Comparison of percutaneous and surgical tracheostomies

Long-Term Follow-up of Percutaneous Dilatational Tracheostomy in the Intensive Care Unit

OBJECTIVE

The primary objective was to analyze percutaneous dilatation tracheostomy (PDT) management in the intensive care unit (ICU) by comparison with surgical tracheostomy (ST) outside of the ICU, with respect to: (i) long-term postoperative outcomes, including rate of follow-up, return to the emergency department, and major and minor complications; (ii) timing of decannulation, including time to decannulation, decannulation after >30 days, and decannulation at discharge. The secondary objective was to compare perioperative outcomes, including major and minor complications.

METHODS

A retrospective study from April 2013 to 2024 at a tertiary referral center. Eligible patients included those over 18 years old without PDT contraindications who received PDT in the ICU or ST.

RESULTS

Final analysis included 250 patients (125 [50%] PDT; 125 [50%] ST). The mean (SD) age of patients was 60.05 (16.41) years, and 85 (34.0%) were female. Compared with the ST group, the PDT group experienced significantly decreased long-term follow-up (41 [39.8%] vs. 115 [95.0%], respectively, p < 0.001), increased emergency department returns (61 [64.2%] vs. 31 [26.1%], p < 0.001), longer time to decannulation (estimated median difference: 11.00 days [95% CI: 7.00 to 15.00, p < 0.001]), increased decannulation after >30 days (23 [34.8%] vs. 13 [12.7%], p < 0.001), and similar postoperative complications (8 [8.4%] vs. 8 [6.8%], p = 0.664). The PDT group experienced significantly more perioperative complications (37 [30.1%] vs. 22 [17.6%], p = 0.021).

CONCLUSION

The decreased long-term follow-up, delayed decannulation, and increased complications after PDT highlight potential pitfalls in ICU tracheostomy management, demonstrating the need for refined protocols, appropriate consultant involvement, and improved patient selection.

LEVEL OF EVIDENCE

3 Laryngoscope, 2025.

Comparative Analysis of Percutaneous Dilatational Tracheotomy and Surgical Tracheotomy in Critically Ill Patients: Outcomes and Complications

OBJECTIVE

To evaluate the outcomes of percutaneous dilatational tracheostomy (PDT) versus surgical tracheostomy (ST) in critically ill patients, focusing on complications, duration of mechanical ventilation (MV), intensive care unit (ICU) length of stay, and mortality.

DESIGN

Retrospective trial SETTING: Single tertiary center PARTICIPANTS: A total of 119 patients receiving invasive MV in a medical ICU INTERVENTIONS: PDT (n = 55) or ST (n = 64) methods MEASUREMENTS AND MAIN RESULTS: The 2 groups showed comparable outcomes in terms of MV duration (36 days for PDT vs 35 days for ST; p = 0.72), ICU stay (43 days for PDT vs 37 days for ST; p = 0.17), and all-cause mortality (71% for PDT vs 64% for ST; p = 0.42). PDT was associated with significantly lower rates of subcutaneous emphysema (0% vs 16%; p = 0.01). Multivariate analysis showed no statistically significant association between tracheostomy technique and ICU mortality or overall complication rates after adjustment for confounders.

CONCLUSION

PDT and ST yield comparable outcomes in critically ill ICU patients, with no significant difference in overall complication rates or mortality. The fewer specific complications for PDT, such as subcutaneous emphysema, highlight its advantages in suitable cases. Individualized patient assessment remains crucial, and further studies are needed to refine tracheostomy practices.

ACR-ARS Practice Parameter for the Performance of Proton Beam Therapy

Purpose

This practice parameter for the performance of proton beam radiation therapy was revised collaboratively by the American College of Radiology (ACR) and the American Radium Society (ARS). This practice parameter was developed to serve as a tool in the appropriate application of proton therapy in the care of cancer patients or other patients with conditions in which radiation therapy is indicated. It addresses clinical implementation of proton radiation therapy, including personnel qualifications, quality assurance (QA) standards, indications, and suggested documentation.

Materials and Methods

This practice parameter for the performance of proton beam radiation therapy was developed according to the process described under the heading The Process for Developing ACR Practice Parameters and Technical Standards on the ACR website (https://www.acr.org/Clinical-Resources/Practice-Parameters-and-Technical-Standards) by the Committee on Practice Parameters - Radiation Oncology of the ACR Commission on Radiation Oncology in collaboration with the ARS.

Results

The qualifications and responsibilities of personnel, such as the proton center Chief Medical Officer or Medical Director, Radiation Oncologist, Radiation Physicist, Dosimetrist and Therapist, are outlined, including the necessity for continuing medical education. Proton therapy standard clinical indications and methodologies of treatment management are outlined by disease site and treatment group (e.g. pediatrics) including documentation and the process of proton therapy workflow and equipment specifications. Additionally, this proton therapy practice parameter updates policies and procedures related to a quality assurance and performance improvement program (QAPI), patient education, infection control, and safety.

Conclusion

As proton therapy becomes more accessible to cancer patients, policies and procedures as outlined in this practice parameter will help ensure quality and safety programs are effectively implemented to optimize clinical care.

Arterial Blood Gas Analysis in Patients with Stridor, and the Impact of Emergency Tracheostomy on It: A Tertiary Care Center Experience

Comparative evaluation of arterial blood gas in patients with stridor, before and after emergency tracheostomy. The present prospective study was conducted in tertiary care Centre from February 2022 to June 2023 on 42 patients who presented with stridor and underwent emergency tracheostomy in our department. After proper history taking and clinical examination, nonsurgical cause of stridor was ruled out. Patients were then classified on the basis of location of cause of stridor (whether oropharyngeal, hypo-pharyngeal, supra-glottic, glottic or sub-glottic). Immediately an arterial blood gas (ABG) analysis was done, and emergency tracheostomy was performed. Following tracheostomy, ABG analysis was done immediately, after 12 h and after 24 h. The mean age of presentation of stridor in our study was 65.02 ± 3.23 years, with male preponderance (Male: female ratio being 3.66:1). Most common etiology of stridor in our study was glottic carcinoma comprising 50%, and least common etiology of stridor was hypopharyngeal carcinoma, and subglottic stenosis comprising 2.4% each. There was statistically significant normalization of ABG in terms of pH, PO2, PCO2, HCO3. Mean pH, PO2, PCO2, and HCO3 before tracheostomy were 7.31, 74.8, 60.6, and 29.8 respectively. Mean pH, PO2, PCO2, HCO3, immediately after tracheostomy were7.38, 91.3, 48.4, and 27.4 respectively. After 12 h of tracheostomy, mean pH, PO2, PCO2, HCO3 were 7.41, 95.4, 42.7, 25.3 respectively. Mean pH, PO2, PCO2, HCO3 24 h after emergency tracheostomy were 7.441, 95.5, 42.8, 24.6 respectively. Emergency tracheostomy in stridor patients improves the acid base and ventilatory status, by relieving the obstruction as evidenced by statistically significant improvement in arterial blood gas values, and can be used as a diagnostic tool in upper airway obstruction.

