Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 8  |  Issue : 4  |  Page : 505-510

Comparative study between percutaneous dilatation tracheostomy and surgical tracheostomy


1 Department of Anaesthesia and Intensive Care, Faculty of Medicine, Ain Shams University, Consultant Intensivest in King Abd El Aziz Specialist Hospital, Taif, Saudi Arabia
2 Madinet Naser, Cairo, Egypt

Date of Submission19-May-2014
Date of Acceptance09-Nov-2014
Date of Web Publication29-Dec-2015

Correspondence Address:
Mohamed G.I.M. Allam
Department of Anaesthesia and Intensive Care, Faculty of Medicine, Ain Shams University, Consultant Intensivest in king Abd El Aziz Specialist Hospital, Taif 10127
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7934.172671

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  Abstract 

Introduction
Tracheostomy is one of the most common procedures performed in the ICU. Tracheostomy decreases the dead space and the effort of breathing, and facilitates suction and chest drainage. The easy placement of the tracheostomy tube makes it the only acceptable method for home ventilation.
Tracheostomy can be performed either through percutaneous dilatation using the Seldinger technique in the ICU or surgically by an ENT surgeon in the operating room (OR). The approach for tracheostomy, whether percutaneous or surgical, remains a point of debate.
Aim
This an observational (prospective cohort) study to compare percutaneous dilatation tracheostomy (PDT) with surgical tracheostomy (ST) with regard to both perioperative and late postoperative complications.
Patients and methods
A total of 200 patients admitted to King Abdulaziz Specialist Hospital between February 2010 and December 2013 were allocated to two groups: group A included 100 patients who had undergone PDT, and group B included 100 patients who had undergone ST. Both perioperative and late postoperative complications were recorded and compared between the two groups.
Changes in blood gases, atelectasis, emphysema, pneumothorax, failure to cannulate the trachea or false passage, tracheal ring fractures, wrong site, and tracheal wall injury were considered perioperative complications, whereas bleeding, infection, stenosis, and tracheoarterial and tracheoesophageal fistula were considered late postoperative complications.
Results
PDT resulted in a significantly higher perioperative complication rate as regards blood gas changes, false passage, and tracheal wall injury, but there was no significant difference with regard to atelectasis, tracheal ring fractures, wrong site, emphysema, and pneumothorax.
However, PDT resulted in a significantly lower postoperative complication rate as regards bleeding and infection, but no statistically significant difference was found in the incidence of stenosis.
Tracheoarterial and tracheoesophageal fistula were not reported in either PDT or ST.
Conclusion
PDT is a safe and reliable method for tracheostomy in all ICU cases and is associated with lower incidence of postoperative complications in terms of bleeding and stomal infection.

Keywords: Percutaneous, dilatation tracheostomy, classic surgical opened tracheostomy in ICUs


How to cite this article:
Allam MG, Eldeek AM. Comparative study between percutaneous dilatation tracheostomy and surgical tracheostomy. Ain-Shams J Anaesthesiol 2015;8:505-10

How to cite this URL:
Allam MG, Eldeek AM. Comparative study between percutaneous dilatation tracheostomy and surgical tracheostomy. Ain-Shams J Anaesthesiol [serial online] 2015 [cited 2019 Jun 19];8:505-10. Available from: http://www.asja.eg.net/text.asp?2015/8/4/505/172671


  Introduction Top


Tracheostomy is one of the most common procedures performed in the ICU. However, indications, risks, benefits, timing, and techniques of the procedure remain controversial [1],[2] .

The decision of when and how to perform a tracheostomy is often subjective; it depends on the experience and must be individualized to the patient [1],[2],[3] .

  1. The use of a tracheostomy tube to mechanically ventilate patients carries many advantages when compared with the use of an endotracheal tube [3] .
  2. The easy replacement of the tracheostomy tube once the tract has been created, along with better nursing and suction and better patient comfort, makes the tracheostomy tube more favorable [4],[5] .
In contrast, the endotracheal tube needs skilled personnel and is more difficult to place; it carries greater risk of complications during intubation in the form of broken teeth, bleeding from the oral and nasal cavity, wrong placement (esophageal intubation), etc. [6],[7] .

