Tracheostomy in the intensive care unit. Part 1: Indications, technique, management

Safety of Percutaneous Dilatational Tracheostomy in Critically Ill Adults With Obesity: A Retrospective Cohort Study

OBJECTIVE

This study aimed to assess the safety and efficacy of endoscopic percutaneous dilatational tracheostomy (PDT) in obese and nonobese critically ill adults.

METHODS

A retrospective study of all cases of PDT performed at two academic health centers between 2016 and 2023 was conducted. Primary outcomes included peri- and postoperative complications stratified by both timing and severity. body mass index (BMI) data were stratified according to the World Health Organization classification (class I obesity defined as BMI ≥ 30, class II obesity ≥35 and <40, class 3 obesity ≥40).

RESULTS

Totally 336 patients underwent a PDT, 279 of whom had available BMI data: 193 (69.2%) patients had a normal BMI, 56 (20.1%) had class I obesity, 15 (5.4%) class II obesity, and 15 (5.4%) class III obesity. The overall complication rates for the class I, II, and III obesity were 8.9%, 13.3%, and 13.3%, respectively. All procedures were successfully completed at the bedside (no conversions to an open approach), and there was no procedure-related mortality. The only accidental decannulation event was in a patient with class III obesity. There was no difference in overall complication rates between patients without obesity and patients with obesity (7.3% vs. 10.5%, respectively, p = 0.370).

CONCLUSION

This study significantly expands the current literature and represents one of the largest studies to date reporting on PDT in patients with obesity.

LEVEL OF EVIDENCE

3 Laryngoscope, 2024.

An Unusual Cause of Failed Tracheal Decannulation—A Case Report

Failure of decannulation may occur due to unexpected upper airway problems. However, the presence of a membrane in between the vocal cords is usually rare. We report a case of a 46-year-old female, who presented with focal seizures and progressed to status epilepticus. She was put on a mechanical ventilator because of hypoxic arrest. As she required prolonged ventilatory support, tracheostomy and gradual weaning from ventilator support to T-piece was done. Following stable hemodynamics, decannulation trial was attempted which failed. Subsequently, bronchoscopy was done to assess the upper airway. It revealed a thick membrane in between the vocal cords. Further examination with an indirect laryngoscope under general anesthesia confirmed the findings, and the membrance was excised. Decannulation was successful the very following day and the patient was discharged with stable hemodynamics.

Preserving the thyroidal isthmus during low tracheostomy with creation of a Björk flap

OBJECTIVES/HYPOTHESIS

Surgical tracheostomy (ST) with creation of an inferiorly based U-shaped tracheal flap, known as the Björk flap, is the most commonly performed. The purpose of this study was to evaluate whether outcome was different in patients who underwent low ST with retraction and preservation of the thyroid isthmus compared to those who underwent high ST with ligation of the thyroid isthmus.

STUDY DESIGN

Retrospective cohort study.

METHODS

We included 1,143 patients who underwent ST with creation of a Björk flap between 2008 and 2015. Different outcome parameters, including complications, decannulation, inpatient mortality, and surgical characteristics, such as length of surgery and height of tracheal incision, were assessed comparing low and high ST.

RESULTS

Complications occurred in 7.7% of patients, of which persistent stoma (4.1%) and hemorrhages (2.7%) were the most common. Low tracheostomy with retraction and preservation of thyroid isthmus was done in 31.4% of cases. Complications did not significantly differ between low and high tracheostomies (8.0% vs. 7.0%, P = .468). Moreover, decannulation rate and inpatient mortality were also not significantly different in low compared to high tracheostomies (P = .816 and P = .152, respectively). However, low tracheostomies were associated with significantly shorter operation times (33.0 ± 0.8 min vs. 38.7 ± 0.5 min, P < .001) and lower tracheal incisions for creation of a Björk flap (P < .001) compared to high tracheostomies.

CONCLUSIONS

Low tracheostomies are as safe as high tracheostomies regarding complications. Due to the fact that low tracheostomies are associated with shorter operation times and lower tracheal incisions, we recommend performong low tracheostomies whenever feasible.

LEVEL OF EVIDENCE

4 Laryngoscope, 128:2783-2789, 2018.

Early vs. late tracheostomy in intensive care settings: Impact on ICU and hospital costs

INTRODUCTION

Up to 12% of the 800,000 patients who undergo mechanical ventilation in the United States every year require tracheostomies. A recent systematic review showed that early tracheostomy was associated with better outcomes: more ventilator-free days, shorter ICU stays, less sedation and reduced long-term mortality. However, the financial impact of early tracheostomies remain unknown.

OBJECTIVES

To conduct a cost-analysis on the timing of tracheostomy in mechanically ventilated patients.

METHODS

We extracted individual length of hospital stay and length of ICU stay data from the studies included in the systematic review from Hosokawa et al. We also searched for any recent randomized control trials on the topic that were published after this review. The weighted length of stay was estimated using a random effects model. Average daily hospital and ICU costs per patients were obtained from a cost study by Kahn et al. We estimated hospital and ICU costs by multiplying LOS with respective average daily cost per patient. We calculated difference in costs by subtracting hospital costs, ICU costs and total direct variable costs from early tracheotomy to late tracheotomy. 95% confidence intervals were estimated using bootstrap re-sampling procedures with 1000 iterations.

RESULTS

The average weighted cost of ICU stay in patients with an early tracheostomy was $4316 less when compared to patients with late tracheostomy (95% CI: 403-8229). Subgroup analysis revealed that very early tracheostomies (<4days) cost on average $3672 USD less than late tracheostomies (95% CI: -1309, 10,294) and that early tracheostomies (<10days but >4) cost on average $6385 USD less than late tracheostomies (95% CI: -4396-17,165).