Safety of cricotracheostomy with skin and tracheal membrane flaps for severe COVID-19 patients

OBJECTIVE

Airway surgery is performed for COVID-19 patients who require long-term tracheal intubation and mechanical ventilation. Tracheostomy sometimes causes postoperative complications represented by bleeding at a relatively high rate in COVID-19 patients. As an alternative surgical procedure to tracheostomy, cricotracheostomy may reduce these complications, but few studies have examined its safety.

METHODS

Data were retrospectively collected for sixteen COVID-19 patients (11 underwent tracheostomy, 5 underwent modified cricotracheostomy). In addition to patients' backgrounds and blood test data, the frequency of complications and additional care required for postoperative complications were collected. Statistical analysis was conducted by the univariate analysis of Fischer analysis and Mann-Whitney U test.

RESULTS

Five cases experienced postoperative bleeding, four cases experienced peristomal infection, and one case experienced subcutaneous emphysema in the tracheostomy patients. These complications were not observed in the cricotracheostomy patients. The number of additional cares for postoperative complications was significantly lower in cricotracheostomy than in tracheostomy patients (p < 0.05).

CONCLUSIONS

Modified cricotracheostomy could be a safe procedure in airway surgery for patients with COVID-19 from the point of fewer postoperative complications and additional care. It might be necessary to select the cricotracheostomy depending on patients' background to reduce postoperative complications.

Tracheal Stenosis in Open Versus Percutaneous Tracheostomy

OBJECTIVE

This study aims to investigate if there is an increased risk of developing tracheal stenosis after tracheostomy with an open versus percutaneous tracheostomy.

METHODS

The patient cohort included patients receiving open or percutaneous tracheostomies at Catholic Health Initiatives Midwest facilities from January 2017 to June 2023. The primary aim was to compare the differences in the risk of developing tracheal stenosis between open and percutaneous tracheostomy techniques. Between-technique differences in the risk of developing tracheal stenosis were assessed via a Cox proportional hazard model. To account for death precluding patients from developing tracheal stenosis, death was considered a competing risk.

RESULTS

A total of 828 patients met inclusion criteria (61.7% open, 38.3% percutaneous); 2.5% (N = 21) developed tracheal stenosis. The median number of days to develop tracheal stenosis was 84 (interquartile range: 60 to 243, range: 6 to 739). Tracheal stenosis was more frequent in patients who received a percutaneous tracheostomy (percutaneous: 3.5% vs. open: 2.0%); however, the risk of developing tracheal stenosis was statistically similar between open and percutaneous techniques (HR: 2.05, 95% CI: 0.86-4.94, p = 0.108).

CONCLUSIONS

This study demonstrates no significant difference in the development of tracheal stenosis when performing an open versus a percutaneous tracheostomy. Tracheal stenosis is a long-term complication of tracheostomy and should not influence the decision about the surgical technique used.

The Importance of Early Percutaneous Dilatational Tracheostomy in Inhalation Injury: A Case Report

Maintaining a patent airway is critical for treating patients with severe inhalation injuries. Percutaneous Dilatational Tracheostomy (PDT) has been used effectively for many patients treated in the Intensive Care Unit (ICU). In addition to its safety for use at the bedside, according to Friedman et al. PDT has the same or even lower complication rate than surgical tracheostomy. PDT can be performed in a shorter time and is more cost-effective. Herein, we report a 44 year old obese woman who sustained an inhalation injury related to a burn. The patient fell headfirst into a pot of boiling water at the time of the burn. The patient showed signs of inhalation injury and suffered a second-to-third degree burn injury. She was treated in the ICU, and early PDT was performed. The procedure was performed by first locating the trachea, followed by a 1-cm incision made between the second and third tracheal ring. She was intubated successfully and treated in the ICU for 7 days. The anesthesiologist chose to perform an early PDT to prevent further complications. This procedure was done successfully despite many comorbidities from the patient, such as being an obese female and having a short neck, which makes finding the exact location for the incision challenging. In this case, the early decision to proceed with PDT showed promising results in decreasing the patient's mortality risk.

Feasibility of Percutaneous Dilatational Tracheotomy in Head and Neck Cancer Surgery: A Preliminary Study

Objective

Percutaneous dilational tracheostomy (PDT) is a technique that can place a tracheostomy tube safely without visually identifying the trachea. We evaluated its feasibility during head and neck cancer surgery.

Summary of background data

PDT has many advantages, such as less bleeding, easier technique, and shorter procedural time.

Methods

Twelve patients who underwent PDT during head and neck cancer surgery from September 2016 to March 2018 were enrolled, and their medical records were reviewed retrospectively. Medical records of another 12 patients who underwent conventional tracheostomy during head and neck cancer surgery were analyzed. PDT was performed using a Ciaglia Percutaneous Tracheostomy Set. The tracheostomy point was determined by palpation without the guidance of bronchoscopy or ultrasonography. Blood loss, procedural time, communication between the cervical wound and tracheostomy wound, and complications were compared between the PDT group and the conventional group.

Results

The PDT group had less blood loss, a shorter procedural time, and a lower incidence of communication between the cervical and tracheostomy wound. There was 1 case of conversion to conventional tracheostomy due to wrong tracheal penetration in the PDT group.

Conclusions

PDT is safe and effective as an adjunctive procedure during head and neck cancer surgery.

Percutaneous Tracheostomy: A Bedside Procedure

Percutaneous tracheostomy is a bedside surgical procedure that creates an opening in the anterior tracheal wall. Tracheostomy is performed in patients expected to require mechanical ventilation for longer than seven to 10 days. This bedside percutaneous tracheostomy has been used since the late 1990s. Tracheotomy tubes are of various kinds like cuffed vs. uncuffed, fenestrated vs. unfenestrated, single lumen vs. double lumen, and metal vs. plastic. Its indications are categorized into emergency vs. elective. The most common emergency indication is acute airway obstruction, and the elective indication is prolonged intubation. There is no absolute contraindication, but a physician should consider severe hypoxia requiring high oxygen and coagulopathy. Percutaneous tracheostomy is a new technique requiring different skills. Advantages of percutaneous tracheostomy are as follows - it is performed at the bedside, procedural time is less, the cost is less, does not need operating schedule time. Percutaneous tracheostomy is generally performed by otolaryngologists, general surgeons, interventional pulmonologists, thoracic surgeons, or intensivists.

Assessment of knowledge regarding tracheostomy care and management of early complications among healthcare professionals

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Healthcare workers should be well versed in identifying tracheostomy management, its complications and responding accordingly.

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Doctors and nurses (131 = 52%) possessed good knowledge about various aspects of tracheostomy care and management.

