Percutaneous tracheostomy, a systematic review

Comparison of Mechanical Forces used in Open Tracheotomy versus Percutaneous Tracheotomy Techniques

OBJECTIVE

To understand the etiology of tracheotomy-induced tracheal stenosis by comparing the differences in techniques and mechanical force applied with open tracheotomy (OT) versus percutaneous tracheotomy (PCT) placement.

METHODS

This study is an unblinded, experimental, randomized controlled study in an ex-vivo animal model. Simulated tracheostomies were performed on 10 porcine tracheas, 5 via a tracheal window technique (OT) and 5 using the Ciaglia technique (PCT). The applied weight during the simulated tracheostomy and the compression of the trachea were recorded at set times during the procedure. The applied weight during tracheostomy was used to calculate the tissue force in Newtons. Tracheal compression was measured by anterior-posterior distance compression and as percent change.

RESULTS

Average forces for scalpel (OT) versus trocar (PCT) were 2.6 N and 12.5 N (p < 0.01), with the dilator (PCT) it was 22.02 N (p < 0.01). The tracheostomy placement with OT required an average force of 10.7 N versus 23.2 N (p < 0.01) with PCT. The average change in AP distance when using the scalpel versus trocar was 21%, and 44% (p < 0.01), with the dilator it was 75% (p < 0.01). The trach placement with OT versus PCT had an average AP distance change of 51% and 83% respectively (p < 0.01).

CONCLUSION

This study demonstrated that PCT required more force and caused more tracheal lumen compression when compared to the OT technique. Based on the increased force required for PCT, we suspect there could also be an increased risk for tracheal cartilage trauma.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:103-107, 2024.

Open Bedside Tracheostomy: Safe and Cost Saving but Underutilized Nationally

OBJECTIVE

To evaluate open bedside tracheostomy (OBT) and compare it with open operating room (OR) tracheostomy and bedside percutaneous dilatational tracheostomy (PDT) in complications and cost. To determine the tracheostomy practice patterns of academic otolaryngology programs.

STUDY DESIGN

Retrospective cohort study and cross-sectional study.

SETTING

Public hospital and tertiary care hospital.

METHODS

Otolaryngology program directors were surveyed to determine their institutions' tracheostomy practice patterns and the factors preventing the implementation of open bedside tracheostomies. A retrospective chart review was done of tracheostomies performed at our institutions from 2009 to 2019 for prolonged mechanical ventilation. Complications, length of intubation, comorbidities, body mass index, demographics, mortality rates, and decannulation rates were recorded. A cost analysis between OBT and PDT was conducted.

RESULTS

Data from 802 patients were analyzed for 449 OBTs, 206 PDTs, and 147 open OR tracheostomies. Complication rates were low. PDTs were more likely to have perioperative tracheal bleeding (P = .028) and mucus plugging (P = .006). OBTs were performed on sicker patients with a higher Charlson Comorbidity Index than PDT and OR tracheostomies. The cost of OBT was less than that of PDT. The survey response rate of tracheostomy practice patterns was 46%. The otolaryngologists at the responding programs all conducted OR tracheostomies, while 52.7% did OBTs and 30.9% PDTs.

CONCLUSION

OBT can be done safely in patients with multiple comorbidities and has a cost that can be less than PDT. Despite these benefits, only 50% of academic institutions routinely performed OBT.

LEVEL OF EVIDENCE: 3

Creation of an Open Bedside Tracheostomy Program at a Community Hospital With a Single Surgeon

Objective

To assess the adverse event rate and operating cost of open bedside tracheostomy (OBT) at a community hospital. To present a model for creating an OBT program at a community hospital with a single surgeon.

Study Design

Retrospective case series pilot study.

Setting

Academic-affiliated community hospital.

Methods

Retrospective chart review of surgical OBT and operating room tracheostomy (ORT) at a community hospital from 2016 to 2021. Primary outcomes included operation duration; perioperative, postoperative, and long-term complications; and crude time-based estimation of operating cost to the hospital using annual operating cost. Clinical outcomes of OBT were assessed with ORT as a comparison using t tests and Fisher's exact tests.

Results

Fifty-five OBT and 14 ORT were identified. Intensive care unit (ICU) staff training in preparing for and assisting with OBT was successfully implemented by an Otolaryngologist and ICU nursing management. Operation duration was 20.3 minutes for OBT and 25.2 minutes for ORT (p = .14). Two percent, 18%, and 10% of OBT had perioperative, postoperative, and long-term complications, respectively; this was comparable to rates for ORT (p = .10). The hospital saved a crude estimate of $1902 in operating costs per tracheostomy when performed in the ICU.

Conclusion

An OBT protocol can be successfully implemented at a single-surgeon community hospital. We present a model for creating an OBT program at a community hospital with limited staff and resources.

Percutaneous tracheostomy in the ICU: a review of the literature and recent updates

PURPOSE OF REVIEW

The following article summarizes the current available knowledge regarding tracheostomy techniques, indications, contraindications, procedure timing, use of assisted technologies and tracheostomy feasibility and safety in high-risk populations. In light of the ongoing corona virus disease (COVID-19) pandemic, a focus was placed on tracheostomy in this unique patient group.

RECENT FINDINGS

Percutaneous dilatation tracheostomy (PDT) is commonly used in the ICU setting. It has been shown to be well tolerated and feasible in a diverse patient population including those regarded to be at high risk such as the obese, coagulopathic and acute respiratory failure patient. This patient profile presented itself frequently in the recent COVID-19 pandemic. Indeed studies showed that PDT is well tolerated in COVID-19 ICU patients leading to reduced ICU length of stay (LOS), decrease in ventilator-associated pneumonia rate (VAP) and reduced duration on invasive mechanical ventilation (IMV). Despite initial concerns, virus transmission from patient to healthcare provider (HCP) was shown to be negligible when proper precautions are taken.

SUMMARY

Bedside PDT in the ICU is a well tolerated procedure having the potential to benefit both the individual patient as well as to improve resource utilization of the healthcare system.

Safety of Percutaneous vs Open Tracheostomy on Intubated Patients in ICU Setting: Which One is Better?