CONCLUSION

This study shows that early tracheostomy can significantly reduce direct variable and likely total hospital costs in the intensive care unit based on length of stay alone. This is in addition to the already shown benefits of early tracheostomy in terms of ventilator dependent days, reduced length of stays, decreased pain, and improved communication. Further prospective studies on this topic are needed to prove the cost-effectiveness of early tracheostomy in the critically ill population.

[The iatrogenic complications of tracheostomy]

The objective of the present study was to analyze the complications of tracheostomy associated with bleeding from the brachiocephalic trunk. A total of 13 protocols of the autopsy study of the patients who had died in the intensive care unit were available for the analysis. These patients had experienced heavy external bleeding from the tracheostomy defect shortly before death. The study has demonstrated that all the victims had the tracheostomy hole localized below the level of the standard dissection of the tracheal rings. Nine patients presented with a damage to the brachiocephalic trunk while four others had a pressure injury to the blood vessels. The study included the elucidation of the possible relationship between the anthropometric characteristics of the patients and the variability of the passage of the brachiocephalic trunk in front of the trachea. The length of the neck was found to usually correlate with the length of the body and the brachiocephalic trunk to run in front of the trachea at the level of its 8th-11th rings. The results of the present study may be instrumental in reducing the risk of complications after tracheostomy.

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.

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.

Timing of tracheotomy in ICU patients: a systematic review of randomized controlled trials

Introduction

The optimal timing of tracheotomy in critically ill patients remains a topic of debate. We performed a systematic review to clarify the potential benefits of early versus late tracheotomy.

Methods

We searched PubMed and CENTRAL for randomized controlled trials that compared outcomes in patients managed with early and late tracheotomy. A random-effects meta-analysis, combining data from three a priori-defined categories of timing of tracheotomy (within 4 versus after 10 days, within 4 versus after 5 days, within 10 versus after 10 days), was performed to estimate the weighted mean difference (WMD) or odds ratio (OR).

Results

Of the 142 studies identified in the search, 12, including a total of 2,689 patients, met the inclusion criteria. The tracheotomy rate was significantly higher with early than with late tracheotomy (87 % versus 53 %, OR 16.1 (5.7-45.7); p <0.01). Early tracheotomy was associated with more ventilator-free days (WMD 2.12 (0.94, 3.30), p <0.01), a shorter ICU stay (WMD -5.14 (-9.99, -0.28), p = 0.04), a shorter duration of sedation (WMD -5.07 (-10.03, -0.10), p <0.05) and reduced long-term mortality (OR 0.83 (0.69-0.99), p = 0.04) than late tracheotomy.

Conclusions

This updated meta-analysis reveals that early tracheotomy is associated with higher tracheotomy rates and better outcomes, including more ventilator-free days, shorter ICU stays, less sedation, and reduced long-term mortality, compared to late tracheotomy.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-1138-8) contains supplementary material, which is available to authorized users.

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.

Surgical tracheotomy performed with and without dual antiplatelet therapy

Some patients who need dual antiplatelet therapy sometimes require tracheotomy. Aim of this study was to compare the rate of complications during and after surgical tracheotomy between patients requiring dual antiplatelet therapy and those without dual antiplatelet therapy. We retrospectively included 79 patients (62% men, mean age 64 ± 14 years) in the period 2007-2011. The following complications were analyzed: need for surgical revision within 24 hours after tracheotomy, need for bronchoscopy within 24 hour after tracheotomy, need for blood transfusion within 24 hours after tracheotomy, death attributed to tracheotomy and any complication attributed to tracheotomy. We compared patients where tracheotomy was performed while receiving dual antiplatelet therapy (n=27, 34%) to patients where tracheotomy was performed without dual antiplatelet therapy (n=52, 66%). Nonsignificant differences between the two groups were observed general characteristics. There were no statistically significant differences in complications after tracheotomy (surgical revision after tracheotomy p=0.63, bronchoscopy after tracheotomy p=0.74, blood transfusion after tracheotomy p=0.59, death attributed to tracheotomy p=1.00 and any complication attributed to tracheotomy p=1.00). The study shows that tracheotomy is safe in cardiac patients on dual antiplatelet therapy.

Tracheostomy timing in traumatic brain injury: a propensity-matched cohort study

BACKGROUND

The optimal timing of tracheostomy in patients with severe traumatic brain injury (TBI) is controversial; observational studies have been challenged through confounding by indication, and interventional studies have rarely enrolled patients with isolated TBI.

METHODS

We included a cohort of adults with isolated TBI who underwent tracheostomy within 1 of 135 participating centers in the American College of Surgeons' Trauma Quality Improvement Program, during 2009 to 2011. Patients were classified as having undergone early tracheostomy (ET, ≤8 days) versus late tracheostomy (>8 days). Outcomes were compared between propensity score-matched groups to reduce confounding by indication. In sensitivity analyses, we used time-dependent proportional hazard regression to address immortal time bias and assessed the association between hospital ET rate and patients' outcome at the hospital level.

RESULTS

From 1,811 patients, a well-balanced propensity-matched cohort of 1,154 patients was defined. After matching, ET was associated with fewer mechanical ventilation days (median, 10 days vs. 16 days; rate ratio [RR], 0.70; 95% confidence interval [CI], 0.66-0.75), shorter intensive care unit stay (median, 13 days vs. 19 days; RR, 0.70; 95% CI, 0.66-0.75), shorter hospital length of stay (median, 20 days vs. 27 days; RR, 0.80; 95% CI, 0.74-0.86), and lower odds of pneumonia (41.7% vs. 52.7%; odds ratio [OR], 0.64; 95% CI, 0.51-0.80), deep venous thrombosis (8.2% vs. 14.4%; OR, 0.53; 95% CI, 0.37-0.78), and decubitus ulcer (4.0% vs. 8.9%; OR, 0.43; 95% CI, 0.26-0.71) but no significant difference in pulmonary embolism (1.8% vs. 3.3%; OR, 0.52; 95% CI, 0.24-1.10). Hospital mortality was similar between both groups (8.4% vs. 6.8%; OR, 1.25; 95% CI, 0.80-1.96). Results were consistent using several alternate analytic methods.

