Is Percutaneous Dilatational Tracheostomy Safe to Perform in the Intensive Care Unit?

Lee D., Chung C.R., Park S.B., Ryu J., Cho J., Yang J.H., Park C., Suh G.Y., Jeon K.

Dennis B.M., Eckert M.J., Gunter O.L., Morris J.A., May A.K.

Bedside percutaneous dilational tracheostomy has been demonstrated to be equivalent to open tracheostomy. At our institution, percutaneous dilational tracheostomy without routine bronchoscopy is our preferred method. My colleagues and I hypothesized that our 10-year percutaneous dilational tracheostomy experience would demonstrate that the technique is safe with low complication rates, even in obese patient populations.We conducted a retrospective review of all bedside percutaneous dilational tracheostomy performed by the Division of Trauma and Surgical Critical Care faculty from 2001 to 2011, excluding patients younger than 18 years of age. All major airway complications and procedure-related deaths were evaluated during the early (≤48 hours postprocedure), intermediate (in hospital), and late (after discharge) periods. Incidence of post-tracheostomy stenosis was also evaluated.There were 3,162 percutaneous dilational tracheostomies performed during the study period. Mean body mass index was 28 (16% with body mass index ≥35), mean Injury Severity Score was 32, and mean APACHE II score was 19. Major airway complications occurred in 12 (0.38%) patients, accounting for 5 (0.16%) deaths. Early major complications included 3 airway losses and 1 bleeding event requiring formal exploration with procedure-related deaths occurring in 3 patients. Intermediate major complications included 2 tube occlusion/dislodgement events with 2 related deaths. Late complications included 5 (0.16%) cases of tracheal stenosis requiring intervention without associated deaths.Bedside percutaneous dilational tracheostomy is safe across a broad critically ill patient population. The safety of this technique, even in the obese population, is demonstrated by its low complication rate. Routine bronchoscopic guidance is not necessary. Specially trained procedure nurse and process improvement programs contribute to the safety and efficacy of this procedure.

Yoo H., Lim S.Y., Park C., Suh G.Y., Jeon K.

Silvester W., Goldsmith D., Uchino S., Bellomo R., Knight S., Seevanayagam S., Brazzale D., McMahon M., Buckmaster J., Hart G.K., Opdam H., Pierce R.J., Gutteridge G.A.

To compare the safety, availability, and long-term sequelae of percutaneous vs. surgical tracheostomy.Prospective, randomized, controlled study.Combined medical/surgical intensive care unit in a tertiary referral hospital.Two hundred critically ill mechanically ventilated patients who required tracheostomy.Tracheostomy by either percutaneous tracheostomy or surgical tracheostomy performed in the intensive care unit.The primary outcome measure was the aggregate incidence of predefined moderate or severe complications. The secondary outcome measures were the incidence of each of the components of the primary outcome. Long-term follow-up included clinical assessment, flow volume loops, and bronchoscopy. Both groups were well matched for age, gender, admission Acute Physiology and Chronic Health Evaluation II score, period of endotracheal intubation, reason for intubation, and admission diagnosis. There was no statistical difference between groups for the primary outcome. Bleeding requiring surgical intervention occurred in three percutaneous tracheostomy patients and in no surgical tracheostomy patient (p = .2). Postoperative infection (p = .044) and cosmetic sequelae (p = .08) were more common in surgical tracheostomy patients. There was a shorter delay from randomization to percutaneous tracheostomy vs. surgical tracheostomy (p = .006). Long-term follow-up revealed no complications in either group.Both percutaneous tracheostomies and surgical tracheostomies can be safely performed at the bedside by experienced, skilled practitioners.

Tabaee A., Geng E., Lin J., Kakoullis S., McDonald B., Rodriguez H., Chong D.

To investigate a correlation between neck length and the incidence of complications after both percutaneous and surgical tracheotomy (ST) and to compare the relative safety of the two procedures at our institution.Prospective, randomized study of patients undergoing tracheotomy at a tertiary care center.Forty-three patients evaluated for tracheotomy at our institution between the years 2003 and 2004 were enrolled in the study and were randomly assigned to receive either an ST or a percutaneous dilatational tracheotomy (PDT). All patients underwent standardized measurement of the cricosternal distance (CSD) in the neutral and extended positions before the procedure. Demographic and procedural variables were recorded, and the occurrence of postoperative complications was followed for 1 week.PDT was performed in 29 patients and ST in 14 patients. The mean CSD of 2.7 cm increased to 3.7 cm after extension with a shoulder roll. PDT required less time (mean 8 vs. 23 minutes) and resulted in less blood loss compared with ST. A trend toward a higher incidence of complications with PDT (40%) compared with ST (7%) and in the first half of our series (learning curve) was noted. This, however, did not reach statistical significance. There was no correlation between the incidence of complications and neck length as determined by the CSD in either group of patients.We failed to demonstrate a correlation between CSD and tracheotomy related complications. Patients with short necks may be at no higher risk during either a PDT or ST. Experience, awareness of complications, and a dedicated team approach are necessary for the safe performance of PDT.