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The poorest scores were regarding cuff pressure (38.9%), suction pressure (39.4%) and first response in tube blockade (31.1%).

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Higher scores were found in age group 26 to 30 years (54.2%) and those having 1-3 years of clinical experience (41.2%).

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No statistically significant assoiation of knowledge regarding tracheostomy care was apparent with age, gender or years of practice.

Introduction

Tracheostomy is commonly performed surgical procedure in ENT practice. Postoperative care is the most important aspect for achieving good patient outcomes. Unavailability of standard guidelines on tracheostomy management and inadequate training can make this basic practice complex. The nursing staff and doctors play a very important role in bedside management, both in the ward and in the intensive care unit (ICU) setup. Therefore, it is crucial that all healthcare providers directly involved in providing postoperative care to such patients can do this efficiently.

Objectives

The objective of this study is to assess the knowledge regarding identification and management of tracheostomy-related emergencies and early complications among healthcare professionals so as to improve practice and further standardization.

Methods

Cross-sectional observational study included two hundred and fifty-four doctors and nurses from four large tertiary care hospitals. The questions used were simple and straightforward regarding tracheostomy suctioning, cuff care, cuff management, tube blockage, and feeding management in patients with tracheostomy.

Results

Based on evidence from our study, knowledge level regarding tracheostomy care ranges from 48% to 52% with knowledge scores above 50% being considered satisfactory. Significant gaps in knowledge exist in various aspects of tracheostomy care and management among healthcare professionals.

Conclusion

Our findings demonstrated an adequate knowledge level among health care professionals ranging from 48% to 52% with knowledge scores above 50% being considered satisfactory and revealed that gaps in knowledge still exist in various aspects of tracheostomy care and management.

Diagnosis by forensic autopsy of cannula malposition resulting in fatal tension pneumothorax after attempted percutaneous tracheostomy: A short communication

Percutaneous tracheostomy is commonly performed in the emergency department or intensive care unit to secure the airways of patients. This procedure is associated with a low incidence of complications; however, some of them, such as iatrogenic pneumothorax, can be fatal. Pneumothorax after percutaneous tracheostomy is most often caused by perforation of the tracheal wall or malposition of the cannula. A woman in her 80s was referred to the emergency department owing to persistent and prolonged coughing. Having speculated that she had acute epiglottitis, and having failed to achieve oral tracheal intubation, the physician performed a percutaneous tracheostomy to secure her airway. However, progressive percutaneous emphysema developed immediately thereafter, and the patient died shortly. Postmortem computed tomography showed bilateral pneumothorax. Forensic autopsy revealed that the tracheostomy cannula had failed to reach the trachea and was erroneously inserted into the right thoracic cavity via peritracheal route. Thus, it was determined that the patient's death was attributable to tension pneumothorax caused by cannula malposition during attempted tracheostomy. To the best of our knowledge, this is the first forensic autopsy case report on fatal tension pneumothorax caused by attempted percutaneous tracheostomy.

The use of distributed random forest model to quantify risk predictors for tracheostomy requirements in septic patients: A retrospective cohort study

The search for early clinical risk factors in the intensive care setting may improve the outcome of critically ill patients. The objective of this retrospective study is to identify and quantify early predictors for patients who would require tracheostomy. Five hundred and forty four septic patients were divided in 2 groups: non-tracheostomized (NT) (n = 484) and tracheostomized (T) (n = 60). The patients consisted of 241 males (49.8%) in NT and 27 (45%) in T group, respectively (P = .4971). The median and interquartile range difference of age of NT group was of 72 years [59-82] and T of 75 [55.0-83.5] (P = .4687). The SAPS 3 for the group NTxT was 70 [55-85] and 85.5 [77-91] (P = .0001), the SOFA of 9 [6-13] and 12 [10-14] (P = .0002). The comparison of logistic regression analysis for predictors of non-tracheostomy and tracheostomy groups showed an adjusted odds ratio (OR) for SAPS 3 range between 74 and 87 of 18.14 (95%CI = 3.36-97.84) and between 88 and 116 of 27.77 (95%CI = 4.43-174.24) (P < .05). For SOFA, the adjusted OR between 10 and 13 was 12.23 (95%CI = 2.46-60.81) and between 14 and 20 was 8.45 (95%CI = 1.58-45.29) (P < .05). The need for blood transfusions and dialysis presented an OR of 2.74 (95%CI = 1.23-6.08) and 3.33 (95%CI = 1.43-7.73) (P < .05), respectively. Our data shows that SAPS 3 ≥ 74, SOFA ≥ 11, blood transfusions and the need for dialysis were independently associated and could be considered major predictors for tracheostomy requirements in septic patients.

Early Percutaneous Dilational Tracheostomy in Trauma Patients After Anterior Cervical Fusion: Propensity-Matched Cohort Study

BACKGROUND

Patients with cervical spinal cord injuries (CSCIs) may be required to undergo tracheostomy. However, in patients undergoing anterior cervical fusion (ACF), percutaneous dilational tracheostomy (PDT) may be delayed given the risk of cross-contamination. We aimed to evaluate the risk of surgical site infection (SSI) in early PDT in patients with traumatic CSCI after ACF.

METHODS

All trauma patients admitted to the intensive care unit from 2008 to 2018 were retrospectively analyzed. Patients with CSCIs who underwent both ACF and PDT were identified, with or without posterior cervical fusion. Cases were classified as having undergone early PDT (≤4 days after ACF) versus late PDT (>4 days after ACF). Propensity scores were matched, and outcomes were compared between matched groups to reduce confounding by indication.

RESULTS

From a total of 133 enrolled patients, a well-balanced propensity-matched cohort of 68 patients was defined. On the basis of the comparison of outcomes after matching, no significant difference in SSI was observed between both groups. There was no patient with SSI in the early PDT group (0%), whereas there were 2 SSI patients (5.9%) in the late PDT group (P = 0.493): The tracheostomy site was involved in 1, and the posterior approach site was involved in the other. Early PDT was associated with a shorter duration of mechanical ventilation (P = 0.042). There were no significant differences in the length of intensive care unit stay and hospital mortality between groups.

CONCLUSIONS

Early PDT within 4 days after ACF did not increase the risk of SSI compared with late PDT in patients with traumatic CSCIs.

Utility of Tracheostomy in Patients With COVID-19 and Other Special Considerations

Introduction

Patients who become severely ill from coronavirus disease 2019 (COVID‐19) have a high likelihood of needing prolonged intubation, making tracheostomy a likely consideration. The infectious nature of COVID‐19 poses an additional risk of transmission to healthcare workers that should be taken into consideration.

Methods

We explore current literature and recommendations for tracheostomy in patients with COVID‐19 and look back at previous data from severe acute respiratory syndrome coronavirus 1 (SARS‐CoV‐1), the virus responsible for the SARS outbreak of 2003.