CONCLUSION

In this observational study, ET was associated with a shorter duration of mechanical ventilation, intensive care unit stay, and hospital stay but not hospital mortality. ET may represent a mechanism to reduce in-hospital morbidity for patients with TBI.

LEVEL OF EVIDENCE

Therapeutic study, level II.

Correction of subclinical coagulation disorders before percutaneous dilatational tracheotomy

BACKGROUND

There is evidence that percutaneous dilatational tracheotomy (PDT) can be safely performed in patients with severe coagulation disorders if these are carefully corrected immediately before the procedure. However, it is currently unclear whether PDT can be performed safely in patients in an Intensive Care Unit (ICU) with uncorrected mild coagulation disorders.

MATERIALS AND METHODS

In a randomised controlled trial we determined the effect of correction of mild coagulation disorders on bleeding during and after PDT. ICU patients planned for bedside PDT with: (i) a prothrombin time (PT) between 14.7-20.0 seconds, (ii) a platelet count between 40-100×10(9)/L and/or (iii) active treatment with acetylsalicylic acid were randomised to receive infusion with fresh-frozen plasma (FFP) and/or platelets ("correction") versus no transfusion ("no correction") before PDT.

RESULTS

We randomised 35 patients to the "correction" group and 37 patients to the "no correction" group. In patients who received FFP, the decrease in PT was marginal (mean decrease 0.40±0.56 seconds); the median increase in platelet counts after transfusion of platelets was 35 [11-47]x10(9)/L. The median blood loss was 3 [IQR: 1-6] grams in the "correction" group and 3 [IQR: 2-6] grams in the "no correction" group (P=0.96).

DISCUSSION

Bleeding during and after bedside PDT in ICU patients with mild coagulation disorders is rare in our setting. Correction of subclinical coagulation disorders by transfusion of FFP and/or platelets does not affect bleeding.

Retrospective study of tracheostomy indications and perioperative complications on oral and maxillofacial surgery service

PURPOSE

Tracheostomy is an extremely common procedure performed by a variety of surgical specialties. The purpose of the present study was to review the intraoperative and perioperative management and complications, present our surgical technique, and discuss the role of our service in providing this care within a large community hospital setting.

PATIENTS AND METHODS

The 112 patients in our retrospective study were divided into 3 subsets: those referred by medical specialties, tumor/reconstructive surgery patients, and trauma victims. Cases of percutaneous dilational and intensive care unit bedside tracheostomy were excluded. Intraoperative and immediately postoperative complications were included. Bleeding complications were defined as those necessitating a return to the operating room. The patients were followed up for a 24-hour period postoperatively.

RESULTS

The medical referral, tumor/reconstructive, and trauma patients made up 55%, 29%, and 16% of the included patients, respectively. The overall complication rate was 2.7%.

CONCLUSIONS

Conventional open tracheostomy in an operating room is associated with a low complication rate. The low incidence of perioperative bleeding can be attributed to the use of electrocautery in the division of the thyroid isthmus. This service provided an exceedingly safe and efficient surgical treatment by focusing on precise surgical protocols in an operating room setting. Intense coordination of consultation response, operating room scheduling, and communication with other services involved in these patients' care is critical to develop and maintain the privilege to provide this treatment. Our report can be used to educate the medical community regarding the role of an oral and maxillofacial surgery service in providing tracheostomy.

Clinical review of adult tracheostomy

Tracheostomy is a surgical procedure which is increasingly being performed in the intensive care unit (ICU) rather than the operating room (Griffiths et al 2005, Delaney et al 2006). Procedural knowledge including postoperative care is essential for ENT surgeons and ICU practitioners alike. Our article aims to highlight the operative technique, surgical complications and various types of tracheostomy tubes available, including their management.

Clinically correlated anatomical basis of cricothyrotomy and tracheostomy

OBJECTIVE

Cricothyrotomy and tracheostomy are performed by physicians in various disciplines. It is important to know the comprehensive anatomy of the laryngotracheal region. Hemorrhage, esophageal injury, recurrent laryngeal nerve injury, pneumothorax, hemothorax, false passage of the tube and tracheal stenosis after decannulation are well known complications of the cricothyrotomy and tracheostomy. Cricothyrotomy and tracheostomy should be performed without complications and as quickly as possible with regards the patients' clinical condition.

METHODS

A total of 40 cadaver necks were dissected in this study. The trachea and larynx and the relationship between the trachea and larynx and the surrounding structures was investigated. The tracheal cartilages and annular ligaments were counted and the relationship between tracheal cartilages and the thyroid gland and vascular structures was investigated. We performed cricothyrotomy and tracheostomy in eleven cadavers while simulating intensive care unit conditions to determine the duration of those procedures.

RESULTS

There were 11 tracheal cartilages and 10 annular ligaments between the cricoid cartilage and sternal notch. The average length of trachea between the cricoid cartilage and the suprasternal notch was 6.9 to 8.2 cm. The cricothyroid muscle and cricothyroid ligament were observed and dissected and no vital anatomic structure detected. The average length and width of the cricothyroid ligament was 8 to 12 mm and 8 to 10 mm, respectively. There was a statistically significant difference between the surgical time required for cricothyrotomy and tracheostomy (p < 0.0001).

CONCLUSION

Tracheostomy and cricothyrotomy have a low complication rate if the person performing the procedure has thorough knowledge of the neck anatomy. The choice of tracheostomy or cricothyrotomy to establish an airway depends on the patients' clinical condition, for instance; cricothyrotomy should be preferred in patients with cervicothoracal injury or dislocation who suffer from respiratory dysfunction. Furthermore; if a patient is under risk of hypoxia or anoxia due to a difficult airway, cricothyrotomy should be preferred rather than tracheostomy.

The incidence and microbial spectrum of ventilator-associated pneumonia after tracheotomy in a selective decontamination of the digestive tract-setting

OBJECTIVES

Tracheotomy is considered to be an independent risk factor for ventilator-associated pneumonia (VAP). Antimicrobial prophylaxis, in particular with coverage of Pseudomonas aeruginosa, is presently advocated. Selective decontamination of the digestive tract (SDD) aims to prevent VAP in critically ill patients, including those after tracheotomy. We determined the incidence and microbial spectrum of VAP after tracheotomy in a SDD-setting.

METHODS

Retrospective analysis of 231 tracheotomized patients during a 2-year period.

RESULTS

Thirteen patients (5.6%) developed VAP. The median [IQR] day of onset was 8.0 [3.0-10.5] days after tracheotomy. The most predominant causative pathogen was Methicillin-sensitive Staphylococcus aureus (MSSA). Timing of tracheotomy was not different between patients developing VAP and those who did not. The type of tracheotomy (percutaneous or surgical, 84.6% versus 15.4%) had no significant influence on the incidence of VAP.

CONCLUSIONS

The incidence of VAP after tracheotomy in a SDD-setting is low, with MSSA as the predominant causative pathogen. Accordingly, if antimicrobial prophylaxis is considered, it may be advisable to cover MSSA in an SDD-setting.

Repeat percutaneous tracheostomy in the neurocritically ill patient

INTRODUCTION

Percutaneous tracheostomy is a widely used and accepted method for long-term mechanical ventilation and airway protection. Neurocritically ill patients sometimes require repeat tracheostomy, which is traditionally considered a relative contraindication for percutaneous procedure. The aim of this study was to determine the safety of repeat percutaneous tracheostomy in neurocritically ill patients with a history of previous tracheostomy.

METHODS

In the 16-bed academic neurointensive care unit, we prospectively enrolled patients who needed new tracheostomy placement for airway protection or prolonged mechanical ventilation and had previously undergone percutaneous tracheostomy placement. We collected data on indications, procedure, periprocedural complications, and outcome of repeated tracheostomy.

RESULTS

Between January 2001 and October 2005, we enrolled 12 consecutive patients (mean age 35.4 +/- 7.0 years) who underwent repeat percutaneous tracheostomy. Head injury was the most common underlying diagnosis (seven patients, 58%). Tracheostomy tube placement was easy and successful in all patients, and none of the patients needed conversion to surgical tracheostomy. In three patients, ultrasound-guided needle aspiration was used before the procedure to confirm the position of the trachea. No patients died or experienced serious complication related to the procedure. Two patients (17%) had a minor periprocedural bleeding, which was controlled with local compression. Long-term outcome was poor, with only two patients alive and off the ventilator at hospital discharge, both with serious disability.

CONCLUSION

Repeat percutaneous tracheostomy can be performed safely in neurocritically ill patients who have undergone previous tracheostomy.

A comparative study of the complications of surgical tracheostomy in morbidly obese critically ill patients

INTRODUCTION

There is little objective comparative information about the postoperative complications of tracheostomy in morbidly obese patients. The aim of this study was to determine the incidence and severity of complications associated with open tracheostomy in critically ill morbidly obese patients during hospitalization.

METHODS

During a six year period, all consecutive morbidly obese patients (body mass index [BMI] of greater than or equal to 40 kg/m2) who underwent an elective open tracheostomy were compared to a control group (BMI of less than 40 kg/m2) of the same institution. Variables examined included age, gender, BMI, Charlson index, and reasons for tracheostomy. All postoperative tracheotomy-related complications that occurred during hospitalization, including death, were recorded.

RESULTS

A tracheostomy was performed in 89 morbidly obese patients out of 427 critically ill patients. A total of 27 complications were recorded in 22 morbidly obese patients (25%) compared to 65 complications in 49 patients (14%) of the control group (p = 0.03). The majority of these complications were minor in origin. Overall, nine serious events were responsible for two deaths in the morbidly obese compared to seven cases and two deaths in the control group (p = 0.001). Life-threatening complications were attributed to tube obstruction and malpositioning of the tracheostomy after being dislodged. In multivariate analysis, morbid obesity (odds ratio 4.4, 95% confidence interval 2.1 to 11.7) was independently associated with increased risk of tracheostomy-related complications.

CONCLUSION

In the present series, morbid obesity is associated with increased frequency and life-threatening complications from conventional tracheostomy. Special techniques and operative policies must be applied to overcome loss of airway control.

Mobilizing the patient in the intensive care unit: the role of early tracheotomy

A large number of studies have evaluated the benefits of early tracheotomy. Heterogeneity in the various studies reviewed in this article is apparent, with early tracheotomy ranging from one to several days, and benefits regarding incidence of pneumonia and mortality are variable. An additional factor likely contributing to the differing results relates to the varied patient populations in the individual studies, which ranged from burn patients to medical ICU patients to trauma patients and head trauma patients. A close look at the studies with the least confounding variables suggests that early tracheotomy has some merit. Most studies suggest that time in the ICU, on mechanical ventilation, and in the hospital is reduced.

Prevention measures for ventilator-associated pneumonia: a new focus on the endotracheal tube

PURPOSE OF REVIEW

The aim of this article is to analyze the aspects related to the endotracheal tube which may influence the development of ventilator-associated pneumonia and to review the possible measures of prevention.

RECENT FINDINGS

The endotracheal tube participates in the pathogenesis of ventilator-associated pneumonia by the elimination of natural defense mechanisms, thereby allowing the entry of bacteria by the aspiration of subglottic secretions or the formation of biofilm on the endotracheal tube. The preventive measures of ventilator-associated pneumonia related to the endotracheal tube include these two mechanisms. It has been suggested that substitution of the endotracheal tube by early tracheostomy may reduce the risk of ventilator-associated pneumonia.

