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Three Part Question

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

Clinical Scenario

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.

Search Strategy

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].

Search Outcome

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

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Massick et al, 2001, USA	164 patients requiring tracheostomy in total. 100 met criteria for bedside procedure:- 50 percutaneous dilational tracheostomy (PDT) 50 bedside surgical tracheostomy (BS) 64 had surgical (TS) tracheostomy in theatre	PRCT (level 1b)	To compare complications and resource utilization. Perioperative complications	Bleeding: PDT=2/ BS=0/ TS=6 Pneumothorax: PDT=0/ BS=0/ TS=1 Conv. to open: PDT=2/ BS=na/ TS=na
			Postoperative complications	Bleeding: PDT=2/ BS=1/ TS=4 Infection: PDT=1/ BS=0/ TS=0 Tube displacement: PDT=4/ BS=0/ TS=0 Cost in $: PDT=910/ BS=436/ TS=2670
Heikkinen et al, 2000, Finland	57 patients requiring tracheostomy PDT 30 Surgical Tracheostomy (ST) 26	PRCT (Level 1b)	To compare the complication rates, time to insertion and cost	Time for insertion PDT mean = 11 m. ST mean = 14 m NS. Moderate bleeding (intra op) seen in PDT= 1. ST= 5 Mean Cost in $ PDT= 161. ST 357 p<0.001.	Small sample size
Freeman et al, 2000, USA	5 studies with 236 patients in total	Meta-analysis (Level 1a)	To compare peri and post procedural complications	Relative to ST, PDT was associated with less operative bleeding (OR 95% CI), 0.15 (0.02 to 0.39). Lower overall complication rate (OR 95% CI), 0.15 (0.07 to 0.29). Lower post operative bleeding (OR 95% CI), 0.39 (0.18 to 0.88). Lower stomal infections (OR 95% CI), 0.02 (0.01 to 0.07). There was no difference between the 2 methods with respect to overall complications.
Dulguerov et al, 1999, Switzerland	65 studies total of 9,514 patients ST Surgical (1960-84) 4185 ST (1985-96) 3512 PCT 1817	Meta-analysis (Level 1a)	Peri and Post operative complications, divided further into severe,intermediate and minor	Serious peri-op complications: 239 per 10000 ST (1960-84). 86 per 10000 ST (1985-96). 146 per 10000 PDT. Serious post op complications: 845 per 10000 ST (1960-84). 256 per 100000 ST (1985-96). 278 per 10000 PDT. Intermediate post op complications: 1063 per 10000 ST (1960-84). 146 per 10000 ST (1985-96). 78 per 10000 PDT. Minor post op. complications: 1372 per 10000 ST (1960-84). 561 per 10000 ST (1985-96). 324 per 10000 PDT	Improved techniques during the duration of study. PCT performed by several techniques
Gysin et al, 1999, Switzerland	70 patients ( ITU and elective patients) requiring tracheostomy randomised to:- PT (Percutaneous) =35 ST (Surgical) =35	PRCT (level 1b)	To see if any differences were present in procedure-related variables, peri op and post op complications Peri op complications	Serious 0 in each gp. Intermediate 0 in ST. 1 in PDT Minor complications: 4 in ST 40%. 14 in PDT 11.4% p=0.013 Difficult Tube placement: 2 in ST.9 in PDT p=0.045	Small sample size Large dropout rate in PDT population reducing the number available for long term evaluation 60 % of patients were elective patients
			Early Post Op Complications	Total 8 in ST(22.8%). 14 in PDT (40%) NS
			Late Post Op Complications	Tracheal cartilage lesion: ST = 1. PDT = 0. NS Delayed closure: ST = 2 PDT = 1 NS Unesthetic scar: ST = 8 PDT = 2 NS
Porter et al, 1999, USA	24 surgical patients requiring tracheostomy were randomised to:- Bedside open (STO) Bedside percutaneous PDT ( 12 in each group) In addition there was 46 patients having open procedure (STT) in theatre	PRCT (level 1b)	Complications Intra procedural	N: PDT 12/ STO 12/ STT theatres 46 Hypoxia:PDT 3/ STO 1/ STT theatres 4 Failed Insertion: PDT 1/ STO 0/ STT theatres 1 Death: PDT 1/ STO 0/ STT theatres 0	Small sample size
			Complications Post procedural	Infection:PDT 0/ STO 0/ STT theatres 2 Death: PDT 0/ STO 0/ STT theatres 1 Decannulation: PDT 0/ STO 0/ STT theatres 1 Bleeding: PDT 0/ STO 0/ STT theatres 1 Pneumothorax: PDT 0/ STO 0/ STT theatres 1
