Dulguerov et al 1999.pdf

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Abstract

http://archive-ouverte.unige.ch/unige:33175

http://archive-ouverte.unige.ch/unige:33175



S pe cia l A rtic le s

Percutaneous or surgical tracheostomy: A meta-analysis

P a v e l D u lg u e ro v , M D ; C la u d in e G y s in , M D ; T h o m a s V . P e r n e g e r , M D , P h D ; J e a n -C la u d e C h e v r o le t , M D

O b j e c t i v e : T o c om p a re p e r c u t a n e o u s w i th s u r g ic a l t r a c h e o s t o m y

u s in g a m e ta -a n a l y si s o f s tu d i e s p u b lis h e d t r o m 1960 t o

1996.

D a ta S o u r c e s : P ub lic a t i o n s o b t a in ed t h ro ug h a M E D L IN E d a t a -

b a s e s e a r c h w ith a B oo l e a n c o m b in a t i o n t r a c h e o s to m y o r t r a -

c h e o t o m y a n d c o m p l i c a t i o n s , w it h c on s t r a in ts f o r h um a n s tu d i e s

a n d E n g l i s h la n g u a g e .

S t ud y S e le c ti o n : P u b li c a tio n s a dd re ss in g a i l p e r i - a nd p os to p -

e r a t i v e c o m p l i c a t io n s . S tu d ie s l im i t e d t o s p e c i f ic t r a c h eo s t o m y

c o m p l ic a t io n s o r c o n ta i n in g in su ff ic i e n t d e t a i l s w e r e e x c lu d e d .

T w o a u t h o r s i n d e pe nd en tl y s e le c t e d th e p u b lic a t io n s .

D a ta E x tr ac ti o n : A l is t o f r e le v a n t s u r g ic a l v a r i a b le s a n d c o m -

p l ic a t i o n s w a s c o m p i le d . C om p l ic a t i o n s w e r e d iv i d e d in t o p e r i -

a n d p os to p e r a t iv e g ro up s a n d fu rt h e r s u bc la s s i f ie d in to s e v e r e ,

i n t e r m e d ia t e , a n d m in o r g r o u p s . B e c a u s e m o s t s t u d ie s o f p e r c u -

t a n e o u s t r a c h e o s t o m y w e r e p u b l i s h e d a f t e r

1985,

s u r g ic a l t r a -

c h e o s to m y s t u d ie s w e r e d iv i d e d in t o tw o p e r io d s : 1 9 6 0 to 1 9 8 4

a n d 1 9 8 5 t o 1 9 9 6 . T h e a r t ic l e s w er e a n a l y z e d in d e p e n d e n t ly b y

th re e in v e s t i g a t o rs , a n d r a re d is cr e p a nc i e s w e r e r e s o l v e d t h ro u g h

d is c u s s io n a n d d a t a r e e x am i n a t io n .

O a ta S y n th e s i s : E a r l i e r s u rg ic a l t r a ch eo s t o m y s tu d ie s n

=

1 7 ;

T

racheostomy was probably

performed in ancient Egypt,

a nd th e first ele ctiv e tra ch eo s-

to my is attrib uted to A sclepia-

des of Bithynia around 100 BC (l, 2). ln

the 19th century, tracheostom y became

a n e sta blish ed p ro ced ure fo r u pp er airw ay

obstruction secondary to a foreign body,

traum a, and infections, such as diphthe-

ria and croup. Tracheostom y w as view ed

as a very dangerous operation until C hev-

alier Jackson (3) defined the surgical

princip les of the procedure, which are

still in u se to day . Jac kso n (3 ) em ph asize d

a lo ng incision, good exp osure, div isio n o f

the thyroid isthmus, and in a later pub-

F r o m th e D ep a r tm e n t o f O to la r y n g o lo g y - H ea d a n d

N e c k S u r g er y (D rs . D u lg ue ro v a nd G y s in ), t h e In st i t u te

o f S oc ia l a nd P re v e n t iv e M e d ic in e (D r. P e r n e g e r ) , a n d

M e d ic a l I n t e n s iv e C a r e , D ep a r tm e n t o f I n t e r n a i M e d i-

c in e ( D r. C he v r o le t ) , U niv e r s i t y o f G e n e v a H os p i t a l,

G e n e va , S w i t z e rla n d .

