Abstract
The present study was aimed to compare percutaneous dilatational tracheostomy (PDT) with that of conventional surgical tracheostomy (ST) in critically ill adult patients requiring tracheostomy for respiratory management. For this purpose 32 critically ill patients, admitted to the ICU between July 2016 and June 2018, were subjected to tracheostomy and randomly divided into two groups (PDT and ST) of 16 patients each. Mean duration of intubation was similar between the two procedures while the mean size of the tracheostomy tube was smaller in percutaneous technique. In comparison, post-operative infection after 7 days seem to be statistically lowered and the length of scar tend to be smaller in PDT patients. Although early and late post-operative complication rates are not statistically significant in the PDT groups, yet investigations of the long-term outcome following PDT are, therefore, necessary. Generally, PDT has lower acute complications than ST, although this may vary by the specific PDT technique. Patient factor may also influence complications. In view of the benefit versus risks in tracheostomy, PDT may be considered the “procedure of choice” for performing elective tracheostomies in critically ill adult patients.
Keywords: Percutaneous dilatational tracheostomy (PDT), Surgical tracheostomy (ST), Intensive care unit (ICU), Operation theatre (OT), Intubation
Introduction
Tracheostomy is usually performed in patients with difficult weaning from mechanical ventilation or some catastrophic neurological insult. Conventional surgical tracheostomy (ST), often performed in critically ill patients who need prolonged respiratory care, involves a full dissection of the pretracheal tissues and insertion of tracheostomy tube into the trachea under direct vision [1]. However, post-operative complications such as bleeding, cellulites – infection of the stoma and bad cosmetic results still exist and are relatively frequent [2]. In addition, critically ill patients require transport from intensive care unit (ICU) to operating theatre (OT) [3]. In 1976, Brantigan and Grow [4] presented encouraging results with elective surgical crico-thyroidotomy, a simple and rapid procedure that has been frequently used in ICU. And the present day percutaneous dilatational thacheostomy (PDT), using a needle, guide-wire and multiple sequentially larger dilators, was introduced by Ciaglia et al. [2] which became increasingly popular, gaining wide-spread acceptance in many ICU and trauma centres as a viable alternative approach. However, most otolaryngologists disagree with its elective use due to complications such as sub-glottic stenosis, vocal cord paralysis and recommend the procedure for emergency situations only [5, 6]. In view of the above facts, the present investigation is aimed to compare between percutaneous dilatational tracheostomy (PDT) versus conventional surgical tracheostomy (ST) in intensive care patients requiring tracheostomy regarding operative parameters and post-operative complications in both the techniques.
Material and Methods
32 critically ill adult patients, admitted to intensive care unit from July 2016 to June 2018 and subjected to tracheostomy, were randomly divided into two groups (16 each for PDT and ST) either for prolonged intubation, airway protection or facilitation of weaning from ventilator (ventilator support) or pulmonary hygine. Patients with distorted anatomy, history of previous surgery at the neck, bleeding disorder, goitre, neck masses, unstable general conditions or cervical spine trauma and age < 18 years were excluded. Informed written consents were obtained from the relatives and the study was prospectively approved by the Hospital’s Ethical Committee for human studies.
All patients undergoing conventional surgical tracheostomy were subjected to I.V. general anaesthesia (using midazolam, fentanyl and cisatracurium) and orotracheal intubation with continuous monitoring of arterial blood pressure, electrocardiography, pulse oximetry, intra-operative blood loss and record of tracheostomy tube size [6]. All patients received controlled ventilation of lungs with an inspired oxygen concentration (FIO2) of 100% [6].
Conventional (open) surgical tracheostomies were performed by surgical specialists in operation room/theatre (OR or OT), using standard surgical techniques.
