI,
1.26-2.57). For secondary outcome measures, we failed to find
a significant association between BMI and death before dis-
charge (RD, 0.0085; 95% CI, −0.14 to 0.17), ventilator depen-
dence at discharge (RD, 0.121; 95% CI, −0.08 to 0.32), and dis-
position (death vs health care facility, RD, 0.05; 95% CI, −0.14
to 0.28; and death vs home, RD, 0.01; 95% C, −0.28 to 0.46).
As detailed in Table 2, patients in the super obese group
had nonsignificant increases in rates of diabetes (RD, 0.23;
95% CI, −0.03 to 0.45; P = .06) and congestive heart failure
(RD, 0.17; 95% CI, −0.04 to 0.38; P = .08). There was a sig-
nificant association between BMI and chronic heart disease
(RD, 0.23; 95% CI, 0.02-0.43; P = .02), pulmonary hyperten-
sion (RD, 0.19; 95% CI, 0.02-0.38; P = .007), lung disease
(RD, 0.39; 95% CI, 0.16-0.58; P < .001), chronic renal insuffi-
ciency (RD, 0.25; 95% CI, 0.07-0.45; P = .002), and obstruc-
tive sleep apnea (RD, 0.55; 95% CI, 0.34-0.70; P < .001). The
association between BMI and hypertension was nonsignifi-
cant (RD, 0.16; 95% CI, −0.07 to 0.37; P = .13).
We failed to show any statistical significance for the hos-
pital length of stay (Cohen d = 0.042), length of time receiving
ventilator assistance (Cohen d = 0.11; P = .65), number of failed
extubations (Cohen d = –0.222; P = .43), and the fraction of in-
spired oxygen before tracheotomy (Cohen d = –0.178; P = .52)
(Table 3). The association between BMI and disposition (death
or discharge to health care facility or home) failed to reach sta-
tistical significance (death vs health care facility, RD, 0.06; 95%
CI, −0.17 to 0.31; death vs home, RD, 0.056; 95% CI, −0.32 to
0.41; P = .82).
The 8 logistic regression models testing the association be-
tween BMI and tracheotomy status at discharge while control-
ling for the individual comorbidities resulted in BMI being a sig-
nificant predictor of tracheotomy status at discharge in 7 models.
Controlling for diabetes, super obese patients had a 12-fold in-
crease in the odds of being discharged with a tracheotomy, com-
pared with obese patients (OR, 12.1; 95% CI 2.3-61.8); control-
ling for hypertension, the OR was 10.8 (95%, CI 2.1-54.6),
controlling for congestive heart failure, the OR was 11.9 (95% CI,
2.3-62.5), controlling for heart disease, the OR was 10.1 (95% CI,
1.9-52.7), controlling for pulmonary hypertension, the OR was
9.4 (95% CI, 1.8-47.1), controlling for lung disease, the OR was
13.1 (95% CI, 2.1-79.3), and controlling for chronic renal insuf-
ficiency, the OR was 8.9 (95% CI, 1.7-44.9). For the model that
included obstructive sleep apnea, the predictive value of BMI
was nonsignificant (OR, 4.5; 95% CI, 0.82 to 24.4).
Patients’ primary diagnoses for hospitalization were sepa-
rated into neurologic, infectious, trauma, or other to allow com-
parison with other literature.9 For the super obese group, neu-
rologic diagnoses were the primary diagnoses for hospitalization
in 4 patients (13%), infection in 7 patients (23%), trauma in 2 pa-
tients (7%), and other for the remaining 18 patients (Table 1). For
the obese group, neurologic diagnoses were the primary diag-
noses for hospitalization in 18 patients (53%), followed by trauma
in 6 patients (18%), and other in 10 patients (29%).
Otolaryngology was the service most likely to perform the
tracheotomy in super obese patients (20 [65%]). General sur-
gery was the next most common service in super obese pa-
tients (9 [29%]), with intensivists performing 2 tracheoto-
mies (7%) in super obese patients. Intensivists performed 16
tracheotomies (47%) in the control group, followed by otolar-
yngology (10 [30%]) and general surgery (8 [24%]).