A d d re ss r e qu es t s f o r r e pr in ts t o : P a v el D u lg ue ro v,

M D , D iv i s io n o f H e a d a n d N e c k S u r g e r y , U n iv e r s it y o f

G en e v a H os p i t a l, 2 4 , r u e M ic h e l i- d u -C re s t , G e n e v a ,

1 2 0 5 S w it z e r la n d . E -m a il : P a ve I.D u lg u e ro v@ h c u g e . c h

C o p y r i g h t

(Ç )

1 9 9 9 b y L ip p in c o t t W il l ia m s & W i lk in s

C ri t C a r e M e d

1999 V o l . 2 7 , N o . 8

p a t i e n t s , 4185 h a v e th e h ig h e s t r a t e s o f b o t h p e r i - 8 . 5 ) a n d

p o s to p e ra tiv e 3 3 ) c om p lic a t i o n s . C o m p a r is on o f r e ce n t s u r g ic a l

= 2 1 ; p a t ie n t s , 3 5 1 2 ) a n d p e r c u t a n e o u s n

=

2 7 ; p a ti e n ts ,

1 8 1 7 ) t r a c h eo s t o m y t r ia ls s h o w s th a t p e r io p e ra tiv e c om p l ic a t io n s

a r e m o re f r e q ue n t w it h th e p e r c u ta n e o us t e c h n iq u e 1 0 v s . 3 ) ,

w h e r e a s p os to p e r a t iv e c o m p l i c a t io n s o cc u r m o re o ft e n w it h s u r -

g i c a l t r a c h e o t o m y 1 0 v s . 7 ) . T h e b u l k o f t h e d i f f e r e n c e s is in

m in o r c o m p l ic a t i o n s , e x c e p t p e r io p e r a t iv e d e a t h 0 .4 4 v s .

0 . 0 3 ) a n d s e r io u s c a r d i o re s p ir a to ry e v e n ts 0 . 3 3 v s . 0 .0 6 ) ,

w h ic h w e r e h ig h e r w it h t h e p e r c u t a n e o u s t e c h n iq u e . H e t e r o g e -

n e i t y a n a ly s is o f c om p lic a t i o n r a t e s s ho w s h ig h e r h e t e r o g e ne i t y in

o ld e r a n d s u r g ic a l t r i a ls .

C o n c l u s i o n s : P e r c u ta n eo us t r a c h eo st o m y i s a s s o c ia t e d w it h a

h ig h e r p re v a le n c e o f p e r io p e ra tiv e c om p li c a t io n s a n d , e sp e c ia lly ,

p e r io p e ra tiv e d e a th s a n d c a r d io re sp ir a to ry a rr e s t s . P o s t o p e ra ti v e

c o m p l i c a t io n r a t e s a r e h ig h e r w it h s u r g ic a l t r a c h e o s t o m y . C ri t

C a r e M e d 1999; 27:1617-1625

K E v W O R O S :r a ch e o s t o m y ; t r a ch e o to m y ; p e r c u t a n e o u s ; s u r g e r y ;

c om p li c at io n s ; m e ta - a n a ly s is ; m o rt a li t y ; r e v ie w ; e nd o s co p y ; d e -

v i c e s

lication, avoidance o f incisio n of the first

and second tracheal rings (4).

A lthough the operation becam e codi-

fied, the dev elopm ent of endo trach eal in-

tubation (5, 6) grèatly facilitated th e pro-

ce du re b y re mo vin g its em erg en cy statu s in

nume rous c as es . A I so , c on tr ol o f d ipht he ri a

b y im m un iz atio n a nd th e av ailab ility o f an -

tibio tics for the treatm ent of upp er airw ay

in fec tio ns m ad e trac heb stomy an e lectiv e

procedure for m ost patients. The indica-

tio ns o f t he p ro ced ure ex ten ded b ey on d u p-

p er a irw ay obs tru cti on to e nc ompas s tre at-

m ent of chronic obstructive pulm onary

d is ea se a fte r th e re aliz atio n t ha t tra ch eo s-

tomy reduces pulm onary dead space (7),

p ro vides access fo r clearing of ab undant

p ulm on ary sec retio ns in n um ero us p ath ol-

ogies (7, 8), and improves the patient's

com fort during w eaning from the resp ira-

tO I. Probably the m ost dram atic m edical

advance attributable to tracheostom y w as

in the management of poliomyelitis-

in du ced resp irato ry p ara ly sis b y u sin g tra-

c he ostomy to d eliv er p os itiv e p re ss ure v en -

t il at ion ( 9) .