Holdgaard et al, 1998, Scandinavia	60 patients requiring tracheostomy PDT (percutaneous) N=30 ST (Surgical) N=30	PRCT (level 1b)	To compare safety and efficacy of the 2 techniques:	Duration:ST 15.5 (5-47)/ PDT 11.5 (7-24) p<0.01
			Intra op complications	Minor bleed: ST 24/ PDT 6 p<0.01 Major bleed: ST 2/ PDT 0 NS Cuff puncture: ST 0/ PDT 5 p<0.05 Resistance to tube: ST 0/ PDT 8 p<0.01
			Post op complications	Minor bleed: ST 9/ PDT 2 p<0.05 Major bleed: ST 1/ PDT 1 NS Minor infection: ST 11/ PDT 3 p<0.01 Major infection: ST 8/ PDT 0 p< 0.01 Aspiration: ST 2/ PDT 1 Pneumothorax: ST 0/ PDT 1 Hypoxia: ST 1/ PDT 0
Reilly et al, 1997, USA	25 patients requiring tracheostomy:- Percutaneous endoscopic tracheostomy (PET) N=10 Percutaneous doppler tracheostomy (PDT) N=10 Surgical Tracheostomy (ST) N=5	PRCT (level 2b)	To determine whether hypercarbia occurs during tracheostomy and the extent of [delta] PaCO2 for each method	No significant intra procedural complications seen Max [delta] Pa CO2 ( mm Hg): PET 24+/-3* PDT 8+/-2 ST 3+/-1 p<0.005 Max [delta] pH: PET -0.16 +/- 0.02* PDT -0.07 +/- 0.02 ST -0.04 +/- 0.01 * p<0.05 v PDT and ST	Small sample size
Graham et al, 1996, Canada	Patients requiring elective tracheostomy for prolonged mechanical ventilation Randomised to:- Percutaneous (PDT) N = 31 Operative (ST) N = 29	Retrospective cohort study (level 3b)	To compare complication rates between the 2 methods - Major complications:	Aspiration: PDT=0 ST=1 Bleeding: PDT=2 ST=0 Infection: PDT=1 ST=0 Pneumothorax (chest drain): PDT=1 ST=2 Delayed airway loss: PDT=2 ST=0 Procedural airway loss: PDT=1 ST=1 Pneumonia: PDT=0 ST=1 Total: PDT=7 ST=5	Small sample size
			To compare complication rates between the 2 methods - Minor complications:	Air leak: PDT=6 ST=4 Bleeding: PDT=1 ST=2 Infection: PDT=1 ST=3 S/C emphysema: PDT=1 ST=1 Pneumothorax (no drain): PDT=1 ST=1 Haematoma: PDT=1 ST=0 Pneumo-mediastinum:PDT=12 ST=12 1 1
Friedman et al, 1996, USA	53 patients requiring tracheostomy in the ICU setting PDT(percutaneous) N=26 ST (Surgical) N=27	PRCT (level 2b)	To compare complications: BP<90mmHg SaO2<90% Bleeding (ml)-Small 25-100, Mod 100-250, Severe >250	Complications Intraprocedure:Duration min: PDT 8.2+/- 4.9 ST 33.9+/-14 Lowest Sao:PDT 97.6+/-3.1 ST 95.4+/-3.9 Low BP: PDT 4 ST 3 Low Sao2: PDT 0 ST 3 Small bleed: PDT 3 ST 3 Para tracheal insertion: PDT 1 ST 0 Complications Post procedure:Accidental decannulation: PDT 1 ST 4 Severe bleed: PDT 1 ST 1 Small bleed: PDT 1 ST 3 Infection: PDT 0 ST 4 Total: PDT 3 ST 12(p<0.05 for ST only)	Small sample size
Crofts et al, 1995, Canada	53 consecutive patients requiring tracheostomy PDT(percutaneous) N = 25 ST(Surgical) N = 28	PRCT (level 2b)	To compare complication rates between group	Minor bleed: PDT 3 ST 3 Atelectasis: PDT 1 ST 1 Cuff leak: PDT 0 ST 2 Stomal infection: PDT 0 ST 1 Pneumothorax: PDT 0 ST 1	Small sample size
Hazard et al, 1991, USA	46 patients in respiratory failure in whom tracheostomy was indicated. Randomised to Gp. 1. Operative tracheostomy N= 24 Gp. 2. Percutaneous tracheostomy N=22	PRCT (level 2b)	Adverse events related to tracheostomy	Pre decannulation: 24 in each group Procedure duration: 13.5+/- 7.3 mins Gp. 1. v 4.3 +/- 2.2 mins Gp. 2 p< 0.001 Bleeding: 4 Gp.1 v 1 Gp.2 Infection: 8 Gp.1 v 1 Gp.2 p<0.01 Pneumothorax: 1 Gp.1 v 1 Gp.2 After Decannulation: 8 in Gp. 1, 11 in Gp.2 Delayed Healing: 3 Gp. v 0 Gp.2 Stenosis: 5 Gp.1 v 2 Gp.2 p< 0.05 Deformity score >3: 2 Gp.1 v 1 Gp.2	Small sample size
Griggs et al, 1991, Australia	227 patients requiring tracheostomy randomised to:- 153 percutaneous tracheostomy (PDT) 74 surgical tracheostomy (ST)	PRCT (level 1b)	Adverse effects related to tracheostomy	Death:ST : PDT 1:0 Primary bleed: ST : PDT 1:2 Secondary bleed: ST : PDT 2:4 Pneumothorax: ST : PDT 1:0 Wound infection: ST : PDT 5:0 Wound breakdown: ST : PDT 2:0 Total complication rate: ST : PDT 18.9%:3.9%