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 Tracheotomy Outcomes in Super Obese Patients Original Investigation Research

Nine of the tracheotomies in the super obese group (29%)

Table 3. Patient Outcomes
were performed via a bedside percutaneous dilation trache-
otomy, compared with 32 tracheotomies (94%) in the obese Valuea
group. Ten super obese patients (32%) underwent cervical de- Super Obese Obese
Outcome (n = 31) (n = 34) P Value
fatting and 9 super obese patients (29%) had a tracheal mar- Days receiving ventilator 15.0 (15.5) 16.9 (17.9) .65
gin sewn to the skin or Bjork flap as part of the procedure. support, mean (SD)
The most common style of tracheotomy tube placed in su- FiO2 before tracheotomy, 50.6 (19.0) 47.7 (12.8) .52
mean (SD), %
per obese patients was an extended length tracheotomy tube (16
Failed extubations 10 (32) 8 (24) .43
[52%]), with the remainder receiving either cuffed or uncuffed
Postoperative bleeding 2 (7) 2 (6) .92
traditional length tracheotomy tubes. Two patients in the obese
Tracheotomy tube dislodged 1 (3) 0 .29
group (6%) required an extended length tracheotomy tube.
Tracheitis 3 (10) 0 .06
There was a very low rate of reported complications, with
Percutaneous dilated 9 (29) 32 (94) <.001
only 2 super obese patients losing more than 20 mL of blood tracheotomy
during the procedure. Postoperative tracheitis was the most Cervical neck defattening 10 (32) 0 <.001
common complication, occurring in 3 super obese patients Standard tracheotomy tube 21 (68) 30 (88) .04
(10%). Accidental decannulation occurred in 1 super obese pa-
Extended-length disposable 16 (52) 2 (6) <.001
tient (3%) and minor postoperative hemorrhage requiring non- inner cannula tracheostomy
tube
surgical intervention occurred in 2 super obese patients. The
Disposition
overall complication rate for super obese patients was 19% (6
Home 9 (29) 9 (27) .82
patients). The obese group maintained similar low rates of re-
Health facility 17 (55) 22 (65)
ported complications, with 4 patients losing more than 20 mL
of blood during the procedure. Postoperative tracheitis and ac- Death 4 (13) 3 (9)

cidental decannulation did not occur in any obese patients. Tracheotomy status

Minor postoperative hemorrhage requiring surgical interven-
tion occurred in 2 obese patients.
The super obese population had a high rate of medical co-
morbidities, including 19 patients (61%) with diabetes, 26 (84%)
with hypertension, 9 (29%) with congestive heart failure, 6
(19%) with pulmonary hypertension, 14 (45%) with lung dis-
ease, 8 (26%) with chronic renal insufficiency, and 18 (58%)
with obstructive sleep apnea (Table 2). There was a statisti-
cally significantly difference in most of these comorbidities
when compared with the obese group. Patients in the obese
group had a lower rate of diabetes (13 [38%]) and very few pa-
tients had pulmonary hypertension, congestive heart failure,
chronic renal insufficiency, or obstructive sleep apnea.
The most common outcome was tracheotomy dependence,
in 25 super obese patients (81%). Ventilator dependence at dis-
charge was also relatively common, seen in 7 super obese patients
(23%). Four super obese patients (13%) died while hospitalized
and 17 (55%) were transferred to a health care facility. Only 2 su-
per obese patients (7%) were decannulated before discharge. Pa-
tients in the obese group were less likely to be tracheotomy de-
pendent on discharge, with 16 (47%) being dependent and only
4 (12%) being ventilator dependent at discharge. Most patients
in the obese group (22 [65%]) were discharged to a health care
facility, 3 (9%) died while hospitalized, and 15 (44%) were decan-
nulated before discharge. We failed to show any statistically sig-
nificant difference between the super obese and obese groups
when considering the discharge location.
Discussion
Our series of patients experienced a very high rate of trache-
otomy dependence and very low rates of decannulation. The
81% rate of tracheotomy dependence among super obese pa-
tients is higher than in other studies examining the rates of tra-
Tracheotomy dependent 25 (81) 16 (47) <.001
Ventilator dependent 7 (23) 4 (12) .23
Decannulation 2 (7) 15 (44) <.001
Abbreviation: FiO2, fraction of inspired oxygen.
a
Data are presented as number (percentage) of patients unless otherwise
indicated.
cheotomy dependence in obese patients. A recent study by
Byrd et al9 reported a tracheotomy dependence rate of 49.0%
in 50 of 102 obese patients undergoing tracheotomy. Our con-
trol group of obese patients had a 47% rate of tracheotomy de-
pendence, which is more consistent with the results ob-
tained in the recent study by Byrd et al. Similarly, the
decannulation rate of 7% among super obese patients in our
study was also significantly lower than in the study by Byrd
et al.9 We cannot exclude differences in clinical practice com-
pared with other institutions, although this possibility seems
unlikely owing to general adherence to the clinical consensus
statement at our institution.
This elevated rate of tracheotomy dependence is not sur-
prising given the altered respiratory physiology in super obese
patients.5 The high level of tracheotomy dependence is likely
explained by obesity hypoventilation syndrome, which is de-
fined as the presence of obesity (BMI ≥30), chronic hypercap-
nia (PaCO2 ≥45 mm Hg), and sleep-disturbed breathing.14 In the
management of patients with obesity hypoventilation syn-
drome, the use of a tracheotomy is usually reserved for pa-
tients with significant upper airway resistance.15
The rate of in-hospital mortality is similar to, although
slightly lower than, that in other studies examining the mor-
tality rate in tracheotomy (2%-35%).2,8-10,16 In our series, the
mortality rate was 13% among super obese patients. The rea-
son for this lower mortality rate may be owing to the rela-
tively young super obese patient population, with a mean age
of 50 years.