Antonelli M., Michetti V., Di Palma A., Conti G., Pennisi M.A., Arcangeli A., Montini L., Bocci M.G., Bello G., Almadori G., Paludetti G., Proietti R.

To compare the outcomes and the short- and long-term complications of percutaneous translaryngeal tracheostomy (TLT) and surgical tracheostomy (ST).Prospective, randomized clinical trial with 1-yr double-blind follow-up.A general intensive care unit of a university hospital.A total of 139 consecutive critically ill patients who required a tracheostomy between February 2001 and June 2002 were randomly assigned to receive either ST or TLT.TLTs were performed more rapidly than STs (17 +/- 10 mins vs. 22 +/- 6 mins, p = .003). Early complications were rare in both groups. Major postoperative bleeding was less frequent with TLT (0 [0%] vs. 6 [8%], p = .03). Only one case of bleeding (in the ST group) required blood transfusion. Immediately after tracheostomy, six TLT patients (9%) and six patients (8%) in the ST group (p = .56) developed culture-confirmed bacteremia with microbes previously isolated from the pharynx or trachea. Group rates for stomal infections and pneumonia after tracheostomy were similar. At 1-yr follow-up, the overall survival rate was 27%, and 14 patients (45% of survivors) still had open tracheostomies. Both groups rated their quality of life as moderately to severely compromised, and the deterioration was strictly related to the presence of tracheostomy. One TLT and two ST survivors (p = .53) had clinical signs of tracheal stenosis, and bronchoscopy revealed narrowing of >50%.Compared with ST, the main advantages of TLT are that it is more rapid and associated with less postoperative bleeding. Infectious complications, particularly postoperative bacteremia, and long-term effects (physical and emotional) are similar with the two procedures.

Heikkinen M., Aarnio P., Hannukainen J.

Percutaneous dilational tracheostomy (PDT) is increasingly used in intensive care units (ICU), and it has a low incidence of complications. The aim of this study was to compare the costs, complications, and time consumption of PDT with that of conventional surgical tracheostomy (ST) when both procedures were performed in the ICU.The study was a prospective, randomized trial.The procedures were performed routinely in the ICU of Satakunta Central Hospital.During a 23-month period from December 1995 to November 1997, 30 patients underwent PDT and 26 patients had ST. In one patient, PDT was converted to ST. All patients were receiving ventilation in the ICU, and all tracheostomies were performed at the patient's bedside in the ICU. The Portex percutaneous tracheostomy kit was used for all PDTs.The mean time to perform PDT was 11 mins (SD, 6; range, 2-40), and the mean time to perform ST was 14 mins (SD, 6; range, 3-39). In the PDT group, five patients had moderate bleeding during the procedure. In three patients, the bleeding was resolved with compression; in one patient, it was resolved with ligation of the vessel; and in one patient, it was resolved with electrocoagulation. Bleeding did not cause any complications afterward. In the PDT group, one patient had minimal oozing from the wound edge on the first postoperative day and it was resolved spontaneously. In the ST group, there were no intraprocedural complications. One patient had bleeding from the wound on first postoperative day. The sutures were removed, and the bleeding vessel was ligated. The mean cost (in U. S. dollars) of PDT was $161 (SD, 10.4; range, $159-$219), and the mean cost of ST was $357 (SD, $74; range, $239-$599). The cost of PDT was significantly lower than the cost of ST (p < .001).We found that PDT is a cost-effective procedure in critically ill ICU patients. Although we performed ST at the bedside in the ICU to avoid the risks associated with moving critically ill patients to the operating room, we found PDT to be a simple and safe procedure.

Massick D.D., Yao S., Powell D.M., Griesen D., Hobgood T., Allen J.N., Schuller D.E.

R. Donaldson D., Emami A.J., Wax M.K.

Holdgaard H.O., Pedersen J., Jensen R.H., Outzen K.E., Midtgaard T., Johansen L.V., Møller J., Paaske P.B.

As no clinical randomised studies have previously been performed comparing complications with the Ciaglia Percutaneous Dilatational Tracheostomy Introducer Set (PDT) and conventional surgical tracheostomy (TR), we designed a study with the aim of comparing the efficacy and safety of the two techniques.Sixty patients selected for elective tracheostomy were randomised for either PDT (30 patients) or TR (30 patients). All patients had general anaesthesia and were ventilated with 100% oxygen. Furthermore, lidocaine with epinephrine 1% (3-5 ml) was used for local analgesia and to minimise bleeding during the procedure.The median time for insertion of the tracheostomy tube was 11.5 min (range 7-24 min) in the PDT group and 15 min (range 5-47 min) in the TR group (P

Moon J.S., Cho Y.N., Shin K.M., Hong S.Y., Choi Y.R., Ahn M.S.

Kwon J., Kim Y.O., Ryu J.