Three Part Question
In [patients who have undergone bronchoscopy guided percutaneous dilational tracheostomy in intensive care] is a [routine chest x ray necessary] to [rule out immediate postoperative complications like pneumothorax, pneumomediastinum or malposition of tube].
In the Intensive care unit, a bronchoscopy guided percutaneous dilational tracheostomy (PDT) was performed. There were no clinical signs to suggest immediate post-operative complications like pneumothorax, pneumomediastinum or malposition of tracheostomy tube. You wonder whether a chest X-ray is appropriate to rule out the above mentioned complications.
Medline 1966-05/04 using the Ovid interface.
[percutaneous.mp. OR seldinger.mp.] AND [tracheostomy.mp. OR exp tracheostomy/ OR tracheostom$.mp. OR tracheotom$.mp. OR exp tracheotomy/ ] AND [exp postoperative complications/ OR complications.mp.] LIMIT to human.
Altogether three hundred twenty-four (324) papers were found, six (6) of which were relevant to the three part question. These six papers are shown in the table
|Author, date and country
||Study type (level of evidence)
|Hoehne et al,|
|73 patients underwent bronchoscopy guided PDT. The majority of the tracheostomies were in trauma patients who needed prolonged ventilatory support.||Retrospective chart review||Operative complications detected on CXRs||There were no complications identified on postprocedure chest X-ray.||Retrospective review of chest X-rays in a small patient group|
|Datta et al,|
|Sixty medicalsurgical ICU patients who underwent PDT under
bronchoscopic visualization, for persistent ventilator dependence.||Retrospective chart review||Operative complications detected on CXRs||In 2 of the 60 patients (3.3%) complications were detected on the post procedure CXRs. One with a pneumomediastinum and the other with a tension pneumothorax.||Retrospective review of chest X-rays in a small patient group.|
|181 patients admitted between July 1998 and June 2000 who
underwent PDT under bronchoscopic guidance, for mechanical ventilation.||Prospective collection of data||Postoperative pneumothorax or pneumomediastinum or malposition of tube.||No patient had postoperative pneumothorax, pneumomediastinum or malposition of tube.||Small number of patient group.|
|Polderman et al,|
|174 critically ill patients in the ICU who underwent
bronchoscopic guided PDT.||Prospective study||Postoperative pneumothorax or pneumomediastinum or malposition of tube.||No patient had postoperative pneumothorax, pneumomediastinum or malposition of tube.||Small number of patients group|
|Beiderlinden et al,|
|136 bronchoscopy guided PDT were performed on mechanically
ventilated patients in ICU.||Prospective study||Postoperative pneumothorax or pneumomediastinum or malposition of tube.||No patient had postoperative pneumothorax, pneumomediastinum or malposition of tube.||Small number of patients group|
|Berrouschot et al,|
|76 patients underwent PDT. In 41 patients, PDT was performed
"blind." In 35 patients it was executed with simultaneous
bronchoscopic monitoring.||Prospective study||The type and rate of complications of the two groups were compared. It looked into the incidence of complications in these two groups.||One death due to tension pneumothorax in the group where PDT was performed "blind." No incidence of pneumothorax/ pneumomediastinum/malposition of tube, where PDT was under bronchoscopic guidance.||Small number of patients group|
The study of Hoehne F et al and Datta D et al are retrospective, so the evidence base is limited. Although all these 6 studies are based on small number of patient groups, it is apparent that all these studies unanimously agree on the following point. There is no benefit in doing routine chest-rays to rule-out immediate postoperative complications like pneumothorax, pneumomediastinum and malposition of tube, following bronchoscopy guided PDT.
Clinical Bottom Line
At present there is no clinical evidence to support routine post-procedure chest X-ray following bronchoscopy guided percutaneous dilational tracheostomy (PDT). But larger study is required to answer this clinical query.
- Hoehne F, Ozaeta M, Chung R, et al. Routine chest X-ray after percutaneous tracheostomy is unnecessary. American Surgeon 2005; 71:51-3.
- Datta D, Onyirimba F, McNamee MJ, et al. The utility, of chest radiographs following percutaneous dilational tracheostomy. Chest 2003; 123:1603-6.
- Gambale G, Cancellieri F, Baldini U, Vacchi Suzzi M, Baroncini S, Ferrari F,Petrini F, et al. Ciaglia percutaneous dilational tracheostomy. Early and late complications and follow-up. Minerva Anestesiologica 2003; 69:825-30;830-3.
- Polderman KH, Spijkstra JJ, de Bree R, Christiaans HM, Gelissen HP, Wester JP, Girbes AR, et al. Percutaneous dilatational tracheostomy in the ICU: optimal organization, low complication rates, and description of a new complication. Chest 2003; 123:1595-602.
- Beiderlinden M, Karl Walz M, Sander A, Groeben H, Peters J, et al. Complications of bronchoscopically guided percutaneous dilational tracheostomy: beyond the learning curve. Intensive Care Medicine 2002; 28:59-62.
- Berrouschot J, Oeken J, Steiniger L, Schneider D, et al. Perioperative complications of percutaneous dilational tracheostomy. Laryngoscope 1997; 107:1538-44.