Results

Given the severity and clinical uncertainty of patients with COVID‐19 and the increased risk of transmission to clinicians, careful consideration should be taken prior to performing tracheostomy. If tracheostomy is performed, we recommend a bedside approach to limit exposure time and number of exposed personnel. Bronchoscopy use with a percutaneous approach should be limited in order to decrease viral exposure.

Conclusion

Thorough preprocedural planning, use of experienced personnel, enhanced personal protective equipment where available, and a thoughtful anesthesia approach are instrumental in maximizing positive patient outcomes while successfully protecting the safety of healthcare personnel. Laryngoscope, 130:2546–2549, 2020

Multispecialty tracheostomy experience

INTRODUCTION

Tracheostomy is a common surgical procedure used to create a secure airway in patients, now performed by a variety of specialties, with a notable rise in critical care environments. It is unclear whether this rise is seen in units with large head and neck surgery departments, and how practice in such units compares with the rest of the UK.

METHODS

A three-year retrospective audit was carried out between anaesthetic, surgical and critical care departments. All tracheostomy procedures were recorded anonymously.

RESULTS

A total of 523 tracheostomies were performed, 66% of which were in men. The mean patient age was 60 years. The majority (83%) were elective, performed for various indications, while the remaining 17% were emergency tracheostomies performed for pending airway obstruction. A fifth of the tracheostomies were percutaneous procedures. Most emergency tracheostomies (78%) were performed by otolaryngology. Three cricothyroidotomies were performed within critical care and theatres. Complications related to tracheostomy occurred in 47 cases (9%), most commonly lower respiratory tract infection. The mean time to decannulation was 12.8 days.

CONCLUSIONS

This paper discusses the findings of a comprehensive, multispecialty audit of tracheostomy experience in a large health board, with over 150 tracheostomies performed annually. Elective cases form the majority although there is a significant case series of emergency tracheostomies performed for a range of pathologies. Around a quarter of those requiring tracheostomy ultimately died, mostly as a result of advanced cancer.

Dilatational Percutaneous vs Surgical TracheoStomy in IntEnsive Care UniT: A Practice Pattern Observational Multicenter Study (DISSECT)

Introduction

Tracheostomy is among the common procedures performed in the intensive care unit (ICU), with percutaneous dilatational tracheostomy (PDT) being the preferred technique. We sought to understand the current practice of tracheostomy in Indian ICUs.

Materials and methods

A pan-India multicenter prospective observational study, endorsed and peer-reviewed by the Indian Society of Critical Care Medicine (ISCCM), on various aspects of tracheostomy performed in critically ill patients was conducted between September 1, 2019 and December 31, 2019. The SPSS software was used for the statistical analysis. Cross tables were generated and the chi-square test was used for testing of association. The p value < 0.05 was considered statistically significant.

Results

Out of 67 ICUs that participated, 88.1% were from private sector hospitals. A total of 923 tracheostomies were performed during the study period; out of which, 666 were PDT and 257 were surgical tracheostomy (ST). Coagulopathic patients received more platelet transfusion [p = 0.037 with platelet count (PC) < 50 × 10⁹, p = 0.021 with PC 50–100 × 10⁹] and fresh frozen plasma transfusion in the ST group (p = 0.0001). The performance of PDT vs ST by day 7 of admission was 28.4% vs 21% (p = 0.023). The single dilator technique (60.4%) was the preferred technique for PDT followed by the Grigg's forceps and then the multiple dilator technique. Fiberoptic bronchoscope (FOB) and ultrasonography (USG) were used in 29.3% and 16.8%, respectively, for guidance during tracheostomy. Most of the PDTs were performed by a trained intensivist (74.2%), whereas ST was mostly done by an ENT surgeon (56.8%). Percutaneous dilatational tracheostomy resulted in less hemorrhagic (2.6% vs 7%, p = 0.002) and desaturation complications (2.3% vs 6.6%, p = 0.001) as compared to ST. The duration of procedure was shorter in the PDT group (average shortening by 9.2 minutes) and the ventilator-free days (VFD) were higher in the PDT group. The cost was less in PDT by approximately Rs. 13,104.

Conclusion

Percutaneous dilatational tracheostomy, especially the single dilator technique, is preferred by clinicians in Indian ICUs. The incidence of minor complications like hemorrhagic episodes is lower with PDT. Percutaneous dilatational tracheostomy was found to be cheaper on cost per patient basis as compared to ST (with or without complications).

How to cite this article

Gupta S, Tomar DS, Dixit S, Zirpe K, Choudhry D, Govil D, et al. Dilatational Percutaneous vs Surgical TracheoStomy in IntEnsive Care UniT: A Practice Pattern Observational Multicenter Study (DISSECT). Indian J Crit Care Med 2020;24(7):514–526.

Tracheostomy in Adult Intensive Care Unit: An ISCCM Expert Panel Practice Recommendations

BACKGROUND AND AIM

Critically ill patients on mechanical ventilation undergo tracheostomy to facilitate weaning. The practice in India may be different from the rest of the world and therefore, in order to understand this, ISCCM conducted a multicentric observational study "DIlatational percutaneous vs Surgical tracheoStomy in intEnsive Care uniT: A practice pattern observational multicenter study (DISSECT Study)" followed by an ISCCM Expert Panel committee meeting to formulate Practice recommendations pertinent to Indian ICUs.

MATERIALS AND METHODS

All existing International guidelines on the topic, various randomized controlled trials, meta-analysis, systematic reviews, retrospective studies were taken into account to formulate the guidelines. Wherever Indian data was not available, international data was analysed. A modified Grade system was followed for grading the recommendation.

RESULTS

After analyzing the entire available data, the recommendations were made by the grading system agreed by the Expert Panel. The recommendations took into account the indications and contraindications of tracheostomy; effect of timing of tracheostomy on incidence of ventilator associated pneumonia, ICU length of stay, ventilator free days & Mortality; comparison of surgical and percutaneous dilatational tracheostomy (PDT) in terms of incidence of complications and cost to the patient; Comparison of various techniques of PDT; Use of fiberoptic bronchoscope and ultrasound in PDT; experience of the operator and qualification; certain special conditions like coagulopathy and morbid obesity.

CONCLUSION

This document presents the first Indian recommendations on tracheostomy in adult critically ill patients based on the practices of the country. These guidelines are expected to improve the safety and extend the indications of tracheostomy in critically ill patients.

HOW TO CITE THIS ARTICLE

Gupta S, Dixit S, Choudhry D, Govil D, Mishra RC, Samavedam S, Tracheostomy in Adult Intensive Care Unit: An ISCCM Expert Panel Practice Recommendations. Indian J Crit Care Med 2020;24(Suppl 1):S31-S42.