Further, data from many studies suggest that the effort of breathing, airway resistance, peak inspiratory pressure, and auto-positive end expiratory pressure (PEEP) decrease after tracheostomy in both mechanically ventilated and spontaneously breathing patients [7],[8] .

Percutaneous dilatation tracheostomy (PDT) offers numerous advantages compared with operative tracheostomy. It requires shorter time to perform, is less expensive, and can be performed faster (because the operative room does not have to be scheduled). In addition, percutaneous tracheostomy involves fewer postoperative complications compared with surgical tracheostomy (ST) [9] . In a meta-analysis of randomized controlled trials involving 1212 patients, PDT showed significantly lower incidence of postoperative infection and bleeding compared with ST; yet, perioperative complications such as changes in blood gases and low SpO 2 during the procedure, wrong site, surgical emphysema or pneumothorax, and tracheal ring fractures with or without anterior or posterior tracheal wall injury appeared to be statistically the same in both PDT and ST [10],[11],[12] .

History

  1. The percutaneous technique of tracheostomy was developed after Seldinger described needle replacement over a guidewire for arterial catheterization in 1953.
  2. In 1955, Shelden and colleagues reported the first attempt to perform percutaneous tracheostomy percutaneous tracheostomy (PCT) and his method for PCT caused multiple complications and fatalities secondary to laceration of vital structures from trocar.
  3. In 1969, Toye and colleagues reported a tracheostomy technique based on a single tapered dilator with a recessed cutting blade. This dilator was advanced into the airway over a guiding catheter. The blade was designed to cut tissues under tension as the dilator was forced into the trachea.
  4. In 1985, Ciaglia and colleagues described PDT, a method based on needle guidewire airway access followed by serial dilations with sequentially larger dilators.
  5. In 1990, Griggs and colleagues reported the guidewire dilator forceps method.
  6. In 1997, Fantoni used a specially designed cannula to dilate the trachea in a retrograde manner.
  7. In 2000, Byhahn and colleagues reduced the risk for posterior tracheal wall injury and reduced the risk of bleeding using his hydrophilically coated curved dilator in single-step dilatation.
  8. In 2002, the latest variation of PDT was introduced by Frova through controlled rotating dilatation.
  9. A large number of studies have been published over the last two decades comparing several techniques of PDT with open ST. Most studies suggest lower complication rates with PDT.
  10. PDT involves smaller skin incisions, less tissue trauma, lower incidence of wound infection, and lower cost.
Indication of percutaneous dilatation tracheostomy

Indications for PDT are the same as those for standard ST [12],[13],[14] :

  1. Airway obstruction due to:


    1. Inflammatory disease.
    2. Congenital anomaly (e.g. laryngeal hypoplasia, vascular web).
    3. Supraglottic or glottic pathologic condition (e.g. neoplasm, bilateral vocal cord dysfunction, or paralysis).
    4. Laryngeal trauma or stenosis.
    5. Facial fractures that may lead to upper airway obstruction.
    6. Edema, granulomatous inflammation, trauma, or infection of the vocal cord.
  2. Need for prolonged mechanical ventilation.
  3. Need for improved pulmonary toilet.
  4. Prophylaxis in elective head and neck surgery involving the airways.
  5. Need for home continous positive air way pressure (CPAP) or home ventilation.
Contraindication of percutaneous dilatation tracheostomy

What constitutes absolute and relative contraindications has become a matter of debate. Many surgeons perform PDT even in obese patients and in those with coagulopathy [15],[16] .

Kornblith et al. [17] reviewed 1000 patients who underwent bedside PDT over 10 years and made the following observations:

Absolute contraindications [18],[19],[20] :

  1. Patient age under 8 years.
  2. Necessity for emergency airway access.
  3. Gross anatomical distortion due to:


    1. Hematoma.
    2. Tumor.
    3. Thyromegaly.
    4. High innominate artery.


Relative contraindications [21],[22] :

  1. Obesity, short neck.
  2. Presence of coagulopathy.
  3. Platelet count less than 50 000/cm 3 .
  4. Need for PEEP more than 20 cm H 2 O.
  5. Evidence of infection, soft tissue obstruction, surgical scar in the midline of the neck.
Aim of the study

This is an observational (prospective cohort) study aimed to compare PDT and ST as regards both perioperative and postoperative complications.


  Patients and methods Top


A total of 200 patients were admitted to the ICU of King Abdulaziz Specialist Hospital between February 2010 and December 2013. All of them had either medical causes or surgical causes for prolonged intubation and ventilation.

Inclusion criteria for patients subjected to PDT:

  1. Age more than 8 years.
  2. Prolonged intubation and ventilation for 2 or more weeks.
  3. Normal coagulation profile.
  4. Satisfactory surface anatomy.
Exclusion criteria for patients subjected to PDT:

  1. Obese, short neck.
  2. Prothrombin time (PT) more than 1.5 times the normal value.
  3. Partial thromboplastin time (PTT) more than 1.5 times the normal value.
  4. Platelet count less than 50 000 cm 3 .
  5. No midline scar or obstruction by soft tissue.
Exclusion criteria for ST:

  1. PT more than 1.5 times the normal value.
  2. PTT more than 1.5 times the normal value.
  3. Platelet count less than 50 000 cm 3 .
The 200 patients were randomly divided into two groups (using opaque envelopes): group A was assigned for PDT and group B for ST; each group composed 100 patients.

King Abdulaziz research and ethical committee approved the project.

A written consent from all patients was taken either from the patient if conscious or from their first-degree relative.

All events and complications were recorded during the tracheostomy either by percutaneous dilatation technique or surgical technique:

  1. Hypoxia (any drop in SpO 2 less than 90%, even transient).
  2. Hypercapnia (measured by end-tidal CO 2 >45 mm Hg).
  3. False passage.
  4. Failure to cannulate the trachea (only in PDT).
  5. Emphysema or pneumothorax diagnosed by chest radiography immediately after the procedure.
Evaluation of proper site of placement and detection of any complication (tracheal ring fracture or posterior or anterior tracheal wall injury) were carried out by bronchoscopy 2 days after the procedure for complete resolution of any edema if present.

Strict follow-up for postoperative complications 3 weeks after the procedures with respect to bleeding, infection (stomal infection), stenosis, or development of tracheoinnominant or tracheoesophageal fistula.

All the patients of group A assigned PDT using Ciaglia's technique, single dilator Blue Rhino System Cook Critical Care (Cook Medical Inc., Bloomington, USA) size 7 mm internal diameter for females and 8 mm for males using Seldinger technique from Nanjing Hoshin Medical Instrument Co. Ltd.

Change in SpO 2 and blood gases, atelectasis, local surgical difficulties (wrong site, false passage, failure to cannulate the trachea), surgical emphysema, development of pneumothorax, tracheal ring fracture, and failure to cannulate the trachea (only in PDT) were considered perioperative complications, whereas bleeding, infection, stenosis, and tracheoarterial and tracheoesophgeal fistula were considered postoperative complications.

Postoperative bleeding was evaluated by the number of packed red blood cells used postoperatively.

Hypoxia was considered if SpO 2 reduced to less than 90% on the monitor, even transiently, during the procedure.

Atelectasis was diagnosed on the basis of chest radiography performed immediately after the procedure and on the basis of the presence of absorption collapse and white lung opacities.

Stomal infection was documented in our study on the basis of the following:

  1. Local signs of infection (edema, redness, discharge).
  2. Culture from the discharge around the stoma.
Stenosis was documented in our study by bronchoscopy 2 and 3 weeks later.

Statistical analysis

Data were collected and entered into a personal computer and statistically analyzed using statistical package for the social sciences (SPSS, version 20; SPSS Inc., Chicago, Illinois, USA).

Data were presented as number and percentage for categorized parameters, and the c2 -test was used for analysis. The level of significance was 0.05.


  Results Top


The results are shown in [Table 1] [Table 2] [Table 3] [Table 4] and [Figure 1] and [Figure 2].
Figure 1: Perioperative complications in the two studied groups. Data are presented as percentage

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Figure 2: Postoperative complications in the two studied groups. Data are presented as percentage. RBCS, red blood cells

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Table 1 Demographic data in both groups

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Table 2 Causes of prolonged ventilation in both groups

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Table 3 Perioperative complications recoded in both groups

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Table 4 Postoperative complications recorded in both groups

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  Discussion Top


PDT is becoming the accepted way of tracheostomy in the ICU. This less expensive and rapid technique makes it the preferred tracheostomy technique in most of the ICUs, but its safety continues to remain a major point of research compared with the safety of open ST [23],[24] .