To study the safety of percutaneous vs open tracheostomy approaches on patients requiring long term ventilation in ICU setting. It is a prospective study done over a period of 2 years on 105 patients requiring long term ventilation in ICU set up in a tertiary care hospital. Patients were subjected to either open approach or percutaneous tracheostomy bedside in ICU itself. Then patients were followed during their hospital stay to look for any tracheostomy related complications. Data regarding age, gender, indications of long term ventilation and complications were compiled and analysis was done. It was found that most of the patients were of male gender (88.6%) in the age group of 50-59 years of age. The most common cause for tracheostomy was head injury secondary to road traffic accident, seen in 79 out of 105 cases. On comparing complications rate, there was no statistically significant difference in both the groups. However rate of peristomal infection is more with open approach group (P < 0.05). Percutaneous tracheostomy can be performed safely in ICU as a bedside procedure. There is significant reduction in peristomal infection with percutaneous tracheostomy and there is no significant difference in other complications between the two groups. Thus percutaneous tracheostomy is as safe as an open approach tracheostomy in properly selected cases.

Clinical Value of Bronchoscopy in Acute Respiratory Failure

Bronchoscopy may be considered the “added value” in the diagnostic and therapeutic pathway of different clinical scenarios occurring in acute respiratory critically ill patients. Rigid bronchoscopy is mainly employed in emergent clinical situations due to central airways obstruction, haemoptysis, and inhaled foreign body. Flexible bronchoscopy (FBO) has larger fields of acute applications. In intensive care settings, FBO is useful to facilitate intubation in difficult airways, guide percutaneous dilatational tracheostomy, and mucous plugs causing lobar/lung atelectasis. FBO plays a central diagnostic role in acute respiratory failure caused by intra-thoracic tumors, interstitial lung diseases, and suspected severe pneumonia. “Bronchoscopic” sampling has to be considered when “non-invasive” techniques are not diagnostic in suspected ventilator-associated pneumonia and in non-ventilated immunosuppressed patients. The combined use of either noninvasive ventilation (NIV) or High-flow nasal cannula (HFNC) with bronchoscopy is useful in different scenarios; the largest body of proven successful evidence has been found for NIV-supported diagnostic FBO in non-ventilated high risk patients to prevent and avoid intubation. The expected diagnostic/therapeutic goals of acute bronchoscopy should be balanced against the potential severe risks (i.e., cardio-pulmonary complications, bleeding, and pneumothorax). Expertise of the team is fundamental to achieve the best rate of success with the lowest rate of complications of diagnostic and therapeutic bronchoscopic procedures in acute clinical circumstances.

Percutaneous tracheostomy in COVID-19 patients: a new apneic approach

Background

Percutaneous dilation tracheostomy is an aerosol-generating procedure carrying a documented infectious risk during respiratory virus pandemics. For this reason, during the COVID-19 outbreak, surgical tracheostomy was preferred to the percutaneous one, despite the technique related complications increased risk.

Methods

We describe a new sequence for percutaneous dilation tracheostomy procedure that could be considered safe both for patients and healthcare personnel. A fiberscope was connected to a video unit to allow bronchoscopy. Guidewire positioning was performed as usual. While the established standard procedure continues with the creation of the stoma without any change in mechanical ventilation, we retracted the bronchoscope until immediately after the access valve in the mount tube, allowing normal ventilation. After 3 minutes of ventilation with 100% oxygen, mechanical ventilation was stopped without disconnecting the circuit. During apnea, the stoma was created by dilating the trachea and the tracheostomy cannula was inserted. Ventilation was then resumed. We evaluated the safeness of the procedure by recording any severe desaturation and by performing serological tests to all personnel.

Results

Thirty-six patients (38%) of 96 underwent tracheostomy; 22 (23%) percutaneous dilation tracheostomies with the new approach were performed without any desaturation. All personnel (150 operators) were evaluated for serological testing: 9 (6%) had positive serology but none of them had participated in tracheostomy procedures.

Conclusion

This newly described percutaneous dilation tracheostomy technique was not related to severe desaturation events and we did not observe any positive serological test in health workers who performed the tracheostomies.

A Modified Translaryngeal Tracheostomy Technique in the Neurointensive Care Unit. Rationale and Single-center Experience on 199 Acute Brain-damaged Patients

BACKGROUND

Brain-injured patients frequently require tracheostomy, but no technique has been shown to be the gold standard for these patients. We developed and introduced into standard clinical practice an innovative bedside translaryngeal tracheostomy (TLT) technique aided by suspension laryngoscopy (modified TLT). During this procedure, the endotracheal tube is left in place until the airway is secured with the new tracheostomy. This study assessed the clinical impact of this technique in brain-injured patients.

MATERIALS AND METHODS

This is a retrospective analysis of prospectively collected data from adult brain-injured patients who had undergone modified TLT during the period spanning from January 2010 to December 2016 at the Neurointensive care unit, San Gerardo Hospital (Monza, Italy). The incidence of intraprocedural complications, including episodes of intracranial hypertension (intracranial pressure [ICP] >20 mm Hg), was documented. Neurological, ventilatory, and hemodynamic parameters were retrieved before, during, and after the procedure. Risk factors for complications and intracranial hypertension were assessed by univariate logistic analysis. Data are presented as n (%) and median (interquartile range) for categorical and continuous variables, respectively.

RESULTS

A total of 199 consecutive brain-injured patients receiving modified TLT were included. An overall 52% male individuals who were 66 (54 to 74) years old and who had an admission Glasgow Coma Scale of 7 (6 to 10) were included in the cohort. Intracerebral hemorrhage (30%) was the most frequent diagnosis. Neurointensivists performed 130 (65%) of the procedures. Patients underwent tracheostomy 10 (7 to 13) days after intensive care unit admission. Short (ie, <2 min) and clinically uneventful increases in ICP>20 mm Hg were observed in 11 cases. Overall, the procedure was associated with an increase in ICP from 7 (4 to 10) to 12 (7 to 18) mm Hg (P<0.001). Compared with baseline, cerebral perfusion pressure (CPP), respiratory variables, and hemodynamics were unchanged during the procedure (P-value, not significant). Higher baseline ICP and core temperature were associated with an increased risk of complications and intracranial hypertension. Complication rates were low: 1 procedure had to be converted to a surgical tracheostomy, and 1 (0.5%) episode of minor bleeding and 5 (2.5%) of minor non-neurological complications were recorded. Procedures performed by intensivists did not have a higher risk of complications compared with those performed by ear, nose, and throat specialists.

