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. 2000 Jun 17;320(7250):1668.

Recent advances in intensive care

Percutaneous tracheostomy may not be more effective than open technique

Natalie Brookes 1, David Howard 1
PMCID: PMC1127437  PMID: 10905837

Editor—In his review of recent advances in intensive care Stott emphasised the efficacy of percutaneous tracheostomy over the conventional open surgical approach.1 We agree that percutaneous tracheostomy may indeed be the preferred method in selected cases, but it is invariably not used in patients who present anatomical challenges such as a short, thick neck; goitre; a history of neck surgery; or a concurrent coagulopathy. Such difficult cases probably represent about a quarter of an average population requiring tracheostomy.

We disagree with Stott's assertion that the incidence of complications has been shown to be lower with percutaneous tracheostomy than with open surgical techniques. The paper quoted in support of this statement—by Hill et al—describes the results of 356 percutaneous procedures performed in a single unit over four years.2 No direct comparison is made with open tracheostomies, and the authors do not report the numbers and type of patients deemed unsuitable for percutaneous tracheostomy and referred for open procedures. The six previous independent series quoted that detailed complication rates for open tracheostomy were published on average nearly 20 years earlier, and a conclusion was reached by comparison with these older studies.

Stott fails to mention Dulguerov et al's meta-analysis reported in 1999, which showed that percutaneous tracheostomy is associated with a higher prevalence of certain complications.3 Their comparison of recent surgical tracheostomy trials (n=21; 3512 patients) and percutaneous tracheostomy trials (n=27; 1817 patients) shows that perioperative complications are more common with the percutaneous technique (10% v 3%), whereas postoperative complications occur more often with the surgical technique (10% v 7%). The bulk of the differences is in minor complications, except perioperative death (0.44% v 0.03%) and serious cardiorespiratory events (0.33% v 0.06%), which were much higher with the percutaneous technique. These authors also noted significantly fewer complications in recent studies compared with older ones.

In the present state of knowledge it would seem unethical to mount a large double blind trial comparing the two techniques as this would subject about a quarter of patients, who would usually be deemed unsuitable for a percutaneous technique, to an increased risk of complications. It is likely that such patients will continue to be referred for open tracheostomy. While this selection bias continues, it is misguided to state that percutaneous tracheostomy holds fewer risks than the open technique.

References

  • 1.Stott S. Recent advances in intensive care. BMJ. 2000;320:358–361. doi: 10.1136/bmj.320.7231.358. . (5 February.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Hill BB, Zweng TN, Maley RH, Charash WE, Toursarkissian B, Kearney PA. Percutaneous dilatational tracheostomy: report of 356 cases. J Trauma. 1996;41:238–243. doi: 10.1097/00005373-199608000-00007. [DOI] [PubMed] [Google Scholar]
  • 3.Dulguerov P, Gysin C, Perneger TV, Chevrolet JC. Percutaneous or surgical tracheostomy: a meta-analysis. Crit Care Med. 1999;27:1617–1625. doi: 10.1097/00003246-199908000-00041. [DOI] [PubMed] [Google Scholar]
BMJ. 2000 Jun 17;320(7250):1668.

Author's reply

Stephen Stott 1

Editor—Brookes and Howard's point that not all patients are suitable for a percutaneous tracheostomy is well made, but the figure quoted of 25% is conjecture and not referenced. As I cannot find any data to produce a figure of my own I will not, but I do question their final paragraph when they state that because of this figure a double blind trial would be unethical. This is curious as nowhere in my article did I suggest that one should be performed.

The meta-analysis referenced looks only at studies published up to 1996 and compares four different percutaneous techniques with surgical tracheostomies performed in two different eras.1-1 As most of the deaths occurring with percutaneous tracheostomy occur with a non-dilatational technique it would seem prudent to exclude these from the analysis.

There have been three published prospective trials comparing dilatational percutaneous tracheostomy with open surgical techniques.1-2–1-4 These show complication rates for percutaneous tracheostomy to be as low as or lower than those for the surgical technique. This, coupled with the reduced cost, avoidance of moving critically ill patients, and low long term complication rates, means that I can still conclude that percutaneous tracheostomy is a significant recent advance.