ln the 1960s, the indications for tra-

cheostomy were clarified (10, 11), and

sterile suction and cannula chang es w ere

in tro du ce d (1 0, 1 2). C uffe d tra ch eo stomy

tubes appeared (13), which presented

new problems such as tracheal stenosis

(14), obstruction of the tube lumen by

prolapsed cuffs, an d even extrusion of the

tra ch eo stomy tu be , sometim es re su ltin g

in fatalities (10, 11 ). A ltho ugh the intro-

d uction of low -pressu re cu ffs for trache-

ostom y tubes certainly helped in reduc-

in g th ese co mplications, these cuffs w ere

also used for endotracheal tubes, allow -

ing for prolonged intubation, and a new

controv ersy began on th e d uration of pro-

lo nged en dotracheal intubation. Th e' ap-

propriate tim ing of tracheostomy in in-

tubated patients is yet to be defined (15).

Several p ublication s have described a

p ro hib itiv ely h ig h ra te o f c om plicatio ns

with surg ica l t ra theostomy

( S g T )

(10 , 11 ,

16-18). Several devices are, therefore,

proposed to create a puncture in the pre-

tracheal skin and soft tissues to allow

access to the tracheal lumen (19-23).

This procedure is called percutaneous

trach eostom y (PcT ) (19) an d is p ro posed

as a new bedside procedure with lower

m orbidity (20). H ow ever, articles sho w-

1 6 1 7



ing PcT com plication rates higher than

th os e fo r S gT h av e b een p ub lis hed (2 3-2 8).

T o cr itic aIJ y e va lu ate th e p ro s an d co ns

of PcT, we reviewed the complication

rates of tracheostom y, both surgi cal and

percutan eo us. B ecause the m ajority of lit-

erature on PcT appears after 1985, the re-

v iew o f S gT c omplica tio ns w as s ub div id ed

in to tw o perio ds: 1 960 to 1 98 4 (S gT 19 60 -

1984) a nd 1985 t o 1996 (SgTI985-1996 )'This

aIJow ed com parison b etw een the tw o p ro-

ced ures d uring th e sam e p eriod of m edical

care, w ith the hope of decreasing the role

of other variables, such as intensive care

equipm ent, m onitoring, reanim ation

techn iq ues and dru gs, and posttracheos-

tom y nursing protocols. ln addition, the

use of low -pressure cuffs has been stan-

dard for the last 15 yrs.

MATER IALS AND METHODS

L iterature Search and A rticle Selection.

The M EDLINE database was searched from

1960 to 1996 with a Boolean combination:

(tracheotomy

or

tracheostomy)

and

complica-

tions. Only human studies published in En-

glish w ere inc lu de d. T o lo cate rec en t p ublic a-

tions not yet indexed in MEDLINE, the

Current C ontent issues for the last 3 m onths

of 19 96 w ere rev ie we d. T he sea rc h w as su pp le -

m ented by cross-checking the references in

each article. T he search w as conducted inde-

p endent ly by two inv es ti ga to rs .

As previously stated, the publications on

SgT com plications were separated in tw o pe-

riods, 1 9 6 0 t o 1984 (SgT l960 -1984) a nd 1985

to 1996 (SgT

1 98 ;;- 19 96 )' T h re e a rt ic le s p ub -

lished in the early 1960s (10, 11, 29) clearly

stated that the procedures w ere perform ed be-

fore 1 96 0 an d w ere, th erefo re , e xclu de d. A Iso ,

tw o a rtic le s o n P cT , p ub lish ed b efo re 19 85 (1 9,

23) and concerning nine patients, were ex-

cluded. W e excluded publications w ith few er

than five patients (28, 30), because these w ere

m ore likely to be selected case reports of ad-

v erse effects ra th er. th an stud ies of rep resen -

tat ive samples .

R eview articles a nd p ub lica tion s lim ite d to

sp ec ifie trac he osto my co mp licatio ns, su ch as

tracheal stenosis and tracheoinnom inate fis-

tula, w ere excluded. T o be included, publica-

tions had to address com plications of trache-

ostomy during the procedure, in the early

postoperative period, and delayed or long-

term com plications. Several articles w ere ex-

cluded because of insufficient data about the

c ompl ic ati on s e nc ou nt er ed ( 31 -4 6).