Antiplatelet agents and anticoagulants increased the bleeding risk of bedside percutaneous dilational tracheostomy in critically ill patients

BACKGROUND

The main objective of this study was to investigate the safety of bedside percutaneous dilational tracheostomy (PDT) by pulmonologists in critically ill patients, and the factors associated with complications resulting from PDT.

METHODS

We retrospectively enrolled critically ill patients who had undergone bedside PDT in the intensive care units (ICUs) and respiratory care center from February 2016 to December 2018.

RESULTS

A total of 312 patients were included for analysis, with a mean age of 69.6 ± 17.7 years. Two hundred and eight of the patients were male (66.7%). The mean acute physiology and chronic health evaluation II score was 25.3 ± 6.3, and the mean body mass index was 22.4 ± 4.2. Most of the patients were intubated due to respiratory disorders (51.3%). Fifty-six patients (17.9%) received antiplatelet agents or an anticoagulant regularly prior to PDT. All enrolled patients were undergone bedside PDT successfully. The total complication rate of PDT was 14.4%. Patients who took antiplatelet agents or anticoagulants regularly before PDT had a higher risk of bleeding than patients who went without (26.8% versus 7.0%, adjusted odds ratio 4.93 [95% f 2.16-11.25], p < 0.001). Finally, a longer length of intubation resulted in a higher probability in the length of ICU stay being ≧28 days (adjusted odds ratio 1.11 [95% CI 1.08-1.14], p < 0.001).

CONCLUSION

Our study demonstrated that it was feasible for pulmonologists to perform bedside PDT in critically ill patients. However, antiplatelet agents and anticoagulants use increased the risk of bleeding in PDT patients.

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.

A Network Comparative Meta-analysis of Percutaneous Dilatational Tracheostomies Using Anatomic Landmarks, Bronchoscopic, and Ultrasound Guidance Versus Open Surgical Tracheostomy

BACKGROUND

Several different tracheostomy techniques (percutaneous and surgical) have been studied extensively in previous direct pairwise meta-analyses. However, a network comparative meta-analysis comparing all has not been conducted before.

OBJECTIVE

We sought to compare three percutaneous dilatational tracheostomy techniques with open surgical tracheostomy technique (performed in the operating room or in the intensive care unit by bedside) in terms of their association with procedure-related major complications and procedure time.

DATA SOURCES

We searched PubMed and Cochrane register of randomized active comparator trials.

DATA EXTRACTION AND SYNTHESIS

A network comparative meta-analysis was performed in Stata using frequentist methodology. Major complications were defined as a composite of a priori-selected procedure-related complications. Tracheostomy techniques that did not require any direct bronchoscopic or ultrasonographic visualization of the entire procedure were grouped under the heading-anatomic landmark-based dilatational tracheostomy (ALDT). This along with bronchoscopic-guided dilatational tracheostomy (BDT), ultrasound-guided (UDT), and surgical tracheostomy (SGT) were compared with each other using network meta-analysis in Stata after all major assumptions (similarity, transitivity, and consistency) for performing a network were met. Log odds ratio (and standard errors) of the comparison of major complications between any two tracheostomy techniques (using indirect estimates) was statistically insignificant. Pairwise meta-analysis showed significant differences in procedure times between SGT and ALDT [mean difference: 9.96 min (SE 3.18)] and between SGT and BDT [15.67 min (SE 3.85)]. The indirect network meta-analysis comparing one versus the other also showed a statistically significant time difference between surgical tracheostomy when compared with every other technique.

CONCLUSIONS

The results of our network meta-analysis show that all tracheostomy techniques are comparable with respect to associated procedure-related complications, but all three percutaneous techniques take far less procedure time compared to the surgical tracheostomy.

Our Experience with Percutaneous and Surgical Tracheotomy in Intubated Critically Ill Patients

Objective

Open surgical tracheotomy (OST) and percutaneous dilatational tracheotomy (PDT) are commonly used for securing airway in intubated critically ill patients. The purpose of this study was to compare the safety of OST and PDT, particularly in intubated critically ill patients.

Methods

The medical records of intubated critically ill patients who underwent tracheotomy between August 2006 and July 2017 were analyzed retrospectively. Minor and major complication rates were compared according to the tracheotomy technique. Preoperative intubation time, postoperative decannulation time, reason for hospitalization, and demographic data, including the Acute Physiology and Chronic Health Evaluation (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores, were evaluated.

Results

A total of 332 cases were enrolled into the study. The minor and major complication rates for both techniques were 27.2%, 8.8%, 9.7% and 3.2%, respectively. Minor and major complication rates were higher in the OST group (p=0.01, p=0.03, respectively). The rate of every single complication was also compared on groups' basis. Accidental decannulation (p=0.02) and pneumothorax (p=0.05) were found to be significantly frequent in the OST group. There was no impact of the preoperative intubation time on the minor (p=0.20) and major complication (p=0.29) rates found. There was no statistically significant difference regarding the postoperative decannulation time (p=0.32). Also, there was no statistically significant difference between two groups in terms of the APACHE II (p=0.69) and SOFA (p=0.37) scores. However, a statistically significant difference between the groups in terms of overall survival was found, in favor of PDT (p<0.001).

Conclusion

This study revealed that PDT is safer than OST, particularly in intubated critically ill patients.

Tracheotomy in the intensive care unit: Guidelines from a French expert panel: The French Intensive Care Society and the French Society of Anaesthesia and Intensive Care Medicine

Tracheotomy is widely used in intensive care units, albeit with great disparities between medical teams in terms of frequency and modality. Indications and techniques are, however, associated with variable levels of evidence based on inhomogeneous or even contradictory literature. Our aim was to conduct a systematic analysis of the published data in order to provide guidelines. We present herein recommendations for the use of tracheotomy in adult critically ill patients developed using the grading of recommendations assessment, development and evaluation (GRADE) method. These guidelines were conducted by a group of experts from the French Intensive Care Society (Société de réanimation de langue française) and the French Society of Anesthesia and Intensive Care Medicine (Société francaise d'anesthésie réanimation) with the participation of the French Emergency Medicine Association (Société française de médecine d'urgence), the French Society of Otorhinolaryngology. Sixteen experts and two coordinators agreed to consider questions concerning tracheotomy and its practical implementation. Five topics were defined: indications and contraindications for tracheotomy in intensive care, tracheotomy techniques in intensive care, modalities of tracheotomy in intensive care, management of patients undergoing tracheotomy in intensive care, and decannulation in intensive care. The summary made by the experts and the application of GRADE methodology led to the drawing up of 8 formal guidelines, 10 recommendations, and 3 treatment protocols. Among the 8 formal guidelines, 2 have a high level of proof (Grade 1±) and 6 a low level of proof (Grade 2±). For the 10 recommendations, GRADE methodology was not applicable and instead 10 expert opinions were produced.