For PDT patient group, the procedure was done at the patient’s bed side in the ICU using the Griggs guide-wire dilating forceps (GWDF) technique through transcervical insertion and the trachea cannulated with 14-G cannula between the first and second, or the second and third tracheal rings and the J-guidewire inserted followed by blunt dilation [2]. The detailed procedure given by Turkmen et al. [6] was adopted. In GWDF technique a 1.5 cm horizontal skin incision was made over the first and third tracheal rings. The pretracheal tissues were dissected with forceps and the trachea was cannulated between 1st / 2nd or 2nd / 3rd tracheal rings. Aspiration of air through the cannula reaffirms correct placement. The J-guidewire was inserted down the cannula into the bronchi and the cannula removed. A 14-G dilator is passed over the guidewire to start stomal formation in the anterior tracheal wall. The guidewire dilating forceps, based on the design of “Howard Kelly” clamp, and is locked in the closed position to pass over the guidewire. The proximal end of the guidewire was held while the guidewire dilating forceps was advanced until resistance was felt at the anterior tracheal wall. The opening of forceps at this point dilates the pretracheal tissues sufficiently to allow subsequent passage of tracheostomy tube. The forceps was then closed again, reapplied on guidewire and advanced until the jaws pass through the anterior tracheal wall, where a loss of resistance was felt. The handles of the forceps can then be raised to align the jaws in the long axis of the trachea and the guidewire dilating forceps was opened to dilate the anterior tracheal wall in one step. After dilation, the forceps was removed in the open position. The tracheostomy tube was mounted on a specially designed obturator and advanced over the guidewire into trachea. The obturator and guidewire were removed and tracheal suction of blood and secretion carried out. Cuff inflation and connection to ventilator allowed auscultation of the lungs and tracheostomy tube was stitched and tied in place with tapes.
The times of tracheal intubation per and post interventional complications were recorded and compared in both thegroups (PDT and ST).
All data were presented as mean ± S.D or median and range when approximate statistical significance was determined and the differences were considered to be statistically significant if p < 0.05.
Results
Demographic data are presented in Table 1 and there was no statistical difference between the two groups regarding age and sex. In both the groups, patients had already received assisted ventilation in ICU for a range of 7–24 days (mean: 12.6 days) due to their suffering from neurological disorder, respiratory disease, cardiovascular disease and head trauma. Duration of endotracheal intubation ranged from 7 to 24 days (13.05 ± 5.16) and 7–20 days (12.06 ± 4.72) for PDT and ST groups respectively with no statistically significant difference. There was no mortality related to both tracheostomy techniques. However, a total of 10 out of 32 patients died because of progression of their underlying diseases while the tracheostomy was functioning well. Of the survived 22 patients, 18 needed decannulation, the time from institution of tracheostomy to decannulation ranged from14-21 days with a mean of 16.1 days. After tracheal decannulation the stoma closed completely within 48–72 h in both the groups. The other four patients survived with their tracheostomies and probably will never be decannulated due to their primary disease. Mean duration of the procedure was nearly similar for both the groups (19 min in PDT versus 21 min in ST), with no statistical differences between them. Mean size of tracheostomy tube used in procedures was smaller in case of PDT group (7.8 ± 0.3) compared with ST group (8.7 ± 0.2). However, post-operative and intra-operative bleeding for both the groups was nearly similar with no statistical difference (Table 2).
Table 1.
Demographic characteristics among patients in the two studied groups
| Characteristics | PDT group (n = 16) |
ST group (n = 16) |
p-value | |
|---|---|---|---|---|
| Age | Mean ± SD | 48.2 ± 15.3 | 50.6 ± 18.4 | NS |
| Range | 24–72 | 25–75 | ||
| Sex | Male N (%) | 9 (56.25) | 8 (50.00) | NS |
| Female N (%) | 7 (43.75) | 8 (50.00) | ||
| Duration of intubation (days) | Mean ± SD | 13.05 ± 5.16 | 12.06 ± 4.72 | NS |
| Range | 7–24 | 7–20 | ||
PDT Percutaneous dilatational tracheostomy, ST Surgical tracheostomy, NS No statistically significant difference
Table 2.