SUMMARY

Aspiration of the subglottic secretions seems to be an effective measure with little risk; decontamination or exhaustive control of the sealing of the cuff has not demonstrated a positive risk/benefit balance. The causal relationship between biofilm and ventilator-associated pneumonia has not been clearly established. Treatment of the biofilm with antibiotics, changes in the composition of the endotracheal tube or mechanical cleansing have achieved a reduction or elimination of the biofilm but their effect on the incidence of ventilator-associated pneumonia has not been studied. The benefit of early tracheostomy in reducing ventilator-associated pneumonia is still controversial.

Endoscopic percutaneous dilatational tracheotomy: a prospective evaluation of 500 consecutive cases

OBJECTIVES/HYPOTHESIS

An evaluation of 500 adult, intubated, intensive care unit patients undergoing endoscopic percutaneous tracheotomy using the multiple and single dilator techniques was conducted to assess the feasibility and safety of the procedure as it compares with surgical tracheotomy. Endoscopy was used in all cases and evaluated as an added safety measure in reducing complications.

STUDY DESIGN

A prospective evaluation of endoscopic percutaneous dilatational tracheotomy in 500 consecutive adult, intubated intensive care unit patients.

METHODS

Between 1990 and 2003, endoscopically guided percutaneous dilatational tracheotomy (PDT) was performed in 500 consecutive adult, intubated patients in the intensive care units (ICU) of three tertiary care adult hospitals. The first 191 patients underwent PDT using the Ciaglia Percutaneous Tracheostomy Introducer Kit (Cook Critical Care Inc., Bloomington, Indiana) and in the remaining 309 patients the Ciaglia Blue Rhino Single Dilator Kit (Cook Critical Care Inc., Bloomington, Indiana) was used. The procedure was contraindicated in the following situations: 1) children, 2) unprotected airway, 3) emergencies, 4) presence of a midline neck mass, 5) inability to palpate the cricoid cartilage, and 6) uncorrectable coagulopathy. The following parameters were recorded preoperatively: age, sex, diagnosis, American Society of Anesthesia (ASA) class, body mass index (BMI), and number of days intubated. Recorded hematologic parameters included hemoglobin (Hgb), platelets, prothrombin time (PT), partial thromboplastin time (PTT), and the international normalized ratio (INR) since it became available in 1998. All patients were ventilated on 100% oxygen and vital signs were continuously monitored. Tracheotomy was carried out under continuous endoscopic guidance using a series of graduated dilators in the first 191 cases, and a single, tapered dilator in the remaining 309 patients. The preoperative data on each patient, along with the type of dilator used, the size of the tube, the intraoperative and postoperative complications, and blood loss information were recorded prospectively and maintained in a computer spreadsheet. Univariate analyses were used in each group separately for each type of dilator to assess the risks of a complication within subgroups defined by each parameter/characteristic, and the statistical significance assessed with a chi test, or Fisher exact test.

RESULTS

The total complication rate was 9.2% (13.6% in the multiple dilator group, and 6.5% in the single dilator group), with more than half of these considered minor. Overall, the two most common complications were oxygen desaturation in 14 cases and bleeding in 12 cases. The absence of serious complications such as pneumothorax and pneumomediastinum are attributable to the use of bronchoscopy. There was no significant association between the rate of complications and age, gender, ASA, weeks intubated, tracheostomy tube size, Hgb levels, platelets, PT, PTT, or INR. There was a statistically significant relationship between experience and the likelihood of complications in the multiple dilator group (P < .0001), with a higher rate of complications in the first 30 patients (40%) compared with 8.7% in the remaining 161 patients. This relationship did not exist for the first 30 patients in the single dilator group. Patients with a BMI of 30 or higher experienced a significantly greater (P < .05) number of complications (15%), compared with an 8% complication rate in patients with a BMI of less than 30. This risk was even more significant for patients with a BMI of 30 or greater who were also in ASA class 4 (11/56 or 20%) (P < .02).

CONCLUSIONS

Endoscopic PDT is associated with a low complication rate and is at least as safe as surgical tracheotomy in the ICU setting. Bronchoscopy significantly decreases the incidence of complications and should be used routinely. While embraced by critical care physicians, endoscopic PDT has been infrequently performed by otolaryngologists. As the airway experts, otolaryngologists are in the best position to learn and teach the procedure as it should be done.

Early tracheostomy for primary airway management in the surgical critical care setting

During a 12-month period, 264 patients with multiple injuries who required mechanical ventilation were admitted to the surgical intensive care unit. One hundred twenty patients (46%) were disengaged from the ventilator, and 38 patients (14%) died. Of the remaining 106 patients (40%) 51 patients (group I) were to receive tracheostomy within 1 to 7 days, and 55 patients (group II) underwent late (8 or more days after admission) tracheostomy. Multiple variables in four categories (admission, operative, ventilatory, and outcome) were analyzed prospectively to define the impact that early tracheostomy had on duration of mechanical ventilation, intensive care stay, and hospital stay. Morbidity and mortality rates of the procedures were assessed. Early tracheostomy, in a homogeneous group of critically ill patients, is associated with a significant decrease in duration of mechanical ventilation, as well as shorter intensive care unit and hospital stays, compared with translaryngeal endotracheal intubation. There were no deaths attributable to tracheostomy, and overall morbidity of the procedures was 4%. We conclude that early tracheostomy has an overall risk equivalent to that of endotracheal intubation. Furthermore, early tracheostomy shortens days on the ventilator and intensive care unit and hospital days and should be considered for patients in the intensive care unit at risk for more than 7 days of intubation. (Surgery 1990;108:655–9.)

Timing of tracheostomy as a determinant of weaning success in critically ill patients: a retrospective study

Introduction

Tracheostomy is frequently performed in critically ill patients for prolonged intubation. However, the optimal timing of tracheostomy, and its impact on weaning from mechanical ventilation and outcomes in critically ill patients who require mechanical ventilation remain controversial.

