• 
• 

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].

Clinical Scenario

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.

Search Strategy

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.

Search Outcome

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

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Hoehne et al, 2005, USA	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, 2003, USA	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.
2003, Italy	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, 2003, Netherlands	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, 2002, Germany	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, 1977, Germany	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

Comment(s)

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.

References

1. Hoehne F, Ozaeta M, Chung R, et al. Routine chest X-ray after percutaneous tracheostomy is unnecessary. American Surgeon 2005; 71:51-3.
2. Datta D, Onyirimba F, McNamee MJ, et al. The utility, of chest radiographs following percutaneous dilational tracheostomy. Chest 2003; 123:1603-6.
3. 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.
4. 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.
5. 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.
6. Berrouschot J, Oeken J, Steiniger L, Schneider D, et al. Perioperative complications of percutaneous dilational tracheostomy. Laryngoscope 1997; 107:1538-44.