CONCLUSIONS

A modified TLT (by means of suspension laryngoscopy) performed by neurointensivists is feasible in brain-injured patients and does not adversely impact ICP and CPP.

Assessment of the percutaneous dilatational tracheostomy technique in experimental manikins and canine cadavers

OBJECTIVE

To evaluate procedure time, ease of placement, and complication rates of percutaneous dilatational tracheostomy (PDT) compared to surgical tracheostomy (ST) in canine cadavers.

DESIGN

Randomized crossover experimental manikin and cadaver study involving 6 novice veterinary students.

SETTING

University teaching hospital.

ANIMALS

Canine tracheostomy training manikin, 24 canine cadavers.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

For training, each student performed 10 PDT and 10 ST procedures on a training manikin, followed by 2 PDT and 2 ST procedures on a canine cadaver. After each training procedure, feedback from bronchoscopy and observers was provided. Final PDT and ST tube placements using new equipment were performed in unused cadavers. Placements were timed, ease of placement was scored using visual analog scales (VAS, 0-10 cm), and complications were assessed by two independent observers using ordinal scales (0-3). Cadaver tracheas were explanted postprocedure to evaluate anatomical damage scores (0-3). Procedure time and VAS scores for PDT and ST procedures were analyzed using mixed-effects linear models, accounting for student, technique, and procedure number with post hoc pairwise comparisons. Data are presented as median (range). For the final cadaver placement, there were no significant differences in placement time (300 seconds [230-1020] vs 188 seconds [116-414], P = 0.210), ease of placement (3.8 cm [2.1-5.7] vs 1.9 cm [0-4.7], P = 0.132), anatomical damage score (1 [0-2] vs 0 [0-1], P = 0.063), or equipment complications score (0 [0-1] vs 0 [0-0], P = 1.000) between PDT and ST, respectively.

CONCLUSIONS

These data suggest that PDT can be performed as quickly, as easily, and as safely as ST in a canine cadaver by novice veterinary students following manikin training. Additional studies will be required to determine if these findings can be translated into veterinary clinical practice.

Cost Comparison of Single-Use Versus Reusable Bronchoscopes Used for Percutaneous Dilatational Tracheostomy

BACKGROUND

Both single-use and reusable bronchoscopes are suitable for percutaneous dilatational tracheostomy (PDT) to visualise the trachea during the insertion process. To determine the least costly option, the price of single-use bronchoscopes must be weighed against the estimated average cost of a bronchoscopy with reusable equipment. In the latter case, the acquisition cost must be spread over the equipment's useful life and other relevant costs, such as reprocessing and repair, must be included.

OBJECTIVE

This study aimed to calculate the cost of using single-use or reusable bronchoscopes per PDT procedure.

METHODS

A systematic literature search was conducted to identify studies comparing the costs of reusable and single-use bronchoscopes for PDT. Inclusion criteria were articles assessing the cost of single-use or reusable bronchoscopes, and where costs were divided into acquisition, reprocessing, and repair costs. A questionnaire regarding repair rates and costs for reusable bronchoscopes was sent to 366 hospitals in the US, UK, and Germany to supplement the identified literature.

RESULTS

Eleven studies met the inclusion criteria. Ninety-nine completed responses were received, of which 31 hospitals used reusable equipment for PDT. Literature research revealed an average acquisition cost of $US135 (SD 152) and reprocessing cost of $US123 (SD 128). Additionally, a combination of data from the literature and the questionnaires gave a repair cost per use of $US148 (SD 242), resulting in a total average cost of $US406 for reusable bronchoscopes and $US249 (SD 36) for single-use bronchoscopes per PDT procedure. Thus, the incremental cost per use of a reusable bronchoscope compared with a single-use bronchoscope was $US157.

CONCLUSIONS

We conclude that significant savings can be made by using single-use bronchoscopes to guide PDT in preference to reusable bronchoscopes. Results depend on hospital setting, the reprocessing procedures, annual bronchoscope procedures, individual repair cost, and repair rates.

Use of low dose of rFVIIa (recombinant Factor VII activated) to control late bleeding after percutaneous dilational tracheostomy

In our case, the use of a low intravenous bolus dose of rFVIIa (recombinant factor VII activated; 15-20 mcg/kg) was effective and uneventful in controlling late postprocedural PDT bleeding associated with thrombocytopenia that cannot be corrected and after all other treatments failed.

Tracheostomy in Patients Who Need Mechanical Ventilation: Early or Late? Surgical or Percutaneous? A Prospective Study in Iran

Tracheostomy can be performed surgically or by percutaneous (percutaneous dilatory tracheostomy, PDT) methods, and it may be used early or late. In a 3-month follow-up, all patients who underwent tracheostomy in Semnan in 2013 were evaluated for complications of tracheostomy considering the method used and the timing of operation. A total of 55 patients underwent tracheostomy (26 cases surgery, 29 cases PDT, 30 cases early, and 25 cases late based on 14 days reference). The mean durations of operation were 19.19 ± 5.78 min in the surgery method and 4.7 ± 2.42 min in the PDT method (P < 0.001). The mean durations of the need for ventilator after the tracheostomy were 10.7 ± 9.25 and 18.6 ± 14.39 days in early and late tracheostomy, respectively (P = 0.024). The mean intensive care unit (ICU) stay were 12.70 ± 10.24 and 23.44 ± 18.49 days (P = 0.014) and the mean hospital stay were 16.04 ± 10.88 and 23.48 ± 18.47 days, respectively (P = 0.100). Short-term complications were observed in six cases (10.09 %) in the surgery group, including emphysema (two), bleeding (two), wound infection (one), and clot formation inside the tube (one). Only one complication (bleeding) occurred in one case in the PDT group. After 3 months, 21 patients survived. Compared with surgery, the most important advantage of the PDT method was its shorter duration of surgery. Nearly half of the patients underwent tracheostomy late, while the majority of the patients in the late group were referred from internal ICU. No major and minor complications were noted during the procedure, as well as no tracheostomy-related deaths were observed. Early tracheostomy was shown to be superior to late, reducing the time of mechanical ventilation and ICU or hospital stay.