Methods

The medical records of patients who underwent tracheostomy in the medical intensive care unit (ICU) of a tertiary medical centre from July 1998 to June 2001 were reviewed. Clinical characteristics, length of stay in the ICU, rates of post-tracheostomy pneumonia, weaning from mechanical ventilation and mortality rates were analyzed.

Results

A total of 163 patients (93 men and 70 women) were included; their mean age was 70 years. Patients were classified into two groups: successful weaning (n = 78) and failure to wean (n = 85). Shorter intubation periods (P = 0.02), length of ICU stay (P = 0.001) and post-tracheostomy ICU stay (P = 0.005) were noted in patients in the successful weaning group. Patients who underwent tracheostomy more than 3 weeks after intubation had higher ICU mortality rates and rates of weaning failure. The length of intubation correlated with the length of ICU stay in the successful weaning group (r = 0.70; P < 0.001). Multivariate analysis revealed that tracheostomy after 3 weeks of intubation, poor oxygenation before tracheostomy (arterial oxygen tension/fractional inspired oxygen ratio <250) and occurrence of nosocomial pneumonia after tracheostomy were independent predictors of weaning failure.

Conclusion

The study suggests that tracheostomy after 21 days of intubation is associated with a higher rate of failure to wean from mechanical ventilation, longer ICU stay and higher ICU mortality.

A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients

OBJECTIVE

The timing of tracheotomy in patients requiring mechanical ventilation is unknown. The effects of early percutaneous dilational tracheotomy compared with delayed tracheotomy in critically ill medical patients needing prolonged mechanical ventilation were assessed.

DESIGN

Prospective, randomized study.

SETTING

Medical intensive care units.

PATIENTS

One hundred and twenty patients projected to need ventilation >14 days.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were prospectively randomized to either early percutaneous tracheotomy within 48 hrs or delayed tracheotomy at days 14-16. Time in the intensive care unit and on mechanical ventilation and the cumulative frequency of pneumonia, mortality, and accidental extubation were documented. The airway was assessed for oral, labial, laryngeal, and tracheal damage. Early group showed significantly less mortality (31.7% vs. 61.7%), pneumonia (5% vs. 25%), and accidental extubations compared with the prolonged translaryngeal group (0 vs. 6). The early tracheotomy group spent less time in the intensive care unit (4.8 +/- 1.4 vs. 16.2 +/- 3.8 days) and on mechanical ventilation (7.6 +/- 2.0 vs. 17.4 +/- 5.3 days). There was also significantly more damage to mouth and larynx in the prolonged translaryngeal intubation group.

CONCLUSIONS

This study demonstrates that the benefits of early tracheotomy outweigh the risks of prolonged translaryngeal intubation. It gives credence to the practice of subjecting this group of critically ill medical patients to early tracheotomy rather than delayed tracheotomy.

Early Tracheostomy versus Prolonged Endotracheal Intubation in Severe Head Injury

BACKGROUND

To see if early tracheostomy (fifth day) reduces duration of mechanical ventilation, ICU stay, incidence of pneumonia and mortality in comparison with prolonged intubation (PI) in patients with head injury.

METHODS

Patients were prospectively included in this study if they met the following criteria: isolated head injury, Glasgow coma scale (GCS) score < or =8 on first and fifth day, with cerebral contusion on CT scan. On the fifth day, randomization was done in two groups: early tracheostomy group (T group, n = 31) and prolonged endotracheal intubation group (I group, n = 31). We evaluated total time of mechanical ventilation, ICU stay, pneumonia incidence and mortality. Complications related to each technique were noted. Analysis of data were performed using Yates and Kruskall Walis tests. p < 0.05 was considered significant.

RESULTS

The two groups were comparable in term of age, sex, and Simplified Acute Physiologic Score (SAPS). The mean time of mechanical ventilatory support was shorter in T group (14.5 +/- 7.3) versus I group (17.5 +/- 10.6) (p = 0.02). After pneumonia was diagnosed, mechanical ventilatory time was 6 +/- 4.7 days for ET group versus 11.7 +/- 6.7 days for PEI group (p = 0.01). There was no difference in frequency of pneumonia or mortality between the two groups.

CONCLUSION

In severe head injury early tracheostomy decreases total days of mechanical ventilation or mechanical ventilation time after development of pneumonia.

Immediate post-operative effects of tracheotomy on respiratory function during mechanical ventilation

INTRODUCTION

Tracheotomy is widely performed in the intensive care unit after long-term oral intubation. The present study investigates the immediate influence of tracheotomy on respiratory mechanics and blood gases during mechanical ventilation.

METHODS

Tracheotomy was performed in 32 orally intubated patients for 10.5 +/- 4.66 days (all results are means +/- standard deviations). Airway pressure, flow and arterial blood gases were recorded immediately before tracheotomy and half an hour afterwards. Respiratory system elastance (Ers), resistance (Rrs) and end-expiratory pressure (EEP) were evaluated by multiple linear regression. Respiratory system reactance (Xrs), impedance (Zrs) and phase angle (phirs) were calculated from Ers and Rrs. Comparisons of the mechanical parameters, blood gases and pH were performed with the aid of the Wilcoxon signed-rank test (P = 0.05).

RESULTS

Ers increased (7 +/- 11.3%, P = 0.001), whereas Rrs (-16 +/- 18.4%, P = 0.0003), Xrs (-6 +/- 11.6%, P = 0.006) and phi rs (-14.3 +/- 16.8%, P = <0.001) decreased immediately after tracheotomy. EEP, Zrs, blood gases and pH did not change significantly.

CONCLUSION

Lower Rrs but also higher Ers were noted immediately after tracheotomy. The net effect is a non-significant change in the overall Rrs (impedance) and the effectiveness of respiratory function. The extra dose of anaesthetics (beyond that used for sedation at the beginning of the procedure) or a higher FiO2 (fraction of inspired oxygen) during tracheotomy or aspiration could be related to the immediate elastance increase.

