Percutaneous vs Surgical Tracheostomy
OVERVIEW
- Percutaneous tracheostomy = reference to a number of different techniques to insert a tracheostomy (gradual dilation, forceps dilation, rhino and translaryngeal techniques)
- Surgical tracheostomy = surgical dissection down to trachea, creation of window in trachea with insertion of tracheostomy tube for ventilation.
PERCUTANEOUS TRACHEOSTOMY
Benefits
- no transport neeeded
- decreased local infection
- less bleeding
- less cosmetic deformity
- quicker
- less planning and logistics
- less expensive and better resource utilisation
- tighter fit
- can be performed earlier
- trend toward less VAP
- trend toward less LOS
Disadvantages
- tissues traversed no visualised
- requires bronchoscopy
- risk of bronchoscope damage
- no improvement in pneumothorax risk
Safety and complications
- 8% complication rate
- occlusion by posterior tracheal membrane
- safety is determined by operator volume
SURGICAL TRACHEOSTOMY
Advantages
- dissection under direct vision
- can avoid aberrant vessel
- better for difficult cases
- time honoured
- best control of the airway
- lower complication rate
Disadvantages
- transport required
- more bleeding
- higher risk of tracheal stenosis
Safety and complications
- 9% complication rate
EVIDENCE
PDT = Ciaglia Technique
- 1999 – Dulguerov et al, Critical Care Medicine
- open vs perc. -> PDT+ Bronch = lowest complication rate in percutaneous group
- percutaneous group = lower post op but higher perioperative complication rate
- 2000 – Cheng et al, Ann Otol Rhinol Laryngol
- meta-analysis (including 4 RCT’s)
- open vs PDT -> PDT = lower risk of infection and bleeding -> PDT + Bronch as safe as open tracheostomy
- 2000 – Freeman et al, Chest
- meta-analysis (including 5 RCT’s)
- open vs PDT -> no overall difference in mortality rate -> PDT: quicker, lower post op complications, less bleeding
- 2006 – Delaney et al, Crit Care Med
- large meta-analysis (17 studies)
- PDT vs open -> PDT: lower wound infection, -> no difference in bleeding and complication rates
- 2007 – Higgins et al, Laryngoscope
- PDT vs open
- meta-analysis (15 studies)
- PDT: less infection, less scarring, trend towards lower complication rate, faster, cheaper, lower conversion rate
- PDT: higher accidental decannulation, no difference in bleeding, subglottic stenosis, death
References and Links
CCC Airway Series
Emergencies: Can’t Intubate, Can’t Intubate, Can’t Oxygenate (CICO), Laryngospasm, Surgical Cricothyroidotomy
Conditions: Airway Obstruction, Airway in C-Spine Injury, Airway mgmt in major trauma, Airway in Maxillofacial Trauma, Airway in Neck Trauma, Angioedema, Coroner’s Clot, Intubation of the GI Bleeder, Intubation in GIH, Intubation, hypotension and shock, Peri-intubation life threats, Stridor, Post-Extubation Stridor, Tracheo-esophageal fistula, Trismus and Restricted Mouth Opening
Pre-Intubation: Airway Assessment, Apnoeic Oxygenation, Pre-oxygenation
Paediatric: Paediatric Airway, Paeds Anaesthetic Equipment, Upper airway obstruction in a child
Airway adjuncts: Intubating LMA, Laryngeal Mask Airway (LMA)
Intubation Aids: Bougie, Stylet, Airway Exchange Catheter
Intubation Pharmacology: Paralytics for intubation of the critically ill, Pre-treatment for RSI
Laryngoscopy: Bimanual laryngoscopy, Direct Laryngoscopy, Suction Assisted Laryngoscopy Airway Decontamination (SALAD), Three Axis Alignment vs Two Curve Theory, Video Laryngoscopy, Video Laryngoscopy vs. Direct
Intubation: Adverse effects of endotracheal intubation, Awake Intubation, Blind Digital Intubation, Cricoid Pressure, Delayed sequence intubation (DSI), Nasal intubation, Pre-hospital RSI, Rapid Sequence Intubation (RSI), RSI and PALM
Post-intubation: ETT Cuff Leak, Hypoxia, Post-intubation Care, Unplanned Extubation
Tracheostomy: Anatomy, Assessment of swallow, Bleeding trache, Complications, Insertion, Insertion timing, Literature summary, Perc. Trache, Perc. vs surgical trache, Respiratory distress in a trache patient, Trache Adv. and Disadv., Trache summary
Misc: Airway literature summaries, Bronchoscopic Anatomy, Cuff Leak Test, Difficult airway algorithms, Phases of Swallowing
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC
