Percutaneous Tracheostomy: A Comprehensive Evaluation

Abstract

Percutaneous tracheostomy (PT) is an ancient procedure that has recently attracted increasing interest. While there are numerous publications in the literature, there remains confusion due to the large variety of techniques and instruments with which it has been performed and the wide disparity in clinical outcome. This study evaluates the international literature on over 1,500 cases, classifies the techniques that have been used, analyzes the safety of each method, and reports a prospective outcome and cost analysis of 130 cases undergoing what we determined to be the safest method. We found that PT performed with the correct instruments and technique under bronchoscopic surveillance has a lower incidence of complications than open tracheostomy (OT). Cost estimation demonstrated that PT may be significantly more expensive than bedside OT. While we recommend PT as a relatively safe and expedient method of tracheostomy for selected intubated patients in an intensive care unit, it does not offer an advantage for patients who must be taken to the operating room, and should not deprive house officers of necessary experience in OT in this setting.

Outcome of bedside percutaneous tracheostomy with bronchoscopic guidance

“…Our complication rate of 8 % is within the range documented in the literature [2,4,9]. Recent literature indicates a rate of superficial mucosal laceration of 0.9±1.4 % [2,11] in those authors using a technique similar to ours.…”

“…Our intraoperative mortality rate of 0 is not unusual when compared to users of a similar technique [2,4,9]. An overall mortality of 40 % in this series is not unusual [10,11] and reflects the mortality of patients requiring long-term mechanical ventilation.…”

“…No patient died as a direct or indirect result of PDT. A recent review [9] reports an average peri-operative mortality rate for 1,116 patients using six different PDT techniques ± with and without bronchoscopy ± at 0.4 %.…”

Incidence of Tracheal Stenosis and Other Late Complications After Percutaneous Tracheostomy

“…[2][3][4][5][6][7][8][9] The perioperative complications of PDT are well described 10,11 and are considered less than for open surgical tracheostomy. 10,11 Late complications, particularly tracheal stenosis, are more difficult to quantify because many patients undergoing PDT are critically ill and may die or be discharged from the hospital before decannulation. In patients who survive their critical illness or injury, access to long-term follow-up is often difficult because of the complexity of follow-up at tertiary referral centers, persistent medical problems, or a reluctance to return for evaluation by survivors who are asymptomatic.…”

“…29,30 Several studies have reported an overall incidence of tracheal stenosis after PDT of 0% to 10%. 10,[12][13][14][15]18 These studies rely primarily on clinical symptoms leading to some form of objective testing in a few patients. Such patient selection may not be representative of the overall population.…”