Tracheotomy in the intensive care unit: guidelines from a French expert panel

Tracheotomy is widely used in intensive care units, albeit with great disparities between medical teams in terms of frequency and modality. Indications and techniques are, however, associated with variable levels of evidence based on inhomogeneous or even contradictory literature. Our aim was to conduct a systematic analysis of the published data in order to provide guidelines. We present herein recommendations for the use of tracheotomy in adult critically ill patients developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. These guidelines were conducted by a group of experts from the French Intensive Care Society (Société de Réanimation de Langue Française) and the French Society of Anesthesia and Intensive Care Medicine (Société Francaise d'Anesthésie Réanimation) with the participation of the French Emergency Medicine Association (Société Française de Médecine d'Urgence), the French Society of Otorhinolaryngology. Sixteen experts and two coordinators agreed to consider questions concerning tracheotomy and its practical implementation. Five topics were defined: indications and contraindications for tracheotomy in intensive care, tracheotomy techniques in intensive care, modalities of tracheotomy in intensive care, management of patients undergoing tracheotomy in intensive care, and decannulation in intensive care. The summary made by the experts and the application of GRADE methodology led to the drawing up of 8 formal guidelines, 10 recommendations, and 3 treatment protocols. Among the 8 formal guidelines, 2 have a high level of proof (Grade 1+/-) and 6 a low level of proof (Grade 2+/-). For the 10 recommendations, GRADE methodology was not applicable and instead 10 expert opinions were produced.

Percutaneous versus surgical strategy for tracheostomy: a systematic review and meta-analysis of perioperative and postoperative complications

PURPOSE

Tracheostomy is one of the most frequently performed procedures in intensive care medicine. The two main approaches are open surgical tracheostomy (ST) and percutaneous dilatational tracheostomy (PDT). This systematic review summarizes and analyzes the existing evidence regarding perioperative and postoperative parameters of safety.

METHODS

A systematic literature search was conducted in the Cochrane Library, EMBASE, LILACS, and MEDLINE to identify all randomized controlled trials (RCTs) comparing complications of ST and PDT and to define the strategy with the lower risk of potentially life-threatening events. Risk of bias was assessed using the criteria outlined in the Cochrane Handbook.

RESULTS

Twenty-four citations comprising 1795 procedures (PDT: n = 926; ST: n = 869) were found suitable for systematic review. No significant difference in the risk of a potentially life-threatening event (risk difference (RD) 0.01, 95% CI - 0.03 to 0.05, P = 0.62, I ² = 47%) was found between PDT and ST. There was no difference in mortality (RD - 0.00, 95% CI - 0.01 to 0.01, P = 0.88, I ² = 0%). An increased rate of technical difficulties was shown for PDT (RD 0.04, 95% CI 0.01, 0.08, P = 0.01, I ² = 60%). Stomal infection occurred more often with ST (RD - 0.05, 95% CI - 0.08 to - 0.02, P = 0.003, I ² = 60%). Both techniques can be safely performed on the ICU. Meta-analysis of the duration of procedure was not possible owing to high heterogeneity (I ² = 99%).

CONCLUSION

ST and PDT are safe techniques with low incidence of complications. Both techniques can be performed successfully in an ICU setting. ST can be performed on every patient whereas PDT is restricted by several contraindications like abnormal anatomy, previous surgery, coagulopathies, or difficult airway of the patient.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015021967.

Tracheostomy Update: When and How

Tracheostomy remains one of the most commonly performed surgical procedures in the setting of acute respiratory failure. Tracheostomy literature focuses on 2 aspects of this procedure: when (timing) and how (technique). Recent trials have failed to demonstrate an effect of tracheostomy timing on most clinically important endpoints. Nonetheless, relative to continued translaryngeal intubation, studies suggest that tracheostomy use is associated with less need for sedation and enhanced patient comfort. Evidence likewise suggests that percutaneous dilational tracheostomy is advantageous with respect to cost and complication profile and should be considered the preferred approach in appropriately selected patients.

Tracheotomy-Related Deaths

BACKGROUND

Tracheotomies are frequently performed on ventilated patients in intensive care and sometimes lead to fatal complications. In this article, we discuss the causes and frequency of death associated with open surgical tracheotomy (OST) and percutaneous dilatational tracheotomy (PDT) on the basis of a review of the pertinent literature.

METHODS

We systematically searched the PubMed, EMBASE, and Cochrane Library databases and the Karlsruhe Virtual Catalog for publications (1990-2015) on tracheotomy-related deaths in adults, using the search terms "tracheotomy" and "tracheostomy." 39 relevant dissertations were included in the analysis as well.

RESULTS

109 publications were included. Of the 25 056 tracheotomies described, there were 16 827 PDTs and 7934 OSTs; for 295 tracheotomies, the technique used was not stated. 352 deaths were reported, including 113 in patients treated with PDT, 49 in those treated with OST, and 190 deaths related to a tracheotomy without specification of the method used. The frequency of death among patients with OST and those treated with PDT was similar: 0.62% for OST (95% confidence interval [0.47; 0.82]) and 0.67% for PDT ([0.56; 0.81]). The most common causes of death and their frequencies, as a percentage of all tracheotomies, were hemorrhage (OST: 0.26% [0.17; 0.40], PDT: 0.26% [0.19; 0.35]), loss of airway (OST: 0.21% [0.13; 0.34], PDT: 0.20% [0.14; 0.28]), and false passage (OST: 0.11% [0.06; 0.22], PDT: 0.20% [KI 0.15; 0.29]).

CONCLUSION

Bias in the data cannot be excluded, as these were not epidemiologic data and the documentation was found to be incomplete. The likelihood of a fatal complication seems to be the same with both tracheotomy techniques as far as can be determined from the available evidence. Tracheotomy-related deaths can be avoided in several ways: by thorough training under the leadership of experienced physicians, by the use of the World Health Organization's Surgical Safety Checklist regardless of where the tracheotomy is performed, and by the continuous vigilance of nursing staff.

Fiber optic bronchoscopy-assisted percutaneous tracheostomy: a decade of experience at a university hospital

Objective

To evaluate the efficacy and safety of percutaneous tracheostomy by means of single-step dilation with fiber optic bronchoscopy assistance in critical care patients under mechanical ventilation.

Methods

Between the years 2004 and 2014, 512 patients with indication of tracheostomy according to clinical criteria, were prospectively and consecutively included in our study. One-third of them were high-risk patients. Demographic variables, APACHE II score, and days on mechanical ventilation prior to percutaneous tracheostomy were recorded. The efficacy of the procedure was evaluated according to an execution success rate and based on the necessity of switching to an open surgical technique. Safety was evaluated according to post-operative and operative complication rates.