Bedside Percutaneous Dilatational Tracheostomy by Griggs Technique: A Single-Center Experience

Background

The study evaluated reliability and outcomes of percutaneous dilatational tracheostomy (PDT) performed via Griggs’ method in the intensive care unit.

Material/Methods

We examined 78 patients who underwent bedside PDT in the intensive care unit (ICU). Demographic characteristics were recorded. In addition, ventilator-related pneumonia, duration of performing PDT, and rates of complications, mortality, and morbidity were assessed.

Results

The mean age of patients was 68.7 years, and 56.4% were females (n=44). The most common indication for ICU was pneumonia (44.9%, n=35), followed by trauma (24.8%, n=13). Mean opening of PDT was 21 minutes. Mean duration of intubation prior to PDT was 21±6 days. Mean FiO₂ before and after PDT was 58.7% and 49.1%, respectively. PEEP ratios before and after PDT were 5 and 3, respectively. Seventy-one patients (91%) needed no sedation after PDT. Mechanical ventilator-induced pneumonia was observed in 32.1% (n=25) of patients. The overall complication rate after PDT was 37.1%, most of which were minor. The most common and early complication of PDT was bleeding (28.2%, n=22). Other minor complications included hypotension (3.8%, n=3), desaturation (3.8%, n=3), and subcutaneous emphysema (1.3%, n=1).

Conclusions

Tracheostomy offers advantages in terms of improving patient comfort, facilitating weaning of patients from the respirator, and providing clearance of pulmonary secretions by reducing pulmonary dead-spaces. PDT is a simple and reliable procedure with lower complication rates. Its advantages include implementation at bedside, with a shortened procedure duration and accelerated wound healing.

Evidence-based guides in tracheostomy use in critical patients

OBJECTIVES

Provide evidence based guidelines for tracheostomy in critically ill adult patients and identify areas needing further research.

METHODS

A task force composed of representatives of 10 member countries of the Pan-American and Iberic Federation of Societies of Critical and Intensive Therapy Medicine and of the Latin American Critical Care Trial Investigators Network developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation system.

RESULTS

The group identified 23 relevant questions among 87 issues that were initially identified. In the initial search, 333 relevant publications were identified of which 226 publications were chosen. The task force generated a total of 19 recommendations: 10 positive (1B=3, 2C=3, 2D=4) and 9 negative (1B=8, 2C=1). A recommendation was not possible in six questions.

CONCLUSION

Percutaneous techniques are associated with a lower risk of infections compared to surgical tracheostomy. Early tracheostomy only seems to reduce the duration of ventilator use but not the incidence of pneumonia, the length of stay, or the long-term mortality rate. The evidence does not support the use of routine bronchoscopy guidance or laryngeal masks during the procedure. Finally, proper prior training is as important or even a more significant factor in reducing complications than the technique used.

Percutaneous tracheostomy

Percutaneous dilatational tracheostomy (PDT) is a commonly performed procedure in critically sick patients. It can be safely performed bedside by intensivists.This has resulted in decline in the use of surgical tracheostomy in intensive care unit (ICU) except in few selected cases. Most common indication of tracheostomy in ICU is need for prolonged ventilation. About 10% of patients requiring at least 3 days of mechanical ventilator support get tracheostomised during ICU stay. The ideal timing of PDT remains undecided at present. Contraindications and complications become fewer with increase in experience. Various methods of performing PDT have been discovered in last two decades. Preoperative work up, patient selection and post tracheostomy care form key components of a successful PDT. Bronchoscopy and ultrasound have been found to be useful procedural adjuncts, especially in presence of unfavorable anatomy. This article gives a brief overview about the use of PDT in ICU.

Early percutaneous dilational tracheostomy does not lead to an increased risk of surgical site infection following anterior spinal surgery

BACKGROUND

Most patients with cervical spinal cord injuries require tracheostomy. The optimal timing is still a matter of debate. Previous studies showed that patients receiving early tracheostomy had fewer ventilator days and decreased rates of pneumonia and were mobilized earlier. Because of the proximity of the anterior approach to the tracheostoma, there is concern about an increased risk of surgical site infection (SSI) related to tracheostomy.

METHODS

This was a retrospective analysis at a Level I trauma center of patient records from 2008 to 2014, identifying all patients with spinal cord injury who received anterior cervical spinal surgery and had early percutaneous dilational tracheostomy (PDT). Follow-up for SSI was performed throughout hospital stay (mean, 110 days; median, 96 days, with lower quartile 89 days and upper quartile 119 days) and at 6 weeks and 3 months (clinical examination and computed tomography scans).

RESULTS

Fifty-one patients underwent anterior spinal surgery with PDT performed within a median of 5 days (range, 1-18 days). Seventy-eight percent (n = 40) of patients had anterior spinal surgery, whereas 22% (n = 11) had a combined anterior-posterior repair. All percutaneous dilational tracheostomies were performed using the Ciaglia single-step dilation technique. Despite an SSI of one patient's cannulation site, no SSI of the anterior approach was observed.

CONCLUSION

Performing a PDT in a timely fashion after anterior spinal surgery does not increase the risk of SSI.

LEVEL OF EVIDENCE

Therapeutic study, level V.

Evidence-based guidelines for the use of tracheostomy in critically ill patients

OBJECTIVES

To provide evidence-based guidelines for tracheostomy in critically ill adult patients and identify areas needing further research.

METHODS

A taskforce composed of representatives of 10 member countries of the Pan-American and Iberic Federation of Societies of Critical and Intensive Therapy Medicine and of the Latin American Critical Care Trial Investigators Network developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation system.

RESULTS

The group identified 23 relevant questions among 87 issues that were initially identified. In the initial search, 333 relevant publications were identified, of which 226 publications were chosen. The taskforce generated a total of 19 recommendations, 10 positive (1B, 3; 2C, 3; 2D, 4) and 9 negative (1B, 8; 2C, 1). A recommendation was not possible in 6 questions.

CONCLUSIONS

Percutaneous techniques are associated with a lower risk of infections compared with surgical tracheostomy. Early tracheostomy only seems to reduce the duration of ventilator use but not the incidence of pneumonia, the length of stay, or the long-term mortality rate. The evidence does not support the use of routine bronchoscopy guidance or laryngeal masks during the procedure. Finally, proper prior training is as important or even a more significant factor in reducing complications than the technique used.

Percutaneous techniques versus surgical techniques for tracheostomy

BACKGROUND

Tracheostomy formation is one of the most commonly performed surgical procedures in critically ill intensive care participants requiring long-term mechanical ventilation. Both surgical tracheostomies (STs) and percutaneous tracheostomies (PTs) are used in current surgical practice; but until now, the optimal method of performing tracheostomies in critically ill participants remains unclear.

OBJECTIVES

We evaluated the effectiveness and safety of percutaneous techniques compared to surgical techniques commonly used for elective tracheostomy in critically ill participants (adults and children) to assess whether there was a difference in complication rates between the procedures. We also assessed whether the effect varied between different groups of participants or settings (intensive care unit (ICU), operating room), different levels of operator experience, different percutaneous techniques, or whether the percutaneous techniques were carried out with or without bronchoscopic guidance.

SEARCH METHODS

We searched the following electronic databases: CENTRAL, MEDLINE, EMBASE, and CINAHL to 28 May 2015. We also searched reference lists of articles, 'grey literature', and dissertations. We handsearched intensive care and anaesthesia journals, abstracts, and proceedings of scientific meetings. We attempted to identify unpublished or ongoing studies by contacting manufacturers and experts in the field, and searching in trial registers.

SELECTION CRITERIA

We included randomized and quasi-randomized controlled trials (quasi-RCTs) comparing percutaneous techniques (experimental intervention) with surgical techniques (control intervention) used for elective tracheostomy in critically ill participants (adults and children).

DATA COLLECTION AND ANALYSIS

Three authors independently checked eligibility and extracted data on methodological quality, participant characteristics, intervention details, settings, and outcomes of interest using a standardized form. We then entered data into Review Manager 5, with a double-entry procedure.

MAIN RESULTS

Of 785 identified citations, 20 trials from 1990 to 2011 enrolling 1652 participants fulfilled the inclusion criteria. We judged most of the trials to be at low or unclear risk of bias across the six domains, and we judged four studies to have elements of high risk of bias; we did not classify any studies at overall low risk of bias. The quality of evidence was low for five of the seven outcomes (very low N = 1, moderate N = 1) and there was heterogeneity among the studies. There was a variety of adult participants and the procedures were performed by a wide range of differently experienced operators in different situations.There was no evidence of a difference in the rate of the primary outcomes: mortality directly related to the procedure (Peto odds ratio (POR) 0.52, 95% confidence interval (CI) 0.10 to 2.60, I² = 44%, P = 0.42, 4 studies, 257 participants, low quality evidence); and serious, life-threatening adverse events - intraoperatively: risk ratio (RR) 0.93, 95% CI 0.57 to 1.53, I² = 27%, P = 0.78, 12 studies, 1211 participants, low quality evidence,and direct postoperatively: RR 0.72, 95% CI 0.41 to 1.25, I² = 24%, P = 0.24, 10 studies, 984 participants, low quality evidence.PTs significantly reduce the rate of the secondary outcome, wound infection/stomatitis by 76% (RR 0.24, 95% CI 0.15 to 0.37, I² = 0%, P < 0.00001, 12 studies, 936 participants, moderate quality evidence) and the rate of unfavourable scarring by 75% (RR 0.25, 95% CI 0.07 to 0.91, I² = 86%, P = 0.04, 6 studies, 789 participants, low quality evidence). There was no evidence of a difference in the rate of the secondary outcomes, major bleeding (RR 0.70, 95% CI 0.45 to 1.09, I² = 47%, P = 0.12, 10 studies, 984 participants, very low quality evidence) and tracheostomy tube occlusion/obstruction, accidental decannulation, difficult tube change (RR 1.36, 95% CI 0.65 to 2.82, I² = 22%, P = 0.42, 6 studies, 538 participants, low quality evidence).

AUTHORS' CONCLUSIONS

When compared to STs, PTs significantly reduce the rate of wound infection/stomatitis (moderate quality evidence) and the rate of unfavourable scarring (low quality evidence due to imprecision and heterogeneity). In terms of mortality and the rate of serious adverse events, there was low quality evidence that non-significant positive effects exist for PTs. In terms of the rate of major bleeding, there was very low quality evidence that non-significant positive effects exist for PTs.However, because several groups of participants were excluded from the included studies, the number of participants in the included studies was limited, long-term outcomes were not evaluated, and data on participant-relevant outcomes were either sparse or not available for each study, the results of this meta-analysis are limited and cannot be applied to all critically ill adults.

Long-Term Outcome Following Tracheostomy in Critical Care: A Systematic Review

OBJECTIVES

The prevalence and impact of longer-term outcomes following percutaneous tracheostomy, particularly tracheal stenosis, are unclear. Previous meta-analyses addressing this problem have been confounded by the low prevalence of tracheal stenosis and a limited number of studies.

DESIGN

Embase, PubMed-Medline, and the Cochrane Central Register of Clinical Trials were searched to identify all prospective studies of tracheostomy insertion in the critically ill. To reflect contemporary practice, the search was limited to studies published from 2000 onward. We scrutinized the bibliographies of returned studies for additional articles. Meta-analyses were undertaken to estimate the pooled risk difference of tracheal stenosis, bleeding, and wound infection comparing different techniques.

MEASUREMENTS AND MAIN RESULTS

We identified a total of 463 studies, 29 (5,473 patients) of which met the inclusion criteria. Nine were randomized controlled trials, six were nonrandomized comparative studies, and 14 were single-arm cohort studies. Risk of wound infection was greater for the surgical tracheostomy than for the Ciaglia multiple dilator technique, pooled risk difference 0.12 (95% CI, 0.02-0.23). We did not identify significant risk differences in other meta-analyses. Pooling across all studies according to the random-effects proportion meta-analysis suggests a higher prevalence of tracheal stenosis, wound infection, and major bleeding for surgical tracheostomies.

CONCLUSIONS

Considering comparative data, there was no significant difference in the prevalence of tracheal stenosis or major bleeding between percutaneous and surgical tracheostomy. In relation to wound infection, we have found a reduction associated with the original Ciaglia technique when compared with that with the surgical tracheostomy. Considering all published data reporting long-term outcomes pooled proportion meta-analysis indicates a trend toward a higher rate of tracheal stenosis and an increased risk of major bleeding and wound infection for surgical tracheostomies. This finding may be biased as a result of targeted patient selection, and further, high-quality long-term comparative data are needed to confirm these findings.