Removal of the tracheostomy tube in the aspirating spinal cord-injured patient

STUDY DESIGN

Four related case reports, occurring within a 10-month time frame during 2001.

OBJECTIVES

Aspiration is commonly reported in the literature as a contraindication to decannulation. We report four examples of successful removal of the tracheostomy tube in the presence of aspiration by an experienced team, utilising a risk management approach.

SETTING

Victorian Spinal Cord Service (VSCS), Austin Hospital, Melbourne, Australia.

METHODS

Four individuals in our unit with traumatic spinal cord injury, three quadriplegic and one paraplegic, presented with aspiration identified by a positive modified Evan's blue dye test or constant coughing, gagging and oxygen desaturation during cuff deflation trials. In three of the four cases, the tracheostomy tube had been in situ for a prolonged period and the patients had failed to progress towards decannulation. A decision was made to decannulate these four patients in spite of the presence of traditionally held contraindications for decannulation. The multidisciplinary team carefully compared the inherent risks of premature decannulation against those of prolonged tracheostomisation. Given the risk associated with this procedure, a closely monitored decannulation protocol was instituted.

RESULTS

All four patients were successfully decannulated with improved quality of life, eating between 1 and 4 days and communicating immediately after decannulation. None experienced respiratory deterioration.

CONCLUSION

It is possible to safely decannulate aspirating spinal cord injured individuals in some instances, using a risk management approach.

Tracheotomy: timing and techniques

PURPOSE OF REVIEW

Until the past 40 years, the timing of tracheotomy was of little concern. It was an emergency procedure developed for the relief of airway obstruction. Following the development of positive pressure ventilation, tracheotomy became an elective procedure. Today, the optimal time for tracheotomy is a subject of dispute and continued investigation. As this operation has become one of the most commonly performed procedures in the intensive care unit, nonoperative dilational methods have gained acceptability. The purpose of this review is to analyze the recent literature and draw insight into the timing and technique of the current state of tracheotomy.

RECENT FINDINGS

Individualized assessment of patients should guide the timing of tracheotomy, with a preference toward early tracheotomy. Percutaneous dilational tracheotomy (PDT) can be performed with equivalent safety to open tracheotomy. Bedside open tracheotomy negates the cost-saving benefits of PDT. Endoscopic guidance in PDT decreases complications with needle placement and posterior tracheal wall injury. Major complications of PDT usually are associated with displacement of the tracheotomy tube.

SUMMARY

Tracheotomy indications have remained unchanged, but the timing of the procedure has advanced to individualized assessment with a predilection for earlier tracheotomy. The traditional operative technique is a much safer procedure today. Percutaneous dilational tracheotomy has become an acceptable alternative with proper patient selection. A multidisciplinary team with a surgeon provides the best care for the patient undergoing percutaneous tracheotomy.

Techniques of surgical tracheostomy

Tracheostomy has become one of the most commonly performed procedures in the critically ill patient. Variations in technique and expertise have led to a wide range of reported procedural related morbidity and rarely mortality. The lack of prospective, controlled trials, physician bias and patient comorbidities further confound the decisions regarding the timing of tracheostomy. With careful attention to anatomy and technique, the operative complication rate should be less than 1%. In such a setting, the risk-benefit ratio of prolonged translaryngeal intubation versus tracheostomy begins to weight heavily in favor of surgical tracheostomy. At exactly what point this occurs remains undefined, but certainly by the tenth day of intubation, if extubation is not imminent, arrangements should be made for surgical tracheostomy by a team experienced with the chosen technique.

Long-term complications of artificial airways

In summary, long-term complications of artificial airways are rare but important sequelae of artificial airways. Many of the potential long-term complications of translaryngeal intubation and tracheotomy are similar and overlapping. Although most patients who undergo these procedures tend to tolerate them without difficulties, significant morbidity and mortality may occur. Identifying the exact cause of the complication may not be possible at times, due to the multiple risk factors involved in the pathogenesis. It is hoped that understanding these potential complications will lead to a more vigilant preventive measures during the institution of long-term artificial airways and a judicious early search for the underlying pathology when a complication is suspected.

Acute complications of artificial airways

In conclusion, though there has been a dramatic reduction in the acute complications of artificial airways in the last hundred years, it remains crucial for the intensivist/anesthesiologist to have an implicit understanding of the anatomy and physiology of the process of ETI. As new techniques such as PDT are introduced, we must investigate their utility compared with the current standard of care in the most rigorous fashion. Additionally, as many of the complications of ETI can lead to increases in morbidity and mortality, prompt diagnosis and management are essential.

Complications of tracheostomy performed in the ICU: subthyroid tracheostomy vs surgical cricothyroidotomy

BACKGROUND

The morbidity of surgical tracheostomy performed in critically ill patients is not well-known. Accordingly, the aim of this prospective study was to determine the incidence and severity of complications associated with subthyroid tracheostomy and cricothyroidotomy when performed in the ICU.

METHODS

Over a 2-year period, individual consecutive patients who were undergoing an elective tracheostomy were studied. Attending physicians elected the timing and technique of the tracheostomy. All procedures were performed at the bedside. A complete laryngeal examination was performed before ICU discharge, prior to decannulation, and 6 months after the tracheostomy.

RESULTS

A tracheostomy (subthyroid, 86 patients; cricothyroidotomy, 32 patients) was performed in 118 of 1,574 patients (mean [+/- SD] age, 54 +/- 18 years; 79 men, 39 women; mean APACHE [acute physiology and chronic health evaluation] II score, 19 +/- 2). No deaths could be attributed to the tracheostomy procedure, and 40 complications occurred in 36 patients (30%), with a similar incidence in both groups (subthyroid group, 30 of 86 patients; cricothyroidotomy, 10 of 32 patients; p = 0.9). The severity and timing of complications were comparable between groups.