Results

The mean age of the group was 64 ± 18 years (203 women and 309 males). The mean APACHE II score was 21 ± 3. Patients remained an average of 11 ± 3 days on mechanical ventilation before percutaneous tracheostomy was performed. All procedures were successfully completed without the need to switch to an open surgical technique. Eighteen patients (3.5%) presented procedure complications. Five patients experienced transient desaturation, 4 presented low blood pressure related to sedation, and 9 presented minor bleeding, but none required a transfusion. No serious complications or deaths associated with the procedure were recorded. Eleven patients (2.1%) presented post-operative complications. Seven presented minor and transitory bleeding of the percutaneous tracheostomy stoma, 2 suffered displacement of the tracheostomy cannula, and 2 developed a superficial infection of the stoma.

Conclusion

Percutaneous tracheostomy using the single-step dilation technique with fiber optic bronchoscopy assistance seems to be effective and safe in critically ill patients under mechanical ventilation when performed by experienced intensive care specialists using a standardized procedure.

Role of the Interventional Pulmonologist in the Intensive Care Unit

Interventional pulmonology is a new field within the pulmonary and critical care medicine specialty with a focus on invasive diagnostic and therapeutic modalities in airway and pleural disorders. The interventional pulmonologist is highly qualified to take a prominent role in the intensive care unit in a consultative fashion to provide assistance with pleural procedures, establishment and care of artificial airways, and management of patients with respiratory failure attributable to structural central airway disorders. The presence of a dedicated operator with advanced skills facilitates access to specialized procedures in an expeditious and safe manner. Clear communication between the interventional pulmonologist and intensivist is vital to ensure a collaborative effort that delivers optimal patient care.

Management of the chronically ventilated patient with a tracheostomy

Tracheostomy is the most common surgical procedure performed on critically ill patients. For those who survive their critical illnesses but remain ventilator-dependent, tracheostomy provides patients with a secure airway that frees the mouth for oral nutrition, enhances verbalized speech, and promotes generalized comfort. Avoiding complications from tracheostomy requires a skilled multi-disciplinary approach to ensure that the benefits outweigh the risks of the procedure.

Comparison of Open, Percutaneous, and Translaryngeal Tracheostomies

INTRODUCTION: With 3 tracheostomy techniques currently available, controversy exists regarding which is safest and most economical. Percutaneous (PDT) and the new translaryngeal (TLT) tracheostomies are cited as more cost-effective than the traditional open surgical procedure because they are bedside techniques. Our objective was to compare the perioperative and postoperative complications of the 3 techniques.

STUDY DESIGN: This was a prospective trial involving 100 consecutive patients who underwent tracheostomy between April and December of 1997 at the London Health Sciences Centre and St Joseph's Health Centre in London, Canada.

RESULTS: Fifty open tracheostomies were performed. Indications included prolonged ventilation (n = 42), airway protection (n = 5), pulmonary hygiene (n = 2), and sleep apnea (n = 1). A tension pneumothorax was the one significant intraoperative complication. Fifteen postoperative complications occurred, most notable of which was a 2-L hemorrhage at 24 hours. Thirty-seven TLTs were performed, 20 in patients with coagulopathy. Indications were prolonged intubation (n = 27), airway protection (n = 9), and pulmonary hygiene (n = 1). One intraoperative complication of accidental decannulation occurred. One postoperative complication, a pretracheal abscess, occurred in a decannulated transplant patient 2 weeks after the procedure. Thirteen PDTs were performed. Indications were prolonged intubation (n = 6), airway protection (n = 6), and tracheal toilet (n = 1). No significant complications occurred.

CONCLUSIONS: TLT and PDT have fewer complications than the traditional open technique. TLT appears to have the greatest utility in the coagulopathic patient.

A Novel, Adaptable Laryngeal Mask to Facilitate a Percutaneous Dilatational Tracheostomy: Proof-of-Concept Prototype Demonstration on a Mannequin Model and Cadaver

BACKGROUND

Most percutaneous dilatational tracheostomy (PDT) mortalities result from airway-related complications. Improved airway pressure management and gas delivery are targets for innovation. This study describes an adaptable laryngeal mask (ALM) designed to remove the bronchoscope from the endotracheal tube (ETT) and place it in a separate lumen. Airflow and device efficacy were evaluated during PDTs with an ALM on mannequins and cadavers, respectively.

METHODS

Procedures were completed by a single physician using an 8.0 mm ETT and the Ciaglia Blue Rhino method on simulation mannequins (TruCorp AirSim Traci) and fresh-frozen cadavers. Mannequin simulation tested the respiratory capabilities of an ALM utilizing a BioPac spirometer and a Maquet Servo ventilator. Qualitative analysis on device efficacy was performed on 2 fresh-frozen cadavers (1 male, 1 female).

RESULTS

Preliminary ventilation testing on a PDT-able mannequin using the ALM showed an increase in airflow reaching the lungs compared with a deflated ETT. During mannequin and cadaver testing, the ALM was placed over the in situ ETT effectively, thereby removing the bronchoscope from the ETT while maintaining a continuous visual of the incision site. Both mannequin and cadaveric testing using an ALM enabled a single physician to safely perform the PDT procedure with minimal assistance.

CONCLUSIONS

Initial testing using an ALM during PDT on mannequins and cadavers showed an improvement in airflow and the removal of the bronchoscope from the ETT, respectively. Further studies using the ALM in a patient population compared with standard techniques would be useful.

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.

Tracheostomy in the ICU

The placement of a tracheostomy has become a routine procedure for intensive care unit patients who are mechanical ventilator dependent for a period of time, usually exceeding 1 or 2 weeks. It is vital for the intensivist to be familiar with all aspects of tracheostomies care including the timing of converting a patient to a tracheostomy, types of procedure, risks and benefits, and issues of daily care including oral feedings, speech, and decannulation. In this article we provide a comprehensive review for the intensivist regarding tracheostomies in the intensive care setting. We specifically review indications, timing, surgical options including percutaneous dilation tracheostomy, complications, decannulation, oral feeding, speaking devises, stomal stents, and routine tracheostomy care.

Airway accidents in critical care unit: A 3-year retrospective study in a Public Teaching Hospital of Eastern India

Background:

Although tracheal tubes are essential devices to control and protect airway in a critical care unit (CCU), they are not free from complications.

Aims:

To document the incidence and nature of airway accidents in the CCU of a government teaching hospital in Eastern India.

Methods:

Retrospective analysis of all airway accidents in a 5-bedded (medical and surgical) CCU. The number, types, timing, and severity of airway accidents were analyzed.

Results:

The total accident rate was 19 in 233 intubated and/or tracheostomized patients over 1657 tube days (TDs) during 3 years. Fourteen occurred in 232 endotracheally intubated patients over 1075 endotracheal tube (ETT) days, and five occurred in 44 tracheostomized patients over 580 tracheostomy TDs. Fifteen accidents were due to blocked tubes. Rest four were unplanned extubations (UEs), all being accidental extubations. All blockages occurred during night shifts and all UEs during day shifts. Five accidents were mild, the rest moderate. No major accident led to cardiorespiratory arrest or death. All blockages occurred after 7^th day of intubation. The outcome of accidents were more favorable in tracheostomy group compared to ETT group (P = 0.001).

