Does a percutaneous tracheostomy have a lower incidence of complications compared to an open surgical technique?

December 8, 2005

December 13, 2005

Anish Patela, Peter Swan, Cardiothoracic Registrar (Department of Cardiothoracic Surgery, Southampton General Hospital, Poole hospital and James Cook University Hospital, Middlesbrough)

Joel Dunning, Department of Cardiothoracic Surgery, Southampton General Hospital, Poole hospital and James Cook University Hospital, Middlesbrough

In patients requiring [prolonged mechanical ventilation] is [open (surgical) tracheostomy] or [percutaneous tracheostomy] superior in [reducing complications]?

One of your patients with borderline pulmonary function is still intubated following CABG 5 days ago. He is haemodynamically stable but his arterial blood gas shows that he is unlikely to be successfully extubated. The ITU staff ask you to site a tracheostomy surgically at the end of your list. In previous units your intensivists routinely inserted them percutaneously. The ITU staff are reluctant for a percutaneous procedure following problems with bleeding earlier that year. As you are unsure of the current evidence on which method is safer you decide to review the literature before returning to the ICU.

Medline 1966 to July 2005 using the OVID Interface.

[exp tracheotomy/OR exp tracheostomy OR tracheostomy.mp] AND [percutaneous.mp OR dilational.mp OR dilatational. mp] AND [surgical.mp OR open.mp].

Two hundred and sixty-four papers were found in Medline. Of these papers 13 provided the best evidence to answer the question. These are summarised in the table

Tracheostomy is a commonly performed procedure in patients in the ICU setting. Previously the open surgical tracheostomy (ST) was the traditional method but in the past 20 years bedside percutanoeus tracheostomy (PDT) has become a popular choice.

Two meta-analyses have been performed [Freeman, Dulguerov]. Freeman et al. suggested the advantages of PDT relative to ST included less peri-stomal bleeding and post-operative infection. Operative time was shorter, absolute difference with 95% CI, 9.84 min (7.83–10.85 min). Overall complication rates and mortality showed no difference. Dulguerov et al. looked at nearly 10,000 patients in 65 studies. Those involving surgical tracheostomy were further divided into those from 1960–1984 and those from 1985–1996. The earlier surgical tracheostomy studies have the highest rate of complication, both procedure related and post-operatively. Comparison between the later surgical trials and the percutaneous trials showed that perioperative complications were more common with the percutaneous technique (10% vs. 3%) and post-operative complications were more common with the surgical technique (10% vs. 7%), however, serious complications including death and serious cardiovascular events were higher in the percutaneous group (0.33% vs. 0.06%).

In those papers that specifically looked into procedure-related complications, although relatively low in both groups, they were seen more frequently in the percutaneous group [Heikkinen, Freeman, Dulguerov, Gysin, Porter, Reilly, Graham, friedman].

Post-operative complications were mainly superficial wound infections and minor bleeding around the wound edges, again low in both groups there was a trend towards fewer complications in the percutaneous tracheostomy groups [Freeman, Dulguerov, Holdgaard, Friedman, Hazard, Griggs].

Porter et al. compared bedside surgical and percutaneous techniques. These results were then compared with ICU patients undergoing tracheostomy in theatre. There was a trend to a higher rate of intraprocedural complications in the bedside percutaneous group. No tracheostomy-related post-procedural complications were seen in either bedside group. Comparison between the surgical bedside and operating theatre groups showed that complications and time to insertion was similar for each group.

Reilly et al. looked specifically at the extent of hyper- carbia and acidosis during percutaneous endoscopic, percutaneous Doppler and standard surgical tracheostomy. Although only small numbers of patients were recruited, significant hypercarbia and acidosis occurred in the percutaneous endoscopic group when compared with the percutaneous Doppler and the open surgical technique.

Time taken for procedure was shown to be quicker in the percutaneous group compared to the surgical group [Heikkinen, Freeman, Porter, Holdgaard, Reilly, Friedman, Hazard, Griggs].

In terms of procedure cost, Massick et al. and Porter et al. showed that the surgical technique was more cost-effective, in contrast Heikkinen et al. showed that only if ICU staff are used, was there a significant cost benefit in performing percutaneous tracheostomy.

Both percutaneous and surgical tracheostomy have overall a low incidence of complications. There is a lower incidence of procedural complications when inserted surgically. There is a lower incidence of post-procedural complications when inserted via the percutaneous route.

1. Massick DD, Yao S, Powell DM, Griesen D, Hobgood T, Allen JN, Schuller DE.. Bedside tracheostomy in the intensive care unit: a prospective randomised trial comparing open surgical tracheostomy with endoscopically guided percutaneous dilational tracheotomy.
2. Heikkinen M, Aarnio P, Hannukainen J.. Percutaneous dilational tra- cheostomy or conventional surgical tracheostomy.
3. Freeman BD, Isabella K, Lin N, Buchman TG.. A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients.
4. Dulguerov P, Gysin C, Perneger TV, Chevrolet JC.. Percutaneous or surgical tracheostomy: a meta-analysis.
5. Gysin C, Dulguerov P, Guyot JP, Perneger TV, Abajo B, Chevrolet JC.. Percutaneous vs. surgical tracheostomy: a double-blind randomized trial.
6. Porter JM, Ivatury RR.. Preferred route of tracheostomy – percutaneous vs. open at the bedside: a randomised, prospective study in the surgical intensive care unit.
7. Holdgaard HO, Pedersen J, Jensen RH, Outzen KE, Midtgaard T, Johansen LV, Moller J, Paaske PB.. Percutaneous dilatational tracheostomy vs. conventional surgical tracheostomy. A clinical randomised study.
8. Reilly PM, Sing RF, Giberson FA, Anderson HL 3rd, Rotondo MF, Tinkoff GH, Schwab CW.. Hypercarbia during tracheostomy: a comparison of percutaneous endoscopic, percutaneous Doppler, and standard surgical tracheostomy.
9. Graham JS, Mulloy RH, Sutherland FR, Rose S.. Percutaneous vs. open tracheostomy: a retrospective cohort outcome study.
10. Friedman Y, Fildes J, Mizock B, Samuel J, Patel S, Appavu S, Roberts R.. Comparison of percutaneous and surgical tracheostomies.
11. Crofts SL, Alzeer A, McGuire GP, Wong DT, Charles D.. A comparison of percutaneous and operative tracheostomies in intensive care patients.
12. Hazard P, Jones C, Benitone J.. Comparative clinical trial of standard operative tracheostomy with percutaneous tracheostomy.
13. Griggs WM, Myburgh JA, Worthley LI.. A prospective comparison of a percutaneous tracheostomy technique with standard surgical tracheostomy.