References

  • 1-1.Dulguerov P, Gysin C, Perneger TV, Chevrolet JC. Percutaneous or surgical tracheostomy: a meta-analysis. Crit Care Med. 1999;27:1617–1625. doi: 10.1097/00003246-199908000-00041. [DOI] [PubMed] [Google Scholar]
  • 1-2.Hazard P, Jones C, Benitone J. Comparative clinical trial of standard operative tracheostomy with percutaneous tracheostomy. Crit Care Med. 1991;19:1018–1024. doi: 10.1097/00003246-199108000-00008. [DOI] [PubMed] [Google Scholar]
  • 1-3.Crofts SL, Alzeer A, McGuire GP, Wong DT, Charles D. A comparison of percutaneous and operative tracheostomies in intensive care patients. Can J Anaesth. 1995;42:775–779. doi: 10.1007/BF03011175. [DOI] [PubMed] [Google Scholar]
  • 1-4.Friedman Y, Fides J, Mizock B, Samuel J, Patel S, Appavu S, et al. Comparison of percutaneous and surgical tracheostomies. Chest. 1996;110:480–485. doi: 10.1378/chest.110.2.480. [DOI] [PubMed] [Google Scholar]
BMJ. 2000 Jun 17;320(7250):1668.

More still needs to be known about immunonutrition

Steven D Heys 1

Editor—I have concerns over one section in Stott's article on recent advances in intensive care.2-1 These concerns relate to the paragraphs on nutrition, and particularly the key points box on page 358; there it is stated that recent work has shown that omega 3 polyunsaturated fatty acids improve mortality in critical illness.

The question of immunonutrition is complex, and the different nutrients used in clinical trials can have different, and opposing, effects on the immune system. For example, L-arginine and glutamine stimulate a variety of immune functions.2-2 In contrast, omega 3 and omega 6 fatty acids inhibit a variety of immune functions.2-2,2-3

The timing of administration of these nutrients may therefore be critically important: although it is generally believed that stimulation of the immune system is beneficial in critically ill patients, this may not always be the case. For example, in certain patients (those with adult respiratory distress syndrome or multiorgan failure) in whom the cytokine cascade and production of inflammatory mediators has been suggested to be excessive, administration of omega 3 and omega 6 fatty acids would be beneficial in reducing production of these mediators.

In terms of immunonutrition affecting clinical outcome in critical illness, a recent critical analysis of all the randomised controlled trials in which L-glutamine was given found little evidence to support its routine clinical use.2-4 A recent meta-analysis found that giving combinations of immunomodulatory nutrients reduced infectious complications but not mortality.2-5

When the use of nutrition in critically ill patients is being considered, these considerations must be taken into account. It is still not clear which patients will benefit from being fed these immunomodulatory nutrients and which may not.

References

  • 2-1.Stott S. Recent advances in intensive care. BMJ. 2000;320:358–361. doi: 10.1136/bmj.320.7231.358. . (5 February.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2-2.Heys SD, Gough DB, Khan L, Eremin O. Nutritional pharmacology and malignant disease: a therapeutic modality. Br J Surg. 1996;83:608–619. doi: 10.1002/bjs.1800830508. [DOI] [PubMed] [Google Scholar]
  • 2-3.Almallah YZ, El-Tahir A, Heys SD, Richardson S, Eremin O. Distal procto-colitis and n-3 polyunsaturated fatty acids: the mechanism(s) of natural cytotoxicity inhibition. Eur J Clin Invest. 2000;30:58–65. doi: 10.1046/j.1365-2362.2000.00581.x. [DOI] [PubMed] [Google Scholar]
  • 2-4.Heys SD, Ashkanani F. Glutamine. Br J Surg. 1999;86:289–290. doi: 10.1046/j.1365-2168.1999.01060.x. [DOI] [PubMed] [Google Scholar]
  • 2-5.Heys SD, Walker LG, Smith I, Eremin O. Enteral nutritional supplementation with key nutrients in patients with critical illness and cancer: a meta-analysis of randomized controlled clinical trials. Ann Surg. 1999;229:467–477. doi: 10.1097/00000658-199904000-00004. [DOI] [PMC free article] [PubMed] [Google Scholar]

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