CONCLUSIONS

In the present series, the incidence and severity of complications associated with conventional subthyroid tracheostomy and surgical cricothyroidotomy performed in the ICU were similar. The bedside cricothyroidotomy, which is technically easier to perform, represents a valuable alternative to conventional tracheostomy in the management of critically ill patients.

Percutaneous dilation tracheostomy during high-frequency oscillatory ventilation

OBJECTIVE

To ascertain the feasibility and the safety of percutaneous dilational tracheostomy in patients with acute respiratory distress syndrome receiving high-frequency oscillatory ventilation.

DESIGN

Case series.

SETTING

Tertiary adult intensive care unit in a university teaching hospital.

PATIENTS

Five patients with acute respiratory distress syndrome.

INTERVENTIONS

Percutaneous dilational tracheostomy during high-frequency oscillatory ventilation.

MEASUREMENTS AND MAIN RESULTS

Percutaneous dilational tracheostomy was safely performed on all five patients. Hemodynamic and respiratory variables remained stable during the procedure. No complications were attributable to either the percutaneous dilational tracheostomy or high-frequency oscillatory ventilation.

CONCLUSIONS

Percutaneous dilational tracheostomy can be safely performed on patients with acute respiratory distress syndrome during high-frequency oscillatory ventilation.

Percutaneous tracheostomy with the guide wire dilating forceps technique: presentation of 171 consecutive patients

BACKGROUND

Evaluation of percutaneous tracheostomy (PT) with the guide wire dilating forceps (GWDF) technique.

METHODS

Prospective study of perioperative complications, retrospective analysis of early and late complications in an ICU in a teaching university hospital.

RESULTS

The success rate of the procedure was 96.5%. The average procedure time in 171 consecutive patients was 5.0 min. Perioperative complications requiring surgical or medical intervention occurred in 6.4% of 171 patients. This included conversion to surgical tracheostomy, which was necessary in six patients (3.5%). Major complications while being cannulated occurred in 2.4% of 164 patients but seemed mostly unrelated with the GWDF technique itself. Late complications (after decannulation) were mostly minor and occurred in 22.6% of 106 patients. Only one patient (0.9%) had a symptomatic tracheal stenosis developed.

CONCLUSION

Percutaneous tracheostomy with the guide wire dilating forceps technique is easy to perform at the bedside with few late complications. However, in our study, perioperative and immediate postoperative bleeding complications (minor and major) occur quite often.

Ultrasound and bronchoscopic controlled percutaneous tracheostomy on trauma ICU

Tracheostomy is a common surgical procedure performed in long-term ventilated patients in intensive care. Since the role of percutaneous dilatational tracheostomy (PDT) on Intensive Care Unit (ICU) has become steadily more important in the last few years, a prospective study was started to evaluate the economic efficiency and to show the minimization of the complication rate of this procedure. In 72 patients we performed PDT as a bedside procedure. Initially the thyroid gland and the subcutaneous vessels were studied by ultrasound in every patient. The puncture of the trachea, the dilatational procedure and the insertion of the tracheal cannula were executed under bronchoscopic monitoring. Finally, a bronchoscopic control view followed via the new cannula to detect intratracheal complications. Mechanical ventilation was maintained during the procedure and controlled by continuous pulse oximetry. According to prior ultrasound findings the place to puncture the trachea was changed in 24% of the patients, in one case tracheostomy was performed as an open conventional procedure. The following complications could be observed: one case involving perforation of a cartilaginous ring, one case with venous bleeding of a small subcutaneous vein and two cases with punctures of the bronchoscope. There were no cases of miscannulation, penetration of the posterior tracheal wall or major bleeding requiring intervention or conversion. The followup study revealed that there was no sign of further complications in any patient. In addition, cost analysis demonstrated that there was a significant economical advantage of PDT in comparison with open standard tracheostomy. Standardized ultrasonographically and bronchoscopically controlled PDT turns out to be a safe, simple and cost effective bedside procedure on ICU. Because of ultrasound examination performed before the procedure, and bronchoscopic surveillance during the procedure, safety of this procedure can be enhanced, thus minimizing the rate of complications.

Percutaneous tracheostomy in critically ill patients: a prospective, randomized comparison of two techniques

OBJECTIVE

To prospectively compare two commonly used methods for percutaneous dilational tracheostomy (PDT) in critically ill patients.

DESIGN

Prospective, randomized, clinical trial.

SETTING

Trauma and general intensive care units of a university tertiary teaching hospital, which is also a level 1 trauma center.

PATIENTS

One hundred critically ill patients with an indication for PDT.

INTERVENTIONS

PDT with the Ciaglia technique using the Ciaglia PDT introducer set and the Griggs technique using a Griggs PDT kit and guidewire dilating forceps.

MEASUREMENTS AND MAIN RESULTS

Surgical time, difficulties, and surgical and anesthesia complications were measured at 0-2 hrs, 24 hrs, and 7 days postprocedure. Groups were well matched, and there were no differences between the two methods in surgical time or in anesthesia complications. Major bleeding complications were 4.4 times more frequent with the Griggs PDT kit. With the Ciaglia PDT kit, both intraoperative and at 2 and 24 hrs, surgical complications were less common (p = .023) and the procedure was more often completed without expert assistance (p = .013). Tracheostomy bleeding was not associated with either anticoagulant therapy or an abnormal clotting profile. Multivariate analysis identified the predictors of PDT complications as the Griggs PDT kit (p = .027) and the Acute Physiology and Chronic Health Evaluation (APACHE) II score (p = .041). The significant predictors of time required to complete PDT were the APACHE II score (p = .041), a less experienced operator (p = .0001), and a female patient (p = .013).

CONCLUSIONS

Patients experiencing PDT with the Ciaglia PDT kit had a lower surgical complication rate (2% vs. 25%), less operative and postoperative bleeding, and less overall technical difficulties than did patients undergoing PDT with the Griggs PDT kit. Ciaglia PDT is, therefore, the preferred technique for percutaneous tracheostomy in critically ill patients.