Intra-operative and post-operative characteristics among both the studied groups
| Characteristics | Severity of complication | PDT group (n = 16) |
ST group (n = 16) |
p-value* |
|---|---|---|---|---|
| Intra-operative bleeding | Minimal | 10 | 11 | NS |
| Moderate | 6 | 5 | ||
| Severe | 0 | 0 | ||
| Post-operative infection after 7 days | Zero | 14 | 5 | NS |
| Mild | 1 | 5 | ||
| Moderate | 1 | 4 | ||
| Severe | 0 | 2 | ||
| Length of Sear (cm) | < 1 cm | 4 | 1 | NS |
| 1–2 cm | 11 | 5 | ||
| > 2 cm | 1 | 10 |
*Statistically significant difference (p-value < 0.05)
Tracheostomy complications in PDT and ST are presented in Table 3. A perusal of the data revealed that PDT had lower number of total complications as compared to ST (20 PDT versus 24 in ST). Though there is no significant difference in intra-operative bleeding in both the groups, yet post-operative infection after 7 days is more in ST group. Similarly the length of scar (cm) is more in ST which results in bad cosmetics of the patients. In the present study, the most important early post-operative complication was stomal infection in three patients of the ST group. The most striking feature of the present study was that none of the complications resulted in significant morbidity such as poor oxygenation, requirement of blood transfusion or aspiration of gastric contents.
Table 3.
Tracheostomy complications in two groups of patients
| Complications | PDT group (n = 16) |
ST group (n = 16) |
p-value* |
|---|---|---|---|
| I.Peri-operative: | |||
| i. Haemorrhage | |||
| Minimal | 10 | 11 | NS |
| Moderate | 6 | 5 | NS |
| ii. False passage | 0 | 0 | NS |
| iii. Pneumothorax | 0 | 0 | NS |
| iv. Deaths | 0 | 0 | NS |
| v. Sub-cutaneous emphysema | 0 | 1 | NS |
| vi. Puncture of endotracheal tube cuff | 1 | 0 | NS |
| II. Post-operative | |||
| i. Haemorrhage (minimal) | 2 | 1 | NS |
| ii. Significant bleeding | 0 | 0 | NS |
| iii. Stomal infection | 0 | 3 | NS |
| iv. Peristomal granuloma | 0 | 1 | NS |
| v. Persistent stoma | 0 | 1 | NS |
| vi. Accidental decannulation | 0 | 1 | NS |
| vii. Tracheal stenosis | 1 | 0 | NS |
| Total complictions | 20 | 24 | |
PDT Percutaneous dilatational tracheostomy, ST Surgical tracheostomy, NS Statistically not significant
Discussion
Elective surgical tracheostomy (ST) is often performed in critically ill patients who need prolonged respiratory care and, therefore, is a widely accepted procedure in the ICU. Despite the long experience with ST, the technique still has many complications with an overall incidence of 6–66% including pneumothorax or sub-cutaneous emphysema (4–17%), tube dislodgement (0–7%), bleeding (3–37%), stomal infection (17–36%) and a mortality rate of 0–5.3% [6, 7]. PDT, on the other hand, has a number of advantages over ST as the former requires only a small skin incision, minimal blunt dissection of the anterior tracheal structures, takes only 1–10 min to perform and is commonly preferred at bed side [5, 8]. Moreover, PDT is associated with a reduction in the incidence of clinically important wound infections compared to traditional ST. Still more importantly there is no evidence that PDT resulted in an increased incidence of clinically significant bleeding, major peri-procedural long term complication [6, 7, 9]. A meta-analysis of five prospective randomized comparisons of the classic work of Ciaglia et al. [2] indicated that PDT and ST (in the OT) witnessed similar and infrequent acute complications for the two techniques. The complications noted and the ranges of their occurrences in the individual reports are summarized in Table 4 [10]. The report included pooled data of 236 patients.
