Is prophylactic minitracheostomy beneficial in high-risk patients undergoing thoracotomy and lung resection?

Abstract

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether prophylactic minitracheostomy (PM) is beneficial in high-risk patients undergoing thoracotomy and lung resection. Altogether, 115 papers were found using the reported search, of which four represented the best evidence to answer the question. Three randomised controlled trials (RCT) compared a total of 161 patients who underwent thoracotomy and received either PM or standard postoperative treatment alone. Another non-RCT of 144 patients observed the reduction of toilet bronchoscopy with the increased use of PM. These are summarised in the Table. The studies assessed the benefit of PM inserted immediately after lung resection surgery in patients perceived as at high-risk of developing pulmonary complications. High-risk defined patients as those who smoked, have poor lung function, ischaemic heart disease, chronic obstructive pulmonary disease, absence/failure of regional analgesia, and/or cerebrovascular accident. In the largest randomised study (102 patients), Bonde et al. [Bonde P, Papachristos I, McCraith A, Kelly B, Wilson C, McGuigan JA, McManus K. Sputum retention after lung operation: prospective randomized trial shows superiority of prophylactic minitracheostomy in high-risk patients. Ann Thorac Surg 2002;74:196-202] concluded that the PM group had a significant reduction in sputum retention and postoperative atelectasis. The authors also reported a reduction in the incidence of pneumonia and toilet bronchoscopy but this did not achieve statistical significance. Issa et al. [Issa MM, Healy DM, Maghur HA, Luke DA. Prophylactic minitracheotomy in lung resection. A randomized controlled study. J Thorac Cardiovasc Surg 1991;101:895-900] were able to demonstrate a significant reduction in the rate of pneumonia in the PM group and Randell et al. [Randell TT, Tierala E, Lepäntalo MJ, Lindgren L. Prophylactic minitracheostomy: a prospective, random control, clinical trial. Eur J Surg 1991;157:501-504] showed a significant reduction in postoperative atelectasis and toilet bronchoscopy in their PM group. Au et al. [Au J, Walker WS, Inglis D, Cameron EW. Percutaneous cricothyroidostomy (minitracheostomy) for bronchial toilet: results of therapeutic and prophylactic use. Ann Thorac Surg 1989;48:850-852] observed a reduction in toilet bronchoscopy from 9% to 4% in a four-year period; however, the authors could not directly relate this to the use of PM but believed it was likely. None of the studies demonstrated a statistical difference in mortality or intensive care unit or hospital length of 38 stay. All the studies reported some complications associated with minitracheostomy (MT) insertion, the incidence of which ranged from 5.6% to 57%. One percent of 227 patients who received MT in the studies experienced a life-threatening complication, the rest were minor and easily controlled. None of the complications resulted in death.

Cricothyroidotomy performed by Seldinger method in the management postoperative sputum retention and atelectasis after lung resection

“…Minitrakeotominin bu amaç ile kullanımının güvenli ve efektif olduğu bildirilmiştir. [1][2][3][4] Göğüs cerrahisi ve üst abdominal cerrahi geçiren ileri yaşlı, fonksiyonel kapasitesi kötü, acil ameliyata alınan, düşük mental kapasiteli, ameliyat öncesi sigara içime öyküsü olan ve kronik obstrüktif akciğer hastalığı (KOAH) olan hastalarda profilaktik olarak kullanılabilir. [1,2] Ayrıca ekstübasyon planlanan ve SR'si olan hastalarda ekstübasyon öncesi uygulanabilir.…”

“…[1] Sekresyon retansiyonu tedavisinde kullanılan diğer yöntemler ile karşılaştırıldığında minitrakeotominin avantajları şunlardır; lokal anestezi altında perkütanöz olarak uygulanabilir, eğitimi olmayan kişiler tarafından kolaylıkla tekrarlayan aspirasyonlar yapılabilir, sekresyonun etkili bir şekilde atılabilmesi için gerekli olan etkili öksürüğü provoke eder, kanülünün ince olması nedeni ile kenarından sekresyon atımına izin verir, hasta tarafından kolay tolere edilir, gerektiğinde kenarından entübasyon tüpünün geçişine izin verir, içinden yüksek konsantrasyonda oksijen verilmesine olanak sağlar, konuşma ve yutma etkilenmez. [1,4] Literatürde Mini-Trach II kullanımına bağlı komplikasyonlar bildirilmiştir. [3] En sık görülen komplikasyon kanama ve lokal hematomdur.…”

“…Diğer komplikasyonlar ise; kanül malpozisyonu (önde mediasten, arkada özofagus), cilt altı amfizemi, ses değişikliği, stridor, ağrı ve enfeksiyondur. [1,3,4] Geç komplikasyon ve mortalite bildirilmemiştir. [1,4] Morbit obezite, boyunda kitle, insizyon bölgesinde enfeksiyon ve hematom, kalsifik krikotiroid membran, koagülopati gibi durumlarda uygulanması kontrendikedir.…”

“…[1] Minitrakeotominin SR için yüksek riskli olan hastalarda profilaktik kullanımı da önerilmektedir. [1,4] Ancak ameliyat sonrası dönemde SR gelişebilecek hastaları yüzde yüz doğru tahmin edebilmek mümkün değildir. Bu da bazı hastalarda gereksiz cerrahi müdahale anlamına gelmektedir.…”

Postoperative Care of Patients Undergoing Lung Resection

“…In their report the prophylactic MT group had a significant reduction in sputum retention and postoperative atelectasis, along with a reduction (not significant) in the incidence of pneumonia and toilet broncoscopy. A recent report by Abdelaziz et al [49] underlines that prophylactic MT facilitates early and regular suctioning of the tracheobronchial tree, and that for high-risk patients it may be beneficial during the critical postoperative period in preventing complications associated with sputum retention. However, they reported that no studies have demonstrated a significant reduction in mortality, intensive care unit or hospital length of stay following MT.…”