Percutaneous tracheostomy in patients on anticoagulants

Aims:

To determine if percutaneous tracheostomy is safe in critically ill patients treated with anticoagulant therapies.

Settings and Design:

Single-center retrospective study including all the patients who underwent percutaneous dilatational tracheostomy (PDT) placement over a 1-year period in a 14-bed, cardiothoracic and vascular Intensive Care Unit (ICU).

Materials and Methods:

Patients demographics and characteristics, anticoagulant and antiplatelet therapies, coagulation profile, performed technique and use of bronchoscopic guidance were retrieved.

Results:

Thirty-six patients (2.7% of the overall ICU population) underwent PDT over the study period. Twenty-six (72%) patients were on anticoagulation therapy, 1 patient was on antiplatelet therapy and 2 further patients received prophylactic doses of low molecular weight heparin. Only 4 patients had normal coagulation profile and were not receiving anticoagulant or antiplatelet therapies. Overall, bleeding of any severity complicated 19% of PDT. No procedure-related deaths occurred.

Conclusions:

PDT was proved to be safe even in critically ill-patients treated with anticoagulant therapies. Larger prospective studies are needed to confirm our findings.

A Prospective Randomized Study Comparing Mini-surgical Percutaneous Dilatational Tracheostomy With Surgical and Classical Percutaneous Tracheostomy: A New Method Beyond Contraindications

Although percutaneous dilatational tracheostomy (PDT) is more accessible and less time-demanding compared with surgical tracheostomy (ST), it has its own limitations. We introduced a modified PDT technique and brought some surgical knowledge to the bedside to overcome some standard percutaneous dilatational tracheostomy relative contraindications. PDT uses a blind route of tracheal access that usually requires perioperational imaging guidance to protect accidental injuries. Moreover, there are contraindications in certain cases, limiting widespread PDT application. Different PDT modifications and devices have been represented to address the problem; however, these approaches are not generally popular among professionals due to limited accessibility and/or other reasons.We prospectively analyzed the double-blinded trial, patient and nurse head evaluating the complications, and collected data from 360 patients who underwent PDT, ST, or our modified mini-surgical PDT (msPDT, Hashemian method). These patients were divided into 2 groups-contraindicated to PDT-and randomization was done for msPDT or PDT in PDT-indicated group and msPDT or ST for PDT-contraindicated patients. The cases were compared in terms of pre and postoperational complications.Data analysis demonstrated that the mean value of procedural time was significantly lower in the msPDT group, either compared with the standard PDT or the ST group. Paratracheal insertion, intraprocedural hypoxemia, and bleeding were also significantly lower in the msPDT group compared with the standard PDT group. Other complications were not significantly different between msPDT and ST patients.The introduced msPDT represented a semiopen incision, other than blinded PDT route of tracheal access that allowed proceduralist to withdraw bronchoscopy and reduced the total time of procedure. Interestingly, the most important improvement was performing msPDT on PDT-contraindicated patients with the complication rate comparable to surgical procedure. Supplements citation missing in the text. Please check supplements video in original manuscript.

A modified technique for percutaneous dilatational tracheostomy: A retrospective review of 60 cases

BACKGROUND

We describe a modified technique for percutaneous dilatational tracheostomy (PDT) using intermittent bronchoscopy and ultrasound (US). This method requires 1 single physician operator and no special airway adjuncts. Our aim is to reduce the complications associated with the current popular PDT technique, that is, accidental intraprocedural airway loss, intraprocedural bleeding, and hypoventilation associated with use of continuous bronchoscopy.

STUDY DESIGN

This is a retrospective review of all PDTs performed on intensive care unit patients at a single nonacademic hospital by a pulmonologist using the modified PDT technique.

RESULTS

Sixty consecutive PDT procedures were performed using the modified technique. Forty-five percent of the patients were considered high-risk individuals for PDT. There were no deaths from the modified PDT procedure. There were no major complications including accidental extubation, major bleeding, posterior tracheal wall laceration, pneumothorax, hemodynamic instability, severe hypoxemia, or infection. The failure rate of PDT was 1.6%. There was no puncture of the bronchoscope, endotracheal tube, or endotracheal tube balloon. All procedures were performed by 1 single physician operator.

CONCLUSION

Our modified technique demonstrates a potential to reduce accidental intraprocedural airway loss and intraoperative bleeding associated with PDT while possibly improving gas exchange and saving procedural costs. This technique needs to be comparatively studied with current popular PDT technique in a prospective trial to firmly establish associated risks and benefits.

Management and maintenance of the airway in cervical necrotising fasciitis: a retrospective analysis of 15 cases

Cervical necrotising fasciitis is a progressive deep infection of the neck associated with high mortality, and skillful management of the airway is critical for operations under general anaesthesia. Tracheostomy under local anaesthesia has been considered the gold standard of airway management in patients with deep neck infections, but it may be difficult or impossible in advanced cases. We report here our experience over 6 years (January 2008 and December 2013) during which a total of 15 patients was diagnosed with cervical necrotising fasciitis. Of 6 patients, admitted between January 2008 and March 2010, 5 had routine tracheostomy under local anaesthesia, 1 had direct laryngoscopy intubation, and 9 who were admitted between Spring 2010 and December 2013 were treated with nasotracheal intubation. Postoperatively all patients were given moderate sedation and analgesia. Nasotracheal intubation was continued until the infection had been controlled. During intubation patency of the endotracheal tube was maintained by humidification with a continuous pump of 0.45% sodium chloride and suction. All 15 patients (10 men and 5 women, mean age 62 years, range 36-93) required an emergency drainage procedure under general anaesthesia. Fourteen of the 15 had evidence of compromise of the airway, but emergency intervention was not required. Since Spring 2010, 9 consecutive patients had required nasotracheal intubation, including 7 video laryngoscopies and 2 fibreoptic bronchoscopies. No other interventions were required. Patients were intubated postoperatively from 3 to 14 days, and there were no problems with the airway. Advanced techniques for control of the airway have a high rate of success in patients with necrotising fasciitis and could be an appropriate alternative to a traditional airway. Postoperative sedation and analgesia should be considered as routine management of pain and anxiety.