Silvester et al. [25] , in 2006, performed a prospective randomized, controlled study on 200 patients comparing the safety of both PDT and ST and found no significant difference in postoperative complications between the PDT group and the open ST group.

In 2009, Seder et al. [26] evaluated ST and PDT as regards cost-effectiveness and long-term complications. This study was conducted on 135 patients divided into two groups: the PDT group and the ST group. They found that PDT was a safer and less expensive than ST [26] .

In a meta-analysis of 17 randomized controlled trials involving 1212 patients performed from 1999 to 2008, it was proven that PDT is less expensive, is less time consuming, and has lower incidence of postoperative complications with regard to bleeding and stomal infection compared with ST, but that PDT carries a higher incidence of perioperative complications such as regards false passage, failure to cannulate the trachea, and pneumothorax [3],[27] . This could be attributed to the wide variation in the surface anatomy of the neck among patients. Still, PDT is considered a blind technique depending on the experience of the intensivist. Further, changes in blood gases during the procedure appear to be higher in PDT, which might be due to considerable movement of the head and higher incidence of kinking of the endotracheal tube during the technique, especially in the hands of less experienced intensivists.

The results of this study were very similar to ours, showing significant difference in some perioperative complications in the PDT technique compared with ST: namely,

  1. Hypoxia (P = 0.036).
  2. Hypercapnia (P = 0.028): the cause of changes in blood gases during the PDT technique were mentioned before.
  3. False passage (P = 0.001): the incidence was higher in PDT because of misleading surface anatomy and floating of the trachea due to lack of supporting connective tissue in some patients.
  4. Injury to the anterior and/or posterior tracheal wall (P = 0.035): this can be attributed to the high force sometimes needed by less experienced intensivists during application of the single dilator used to dilate the Ostia in PDT.
  5. Failure to cannulate the trachea: this was considered a unique complication in PDT and occurs because of the relatively short neck of patients and clumsy rough hands of less experienced intensivists.
  6. Atelectasis: the incidence of atelectasis, despite being higher in group A (40 cases) compared with group B (35 cases), was nonsignificant. The occurrence might have been because of the use of normal saline in the identification of the trachea before inserting the guidewire in the trachea and marked secretion from the tracheal mucosa during application of the dilator in PDT. This small difference was considered nonsignificant in the c2 -test in relation to sample size.
The P value was not found to be significant for tracheal ring fracture and wrong site between the two groups; however, group A had a higher number of complications compared with group B (four cases of tracheal ring fracture in group A and one in group B; 14 cases of wrong site in group A and eight in group B). This might be attributed to the misleading surface anatomy in some patients together with excess force used by less experienced intensivists in putting the dilator in the ostia in the PDT technique.

There was also no significant difference in the incidence of emphysema and pneumothorax between the two groups (P = 0.69 and 0.562, respectively).

PDT involved significantly lower incidence of postoperative complications compared with ST as regards bleeding and infection, which might be attributed to crushing of vessels during PDT and thus less hematoma and less infection due to smaller bloody field. However, no significant difference was found between PDT and ST in stenosis because both are minor procedures with less fibrosis.

No tracheoarterial or tracheoesophageal fistula was reported in either group.

However, another meta-analysis by Silvester et al. [25] conducted in 2006 showed no significant difference between the different techniques used to perform PDT as regards postoperative complications and long-term follow-up because he reported the incidence of complications arising from PDT on the basis of the experience of the intensivist only and stated that there was no statistically significant difference among PDT techniques when performed by experienced intensivists.


  Conclusion Top


From this study we can conclude that PDT is a safe, inexpensive, reliable, and widely used method of tracheostomy, with fewer postoperative complications compared with ST but with more perioperative complications (blood gas changes, false passage, and tracheal injury), which can be reduced if the procedure is performed by skilled intensivists.


  Acknowledgements Top


Conflicts of interest

None declared.

 
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    Figures

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