Conclusions:

The prevalence of airway accidents was 8.2 accidents per 100 patients. Blockages were the most common accidents followed by UEs. Ten out of the 15 blockages and all 4 UEs were in endotracheally intubated patients. Tracheostomized patients had 5 blockages and no UEs.

Difficulties in Management of a Sessile Subglottic Polyp

Benign laryngeal polyps are usually managed with micro-laryngeal surgery. Occasionally surgery becomes challenging because of size of the polyp or its location. Maintaining the anaesthesia and the airway becomes difficult either during immediate management or during excision. Upper airway obstruction still remains the major indication for tracheostomy in many centers. Nowadays Laryngeal tumour has become the main indication of tracheostomy. Conditions like infections, trauma, benign lesions and prolonged intubation were leading indications previously. Otolaryngologist has to decide a method, often on the spot. Here we are presenting such a case where emergency tracheostomy was the only choice.

An overview of complications associated with open and percutaneous tracheostomy procedures

Tracheostomy, whether open or percutaneous, is a commonly performed procedure and is intended to provide long-term surgical airway for patients who are dependent on mechanical ventilatory support or require (for various reasons) an alternative airway conduit. Due to its invasive and physiologically critical nature, tracheostomy placement can be associated with significant morbidity and even mortality. This article provides a comprehensive overview of commonly encountered complications that may occur during and after the tracheal airway placement, including both short- and long-term postoperative morbidity.

The impact of a multidisciplinary safety checklist on adverse procedural events during bedside bronchoscopy-guided percutaneous tracheostomy

BACKGROUND

Bedside procedures are seldom subject to the same safety precautions as operating room (OR) procedures. Since July 2013, we have performed a multidisciplinary checklist before all bedside bronchoscopy-guided percutaneous tracheostomy insertions (BPTIs). We hypothesized that the implementation of this checklist before BPTI would decrease adverse procedural events.

METHODS

A prospective study of all patients who underwent BPTI after checklist implementation (PostCL, 2013-2014, n = 63) at our Level I trauma center were compared to all patients (retrospectively reviewed historical controls) who underwent BPTI without the checklist (PreCL, 2010-2013, n = 184). Exclusion criteria included age less than 16 years, OR, and open tracheostomy. The checklist included both a procedural and timeout component with the trauma technician, respiratory therapist, nurse, and surgeon. Demographics and variables focusing on BPTI risk factors were compared. Variables associated with the primary end point, adverse procedural events, during univariate analysis were used in the multiple variable logistic regression model. A p ≤ 0.05 was significant.

RESULTS

Of 247 study sample patients, no difference existed in body mass index, baseline mean arterial pressure, duration or mode of mechanical ventilation, cervical spine or maxillofacial injury, or previous neck surgery between PreCL and PostCL BPTI patients. PreCL patients were younger (48 [20] years vs. 57 [21] years, p < 0.01) but more often had adverse procedural events compared with PostCL patients (PreCL,14.1% vs. PostCL,3.2%, p = 0.020). After adjusting for age, vitals, BPTI risk factors, and intensive care unit duration after BPTI, multiple variable logistic regression determined that performing the safety checklist alone was independently associated with a 580% reduction in adverse procedural events (odds ratio, 5.8; p = 0.022).

CONCLUSION

Our results suggest that the implementation of a multidisciplinary safety checklist similar to those used in the OR would benefit patients during invasive bedside procedures.

LEVEL OF EVIDENCE

Therapeutic/care management study, level IV.

Brazilian recommendations of mechanical ventilation 2013. Part I

Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumonia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.

Ultra percutaneous dilation tracheotomy vs mini open tracheotomy. A comparison of tracheal damage in fresh cadaver specimens

Background

To compare the ultra percutaneous dilation tracheostomy (PDT) and mini open techniques (MOT) in randomized fixed and fresh cadavers. Assess degrees of damage to tracheal cartilage and mucosa via tracheal lumen and external dissection.

Method

Comparative cadaver study was performed, tracheostomy was placed in 36 cadavers (16 fixed, 20 fresh) from July 2004 to December 2004, in University of Alberta, Canada. PDT (size 7) were placed by intensivist and MOT (size 7) otolaryngologist. Both fixed and fresh cadavers were randomized. Evaluation was done according to gender, ease of landmark, mucosal and cartilage injuries.

Results

Significant differences in mucosal injury (7 of 9 in UPDT VS 0 of 7 in MOT, p value 0.008), and cartilage injury (8 of 9 in UPDT VS 1 of 7 in MOT p value 0.012) were seen in fixed cadavers; and in fresh cadavers, mucosal injury (5 of 10 in UPDT VS 0 of 10 in MOT, p value 0.043), and cartilage injury (5 of 10 in UPDT VS 0 of 10 in MOT, p value 0.043).

Conclusions

PDT resulted in severe damage to mucosa and cartilage, that might contribute to subglottic stenosis preventing decannulation. Considering the injury, MOT has better outcome than UPDT.

Brazilian recommendations of mechanical ventilation 2013. Part I

Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.

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.

[Comparison of early and late percutaneous tracheotomies in adult intensive care unit]

BACKGROUND AND OBJECTIVES

Percutaneous tracheotomy has become a good alternative for patients thought to have prolonged intubation in intensive care units. The most important benefits of tracheotomy are early discharge of the patient from the intensive care unit and shortening of the time spent in the hospital. Prolonged endotracheal intubation has complications such as laryngeal damage, vocal cord paralysis, glottic and subglottic stenosis, infection and tracheal damage. The objective of our study was to evaluate potential advantages of early percutaneous tracheotomy over late percutaneous tracheotomy in intensive care unit.

METHODS

Percutaneous tracheotomies applied to 158 patients in adult intensive care unit have been analyzed retrospectively. Patients were divided into two groups as early and late tracheotomy according to their endotracheal intubation time before percutaneous tracheotomy. Tracheotomies at the 0-7th days of endotracheal intubation were grouped as early and after the 7th day of endotracheal intubation as late tracheotomies. Patients having infection at the site of tracheotomy, patients with difficult or potential difficult intubation, those under 18 years old, patients with positive end-expiratory pressure above 10cmH2O and those with bleeding diathesis or platelet count under 50,000dL(-1) were not included in the study. Durations of mechanical ventilation and intensive care stay were noted.

RESULTS

There was no statistical difference among the demographic data of the patients. Mechanical ventilation time and time spent in intensive care unit in the group with early tracheotomy was shorter and the difference was statistically significant (p<0.05).

CONCLUSION

Early tracheotomy shortens mechanical ventilation duration and intensive care unit stay. For that reason we suggest early tracheotomy in patients thought to have prolonged intubation.