Dilation balloon rupture during percutaneous dilational tracheostomy: using Blue Dolphin kit

A 72-year-old man presented to the high dependency unit following an elective incisional hernia repair. He was extubated in the immediate postoperative period. Following established type 2 respiratory failure (secondary to hospital-acquired pneumonia), he required tracheal intubation and was ventilated in the intensive care unit (ICU). He failed extubation and subsequently had a percutaneous single-stage dilational tracheostomy fitted as indicated. During the tracheostomy, while inflating the dilation balloon (used to dilate the trachea), the balloon burst in the trachea, at a pressure of 3 atmospheres. Following this, the entire dilating unit and tracheostomy tube were removed; no debris was left inside the trachea as confirmed by bronchoscope (used throughout the procedure). He made good recovery and was discharged to a surgical ward. This case report summarises the indications for tracheostomy, and reports the rare event of balloon rupture and how to manage it within the ICU setting.

Griggs percutaneous tracheostomy without bronchoscopic guidance is a safe method: A case series of 300 patients in a tertiary care Intensive Care Unit

Introduction:

Percutaneous tracheostomy (PCT) is being increasingly done by intensivists for critical care unit patients requiring either prolonged ventilation and/or for airway protection.[1] Bronchoscopic guidance considered a gold standard,[23] is not always possible due to logistic reasons and ventilation issues. We share our experience of Griggs PCT technique without bronchoscopic guidance with simple modifications to ensure safe execution of the procedure.

Objective:

The purpose of this study was to evaluate the safety issues and complications of PCT without bronchoscopic guidance in a multi-disciplinary tertiary Intensive Care Unit (ICU).

Materials and Methods:

A retrospective review of consecutive PCTs performed in our ICU between August 2010 and December 2013 by Griggs guide wire dilating forceps technique without bronchoscopic guidance is being presented. It is done by withdrawing endotracheal tube with inflated cuff while monitoring expired tidal volume on ventilator and ensuring the free mobility of guide wire during each step of the procedure, thereby ensuring a safe placement of the tracheostomy tube (TT) in trachea.

Results:

Analysis of 300 PCTs showed 26 patients (8.6%) had complications including 2 (0.6%) patients deteriorated neurologically and 2 (0.6%) deaths observed within 24 h following procedure. The median operating time was 3.5 min (range, 2.5–8 min). There were no TT placement problems in any case.

Conclusion:

Percutaneous tracheostomy can be safely performed without bronchoscopic guidance by adhering to simple steps as described.

Percutaneous and surgical tracheostomy in critically ill adult patients: a meta-analysis

Introduction

The aim of this study was to conduct a meta-analysis to determine whether percutaneous tracheostomy (PT) techniques are advantageous over surgical tracheostomy (ST), and if one PT technique is superior to the others.

Methods

Computerized databases (1966 to 2013) were searched for randomized controlled trials (RCTs) reporting complications as predefined endpoints and comparing PT and ST and among the different PT techniques in mechanically ventilated adult critically ill patients. Odds ratios (OR) and mean differences (MD) with 95% confidence interval (CI), and I² values were estimated.

Results

Fourteen RCTs tested PT techniques versus ST in 973 patients. PT techniques were performed faster (MD, −13.06 minutes (95% CI, −19.37 to −6.76 (P <0.0001)); I² = 97% (P <0.00001)) and reduced odds for stoma inflammation (OR, 0.38 (95% CI, 0.19 to 0.76 (P = 0.006)); I² = 2% (P = 0.36)), and infection (OR, 0.22 (95% CI, 0.11 to 0.41 (P <0.00001)); I² = 0% (P = 0.54)), but increased odds for procedural technical difficulties (OR, 4.58 (95% CI, 2.21 to 9.47 (P <0.0001)); I² = 0% (P = 0.63)). PT techniques reduced odds for postprocedural major bleeding (OR, 0.39 (95% CI, 0.15 to 0.97 (P = 0.04)); I² = 0% (P = 0.69)), but not when a single RCT using translaryngeal tracheostomy was excluded (OR, 0.58 (95% CI, 0.21 to 1.63 (P = 0.30)); I² = 0% (P = 0.89)). Eight RCTs compared different PT techniques in 700 patients. Multiple (MDT) and single step (SSDT) dilatator techniques are associated with the lowest odds for difficult dilatation or cannula insertion (OR, 0.30 (95% CI, 0.12 to 0.80 (P = 0.02)); I² = 56% (P = 0.03)) and major intraprocedural bleeding (OR, 0.29 (95% CI, 0.10 to 0.85 (P = 0.02)); I² = 0% (P = 0.72)), compared to the guide wire dilatation forceps technique.

Conclusion

In critically ill adult patients, PT techniques can be performed faster and reduce stoma inflammation and infection but are associated with increased technical difficulties when compared to ST. Among PT techniques, MDT and SSDT were associated with the lowest intraprocedural risks and seem to be preferable.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-014-0544-7) contains supplementary material, which is available to authorized users.

[Percutaneous dilatational tracheotomy or tracheostomy? Two case reports]

In terms of numbers, percutaneous dilatational tracheotomy (PDT) is the most important tracheotomy technique since it is applied in surgical and nonsurgical disciplines. Where correctly indicated, PDT is a fast, economical and easily reversible procedure. Incorrect indication sometimes necessitates conversion of a PDT into a conventional surgical tracheostomy. In these cases scarring, wound infections and ambiguous anatomical structures can represent a surgical challenge. Where a long-term tracheotomy requirement is predicted, a surgical tracheostomy should be performed.

Single dilator vs. guide wire dilating forceps tracheostomy: a meta-analysis of randomised trials

BACKGROUND

Single dilator technique (SDT) and guide wire dilating forceps (GWDF) are the two most commonly used techniques of percutaneous dilatational tracheostomy (PDT) in critically ill adult patients. We performed a meta-analysis of randomised, controlled trials comparing intraoperative, mid-term and late complications of these two techniques.

METHODS

Pertinent studies were searched in BioMedCentral, PubMed, Embase and the Cochrane Central Register of clinical trials. We selected all randomised studies comparing SDT and GWDF techniques in adult critically ill patients published in a peer-reviewed journal.