Comment(s)

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.

Clinical Bottom Line

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.

References

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. Laryngoscope 2001;111:494–500.
2. Heikkinen M, Aarnio P, Hannukainen J. Percutaneous dilational tra- cheostomy or conventional surgical tracheostomy. Crit Care Med 2000;28:1399–1402.
3. Freeman BD, Isabella K, Lin N, Buchman TG. A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients. Chest 2000 Nov;118(5):1412-8.
4. Dulguerov P, Gysin C, Perneger TV, Chevrolet JC. Percutaneous or surgical tracheostomy: a meta-analysis. Crit Care Med 1999;27:1617–1625.
5. Gysin C, Dulguerov P, Guyot JP, Perneger TV, Abajo B, Chevrolet JC. Percutaneous vs. surgical tracheostomy: a double-blind randomized trial. Ann Surg 1999;230:708–714.
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. Am Surg 1999;65:142–146.
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. Acta Anaesthesiol Scand 1998;42:545–550.
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. Intensive Care Med 1997;23:859–864.
9. Graham JS, Mulloy RH, Sutherland FR, Rose S. Percutaneous vs. open tracheostomy: a retrospective cohort outcome study. J Trauma 1996;41:245–248. discussion 248–250.
10. Friedman Y, Fildes J, Mizock B, Samuel J, Patel S, Appavu S, Roberts R. Comparison of percutaneous and surgical tracheostomies. Chest 1996;110:480–485.
11. 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.
12. Hazard P, Jones C, Benitone J. Comparative clinical trial of standard operative tracheostomy with percutaneous tracheostomy. Crit Care Med 1991;19:1018–1024.
13. Griggs WM, Myburgh JA, Worthley LI. A prospective comparison of a percutaneous tracheostomy technique with standard surgical tracheostomy. Intensive Care Med 1991;17:261–263.