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

FURTHER READING


CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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