Table 4.
Frequency of reported complications in prospective controlled trials that compared ST with PDT (after Durbin, 2005)
| Complications | Patients who experienced the complication (%) | |
|---|---|---|
| ST | PDT | |
| Minor haemorrhage | 0–80 | 0–20 |
| Major haemorrhage | 0–7 | 0 |
| Pneumothorax | 0–4 | 0–4 |
| Accidental decannulation | 0–15 | 0–4 |
| Sub-cutaneous emphysema | 0–4 | 0 |
| Stomal infection | 0–63 | 0–10 |
| Difficult insertion | 0 | 0–27 |
| False placement | 0 | 0–4 |
| Hypoxia | 0–8 | 0–25 |
| Loss of airway/death | 0 | 0–8 |
In this procedure on 32 patients, the PDT was not associated with clinically important haemorrhage (blood loss requiring blood transfusion), purulent infection at the stoma, or any lethal complication. Contrarily, the ST group of 16 had 3 patients with stomal infection which was facilitated by the wide spread dissection required for ST. In the present study, one patient from PDT group had a puncture of the cuff of endo-tracheal tube and one patient in ST group had sub-cutaneous emphysema in the post-operative period (Table 3). The above study gains further support from other perspective studies, suggesting that the serious complication rates of the single step technique in PDT is less than 3% [7, 11]. Another meta-analysis that included case series as well as prospective studies also suggested a better outcome for stoma wound infection and tracheal stenosis with PDT but a higher mortality [10, 12]. Comparison of ST (21 trials, 3,512 patients) and PDT (27 trials, 1,817 patients) demonstrated that perioperative complications are more frequent with PDT (10% versus 3%), whereas post-operative complications were more frequent following ST (10% versus 7%) [10, 12]. Dalaney et al. [13] also mentioned that it is not surprising to find reduced incidence of wound infection with PDT and stated that minimally invasive surgical techniques is a factor for reduction in the rates of surgical site infections [9, 14, 15]. Minor complications such as bleeding not needing intervention, transient desaturation and the need to convert to open procedure from PDT were reported rarely [12].
Though the success of the PDT technique has caused gradual abandoning of the surgical procedure (ST) in adult ICU patients, yet it is not recommended in its present form in emergencies of overlying enlarged thyroid glands, in marked obesity, in children and whenever the cricoids cartilage cannot be definitely palpated [6]. Ciaglia and Graniero [16] opine that peri-operative complications in PDT are few and minor. Many authors also believe that PDT techniques have significant advantages when compared to the standard surgical tracheostomy [6].
Conclusions
In conclusion, PDT technique, though associated with increased technical difficulties when compared with ST [17], is as safe and effective as ST, yet has low incidence of post-operative complications. PDT reduces the overall incidence of wound infection and may further reduce clinical bleeding and mortality when compared to ST. The main advantage of PDT is its application in ICU as a bedside procedure which prevents unnecessary delays and risks of transfer to the operating room. In view of the above, PDT may be considered the “procedure of choice” for performing elective tracheostomies in critically ill adult patients.
Acknowledgements
The authors are highly thankful to Prof. (Dr.) Ashok K. Pandit, Former Director, Centre of Research for Development and Former Head, P.G. Department of Environmental Sciences, University of Kashmir, Srinagar (Jammu and Kashmir) for going through the early draft of the paper and making some useful corrections.
Funding
This research did not receive any grants from funding agencies in the public, commercial or not-for-profit sector.
Declarations
Conflict of Interest
There is no competing interest among the authors and are solely responsible for the content and writing of the paper.
Ethical Approval
Ethical approval was taken from the Institutional Ethical Committee for the purpose of the study. All procedures performed in this study were in accordance with the ethical standards of the institution.
Informed Consent
Informed consent was obtained from all individual participants included in the study.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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