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 Research Original Investigation Tracheotomy Outcomes in Super Obese Patients

There was an overall complication rate for super obese pa-
tients of 19% (6 patients), which is comparable with compli-
cation rates seen in other series of obese and morbidly obese
patients undergoing tracheotomy.2,7,8 Of the 4 super obese pa-
tients who died while hospitalized after the tracheotomy, 3
were African American. There was no correlation found be-
tween any single medical comorbidity or combination of medi-
cal comorbidities and death. None of the 4 deaths could be at-
tributed to complications of the tracheotomy.
The literature is in agreement that percutaneous dilated
tracheotomy is safe and effective when performed on criti-
cally ill obese patients.6,11,17,18 Guinot et al11 identified no dif-
ference in complication rates when comparing tracheotomy
in obese and nonobese patients. Our study helped to confirm
that these previously reported data on obese patients parallel
those of super obese patients.
One somewhat unexpected finding in this case series is the
high rate of discharge to other health care facilities. The low rate
of discharge home reflects the enormous complexity of caring
for an obese patient who is dependent on a tracheostomy.
Owing to lack of follow-up, it is not clear for how long many of
these patients remained in these health care facilities.
Limitations of this study include the small sample size,
which is difficult to overcome in a single-institution experi-
ence on a relatively rare, although increasingly common, dis-
ease process. Multi-institutional data would improve the
sample size. The control group helps to correlate the indica-
tion that super obese patients are more likely to be trache-
otomy dependent on discharge. The lack of long-term fol-
low-up is another weakness. Long-term follow-up would
provide more information for better counseling of patients on
long-term rates of tracheostomy and ventilator dependence.
This study serves as a starting point for further investiga-
tion into the long-term outcomes of super obese patients.
Appropriate preoperative counseling is vital for super obese
patients with high rates of tracheostomy dependence, venti-
lator dependence, and discharge to other health care facili-
ties. Further research is necessary to determine long-term
outcomes of super obese patients undergoing tracheotomy.
Conclusions
Outcomes have not previously been reported, to our knowl-
edge, for super obese patients as a specific population after tra-
cheotomy. Overall, this series demonstrates that trache-
otomy is a safe procedure for airway management of super
obese individuals, with the caveat that these patients will need
extra care after discharge. Appropriate counseling needs to be
conducted with the patients and their families about the low
rates of decannulation and high rates of discharge to other
medical institutions such as skilled nursing facilities. Factors
most likely contributing to these findings include diabetes,
chronic heart disease, pulmonary hypertension, lung dis-
ease, obstructive sleep apnea, and chronic renal insuffi-
ciency seen in super obese patients.

