Synopsis: Percutaneous dilational tracheotomy was shown to be as safe, and more efficiently performed, than surgical tracheotomy in this randomized prospective study.
Source: Friedman Y, et. al. Chest 1996;110:480-485.
In this randomized control trial, adult patients needing artificial airways long-term for ventilatory support or airway protection received either percutaneous dilational tracheotomy (PDT) at the bedside or surgical tracheotomy (ST) in the operating room. Patients were excluded for clinical instability, PEEP greater than 15 cm H2O, uncorrectable coagulopathy, previous tracheostomy or neck surgery, thryomegaly, anatomic distortion, or soft tissue infection of the neck. Patients were comparable in demographics, disease processes, days intubated prior to tracheotomy, APACHE II score, and laboratory values. Complications recorded were: hypotension (systolic < 90 mmHg), hypoxia (pulse oximeter saturation <90%), bleeding (small = 0-100 cc; moderate = 100-250 cc; severe > 250 cc), and wound infection (induration > 1 cm or frank pus).
Of the 53 patients in this study, 26 were randomized to PDT and 27 to ST. The time from randomization to performance of the tracheotomy was significantly shorter for PDT (28.5 ± 27.9 hours) than ST (100.4 ± 95.0 hours [P < 0.001]), as was the duration of the procedure (8.2 vs 33.9 minutes). Saturations during the procedure were lower for a longer period in the ST group, but this difference did not reach statistical significance. One patient in each group experienced major bleeding. One paratracheal insertion occurred in the PDT group but was quickly recognized and corrected. There were no procedure-related deaths in any patient.
Overall, 35% of the patients in the PDT group and 41% of the patients in the ST group sustained an intraprocedure complication. Wound infections were more common in the ST group. Accidental decannulation was more frequent in the ST group (15%) than the PDT (4%) group. Accidental decannulation resulted in death after ST in an obese patient in whom the tube could not be reinserted and intubation failed. One other ST patient died after accidental decannulation and reintubation failure in the presence of a wound infection. Bleeding requiring transfusion occurred in one patient in the PDT group and one patient died of exsanguinating hemorrhage six weeks following ST. Overall mortality was 42% in the PDT group and 33% in the ST group. Only five patients in each group had been successfully decannulated at the time of the study.
COMMENT BY CHARLES G. DURBIN, Jr, MD, FCCM
This study confirms the significant risk of tracheotomy by whatever route it is performed. This is mostly due to presence of severe disease in the patients requiring prolonged airway support. PDT appears a reasonable alternative to ST in terms of procedural risks. Logistically, this procedure is less costly since it is performed in the ICU without the aid (and risks) of general anesthesia. Another benefit was the short time needed to perform PDT compared to ST. This study was too small to identify a difference in rapidity of tracheostomy stoma closure, although this appears to be another benefit of PDT.
This study is important since it randomly assigned patients to the groups. Although PDT appears to have benefits over ST, operator experience may be the most important determinant of success and complications. The high death rate from accidental decannulation and failure of reinsertion in the ST group raises questions about the randomization. Were the groups identical in body habitus? Were obese patients overrepresented in the ST group? Is obesity a contraindication for PDT? These questions remain to be addressed. Before PDT can be endorsed as the method of choice for critically ill patients, questions about long-term complications need to be answered.
COMMENT BY DAVID J. PIERSON, MD
Should we say "tracheotomy" or "tracheostomy?" I have reviewed the literature on this topic, examining both original articles and textbooks, and both terms are used pretty much interchangeably. Two colleagues who are recognized authorities on airway management prefer "tracheostomy," and this seems to be the more commonly used version. The authors of this paper also use "tracheostomy" in their title. However, I think a strong case can be made for a technically "right" and "wrong" usage, and I have taken the liberty of changing it to "tracheotomy" in Dr. Durbin’s abstract and commentary, for the following reason. The suffix "-otomy" refers to a surgical operation in which an organ or other structure is incisedwitness laparotomy, craniotomy, thoracotomy. On the other hand, "-ostomy" refers to an opening created by a surgical proceduresuch as colostomy, ventriculostomy, or thoracostomy.
According to this convention, there should be two terms with different meanings. We should say "tracheotomy" when we are referring to the procedure of creating an opening in the trachea, and "tracheostomy" when we talk about the opening itself. The appliance inserted through a tracheostomy would most logically be called a tracheostomy tube. However, current clinical usage being so thoroughly ingrained, I doubt that this or any other strict convention will be adopted any time soon.