RESULTS

Among 1040 retrieved studies, five eligible studies randomising 363 patients (181 to GWDF, 182 to SDT) were identified. The incidence of the composite outcome difficult cannula insertion/difficult dilation or failure was higher with the GWDF technique (15.5% vs. 4.9 %, P = 0.02). Moreover, intraprocedural bleeding was more common in the GWDF group (19.3% vs. 7.6% in SDT group, P = 0.018). A trend towards an increased incidence of fracture of tracheal rings was noted in the SDT group (6.5% vs. 0.5% in the GWDF group, P = 0.13). No difference in mid-term or long-term complications was observed.

CONCLUSION

GWDF technique is associated with a higher incidence of intraprocedural bleeding and of technical difficulties in completing the procedure (difficult cannula insertions/difficult dilations or failures) compared with the SDT technique. No differences were identified in mid-term and long-term complications. Further studies comparing SDT and GWDF in the general population and in subgroups of high-risk patients (like obese or hypoxaemic patients) are warranted.

Tracheostomy in stroke patients

OPINION STATEMENT

Patients with severe ischemic and hemorrhagic stroke may require tracheostomy in the course of their disease. This may apply to stroke unit patients whose deficits include a severe dysphagia posing such risk of aspiration as it cannot be sufficiently counteracted by tube feeding and swallowing therapy alone. More often, however, tracheostomy is performed in stroke patients so severely afflicted that they require intensive care unit treatment and mechanical ventilation. In these, long-term ventilation and prolonged insufficient airway protection are the main indications for tracheostomy. Accepted advantages are less pharyngeal and laryngeal lesions than with prolonged orotracheal intubation, better oral hygiene and nursing care, and higher patient comfort. Optimal timing of tracheostomy is unclear, in general, as in stroke intensive care unit patients. Potential benefits of early tracheostomy concerning ventilation duration and length of stay, respirator weaning, airway safety, rate of pneumonia, and other complications, outcome and mortality have been suggested in studies on non-neurologic subgroups of critical care patients. Stroke patients have hardly been investigated with regard to these aspects, and mainly retrospectively. A single randomized pilot trial on early tracheostomy in 60 ventilated patients with severe hemorrhagic and ischemic stroke demonstrated feasibility, safety, and less need of sedation. Regarding the technique, bedside percutaneous dilational tracheostomy should be preferred over surgical tracheostomy because of several reported advantages. As the procedural risk is low and early tracheostomy does not seem to worsen the clinical course of the ventilated stroke patient, it is reasonable to assess the need of further ventilation at the end of the first week of intensive care and proceed to tracheostomy if extubation is not feasible. Reliable prediction of prolonged ventilation need and outcome benefits of early tracheostomy, however, await further clarification. Decannulation of stroke patients after discontinued ventilation has to follow reliable confirmation of swallowing ability, as by endoscopy.

Regional anesthesia and analgesia in critically ill patients: a systematic review

Regional anesthesia has become invaluable for the treatment of pain during and after a wide range of surgical procedures. However, its benefits in the nonsurgical setting have been less well studied. Regional anesthesia is an appealing modality for critically ill patients, providing focused and sustained pain control with beneficial systemic effect profiles. Indications for regional anesthesia in this patient group are not limited to surgical and postsurgical analgesia but expand to the management of trauma-related issues, medical conditions, and painful procedures at the bedside. Patients in the critical care unit present special challenges to the regional anesthesiologist, including coagulopathies, infections, immunocompromised states, sedation- and ventilation-associated problems, and factors potentially increasing the risk for systemic toxicity. This review is intended to evaluate the role of regional anesthesia in critically ill patients, to discuss potential benefits, and to provide a summary of the published evidence on the subject.

Percutaneous tracheostomy at the bedside: 13 tips for improving safety and success

We have developed a set of routines and practices in the course of performing a large series (n = 70) of percutaneous dilational tracheostomy (PDT). The 13 tips discussed in this review fall into 4 categories. System factors that facilitate training, patient safety, and avoidance of crises including the use of appropriate personnel, importance of timing, use of premedication, and the utility and content of a preprocedure briefing. Suggestions to prevent loss of the airway include tips on airway assessment, preparation of airway equipment, and use of exchange catheter techniques. Strategies to avoid and manage both microvascular and large-vessel bleeding are discussed. We also discuss the management of common postprocedure problems including tracheostomy tube obstruction, malposition requiring tube exchange or replacement, and air leak. The practical considerations for successful execution of PDT involve common sense, thorough planning, and structured approaches to prevent adverse effects if the procedure does not go as smoothly as expected. These strategies will aid anesthesiologists and intensivists in improving their comfort level, safety, and competence in performing this beside procedure.

[Percutaneous tracheostomy in the ventilated patient]

The medical indications of tracheostomy comprise the alleviation of upper airway obstruction; the prevention of laryngeal and upper airway damage due to prolonged translaryngeal intubation in patients subjected to prolonged mechanical ventilation; and the facilitation of airway access for the removal of secretions. Since 1985, percutaneous tracheostomy (PT) has gained widespread acceptance as a method for creating a surgical airway in patients requiring long-term mechanical ventilation. Since then, several comparative trials of PT and surgical tracheostomy have been conducted, and new techniques for PT have been developed. The use of percutaneous dilatation techniques under bronchoscopic control are now increasingly popular throughout the world. Tracheostomy should be performed as soon as the need for prolonged intubation is identified. However a validated model for the prediction of prolonged mechanical ventilation is not available, and the timing of tracheostomy should be individualized. The present review analyzes the state of the art of PT in mechanically ventilated patients--this being regarded by many as the technique of choice in performing tracheostomy in critically ill patients.

[Update on tracheotomy]

Tracheotomy in mechanically ventilated critically ill patients is a procedure commonly performed in the intensive care unit. The aim is to facilitate respiratory weaning and improve clinical outcome by reducing side effects of prolonged invasive mechanical ventilation and sedation. At the same time, the risk of tracheotomy associated complications must be minimized. Indications, method and timing must be individualized for each patient. Main determinants for decision-making, success and safety are the expected individual clinical benefits, the patient risk factors for complications and aspects of local experience and logistics. This review summarizes current concepts and evidence.