ARTICLE INFORMATION
Accepted for Publication: April 7, 2016.
Published Online: May 26, 2016.
doi:10.1001/jamaoto.2016.1089.
Author Contributions: Mr Marshall and Dr Haas
had full access to all the data in the study and take
responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: Marshall, Haas,
Schweinfurth.
Acquisition, analysis, or interpretation of data: All
authors.
Drafting of the manuscript: Marshall, Haas.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: Marshall, Haas, Replogle.
Obtained funding: Schweinfurth.
Administrative, technical, or material support:
Marshall, Haas, Schweinfurth.
Study supervision: Haas, Schweinfurth.
Conflict of Interest Disclosures: All authors have
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest and
none were reported.
Additional Contributions: Laura House, MD,
University of Mississippi Medical Center, assisted
with data collection. She was not compensated for
her contribution.
REFERENCES
1. Sturm R. Increases in morbid obesity in the USA:
2000-2005. Public Health. 2007;121(7):492-496.
2. Gross ND, Cohen JI, Andersen PE, Wax MK.
‘Defatting’ tracheotomy in morbidly obese patients.
Laryngoscope. 2002;112(11):1940-1944.
3. Flum DR, Belle SH, King WC, et al; Longitudinal
Assessment of Bariatric Surgery (LABS)
Consortium. Perioperative safety in the longitudinal
assessment of bariatric surgery. N Engl J Med.
2009;361(5):445-454.
4. Joshi GP, Ahmad S, Riad W, Eckert S, Chung F.
Selection of obese patients undergoing ambulatory
surgery: a systematic review of the literature.
Anesth Analg. 2013;117(5):1082-1091.
5. Salihoglu T, Salihoglu Z, Zengin AK, Taskin M,
Colakoglu N, Babazade R. The impacts of super
obesity versus morbid obesity on respiratory
mechanics and simple hemodynamic parameters
during bariatric surgery. Obes Surg. 2013;23(3):379-
383.
6. Aldawood AS, Arabi YM, Haddad S. Safety of
percutaneous tracheostomy in obese critically ill
patients: a prospective cohort study. Anaesth
Intensive Care. 2008;36(1):69-73.
7. Kost KM. Endoscopic percutaneous dilatational
tracheotomy: a prospective evaluation of 500
consecutive cases. Laryngoscope. 2005;115(10, pt
2):1-30.
8. El Solh AA, Jaafar W. A comparative study of the
complications of surgical tracheostomy in morbidly
obese critically ill patients. Crit Care. 2007;11(1):R3.
9. Byrd JK, Ranasinghe VJ, Day KE, Wolf BJ,
Lentsch EJ. Predictors of clinical outcome after
tracheotomy in critically ill obese patients.
Laryngoscope. 2014;124(5):1118-1122.
10. Darrat I, Yaremchuk K. Early mortality rate of
morbidly obese patients after tracheotomy.
Laryngoscope. 2008;118(12):2125-2128.
11. Guinot PG, Zogheib E, Petiot S, et al.
Ultrasound-guided percutaneous tracheostomy in
critically ill obese patients. Crit Care. 2012;16(2):R40.
12. McCague A, Aljanabi H, Wong DT. Safety
analysis of percutaneous dilational tracheostomies
with bronchoscopy in the obese patient.
Laryngoscope. 2012;122(5):1031-1034.
13. Ellis P. The Essential Guide to Effect Sizes:
Statistical Power, Meta-Analysis, and the
Interpretation of Research Results. Cambridge, UK:
Cambridge University Press; 2010.
14. Mokhlesi B, Tulaimat A. Recent advances in
obesity hypoventilation syndrome. Chest. 2007;132
(4):1322-1336.
15. McLear PW, Thawley SE. Airway management
in obesity hypoventilation syndrome. Clin Chest Med.
1991;12(3):585-588.
16. Meacham R, Vieira F. Is obesity truly a risk
factor for mortality after tracheotomy? Ann Otol
Rhinol Laryngol. 2012;121(11):733-737.
17. Mansharamani NG, Koziel H, Garland R,
LoCicero J III, Critchlow J, Ernst A. Safety of bedside
percutaneous dilatational tracheostomy in obese
patients in the ICU. Chest. 2000;117(5):1426-1429.
18. Heyrosa MG, Melniczek DM, Rovito P, Nicholas
GG. Percutaneous tracheostomy: a safe procedure
in the morbidly obese. J Am Coll Surg. 2006;202
(4):618-622.

776 JAMA Otolaryngology–Head & Neck Surgery August 2016 Volume 142, Number 8 (Reprinted) jamaotolaryngology.com

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