S ev er al p ub lic at io ns s tr es s th at eme rg en cy

tracheostomy (43, 47) and tracheostomy in

pe diatric p atien ts (1 6, 4 8) are asso ciate d w ith

a much higher rate of complications than

ele ctiv e pro ce du res in a du lt pa tien ts. P cT is an

elective procedure perform ed in intubated

adult patients (20,21,23-27,49-69). A single

article on pediatrie percutaneous tracheos-

1618

t omy b y Tou rs ar kis si an e t a l. ( 70 ), c on ce rn in g

11 patients with a mean age of 16 yrs, was

excluded.

Ide ally , th e co mp lic atio ns o f P cT sh ould be

co mpa re d w ith S gT series in w hich al p atie nts

are adults operated on an elective basis. Al-

though most SgT publications in the more

recent 1985 to 1996 period (26, 56, 57, 60, 64,

65, 68, 71-84) fulfill these criteria, only tw o

SgTl960-1984 articles (17, 85) clearly ex-

clu ded c hild ren an d em erg en t p roc ed ures . B e-

cau se e xc lu din g a Il rem ain ing p ub lica tion s o n

S gT in th e 19 60 to 19 84 p erio d (1 8,4 7,8 6-9 8)

w ould have m aC ie the results difficult to com -

pare w ith com plication rates and articles usu-

al y cited in the literature, these publications

w ere in clud ed , d esp ite th e po ssibility o f a bias.

T he s el ec tio n o f p ub lic ati on s w as p erf orm ed in -

d ep en de ntly b y hv o in vestig ato rs (P D an d C G).

Data

Extraction.

A list of the com plica-

tions of tracheostom y w as com piled from re-

cent review s (99, 100) and supplem ented w ith

the com plications listed in the selected arti-

cles. A somewhat arbitrary separation was

m ad e b etw een p eriop erativ e c om plica tion s,

w hich include com plications during the pro-

cedure and those occurring in the next 24 to

4 8 h rs, an d po sto perativ e- co mp lica tio ns cov -

ering the rem aining tim e interval, w hatever it

w as in th e g iv en pu blicatio n. Id eally , pa tien ts

should have been followed up either until

their death or until the trachea had been al-

low ed to he al for sev eral m on ths after ab la tion

of the tracheostom y tube. Such an extensive

duration was studied in some, but not al ,

publications.

B oth p erio pe rativ e and p osto perativ e co m-

plications w ere further subdivided into seri-

o us, in te rm ediate, an d m in or g rou pin gs. S eri-

ous complications are, for the most part,

o bje ctiv ely d efin ed an d are pro ba bly difficu lt

to m iss (d ea th , ca rd io pulm ona ry a rrest, p ne u-

m othorax, pneum om ediastinum , tracheo-

e so ph ag ea l f is tu la , m ed ia st in it is , s ep si s, in tr a-

trach ea l p osto pe rativ e h em orrh ag e, ca nn ula

obstruction and displacem ent, and tracheal

stenosis). Although the definition of most

c omplic at io ns c la ss ifi ed a s i nte rm ed ia te is p re -

cise and objective, the com plications could

have been m issed in chart review studies. In-

term ediate com plications, w hen recognized

and treated appropriately, should not result in

s er io us mor bi di ty . C ompl ic ati on s c la ss if ie d a s

in te rm ed ia te in cl ud e i nt ra op era ti ve d es at ur a-

tion, lesions of the poste ri or tracheal wal ,

cannula m isplacem ent, sw itch of a PcT proce-

d ure to a surg ica l tec hn iq ue, asp ira tion , p neu -

m onia, atele ctasis, a nd le sio ns o f the trac he al

cartilages. Finally, m inor com plications are

som ew hat subjective, less serious, easier to

correct, and rely on the diligence w ith w hich

th ey a re so ug ht a nd rep orted (in trao perativ e

h emor rh ag e, t ub e f als e p as sa ge , d iff ic ult y w ith

tube placem ent, subcutaneous em physem a,

p osto pe ra tive w ou nd he mo rrh ag e, in fec tio ns

such as wound cellulitis and tracheitis, and

late problem s such as delayed closure of tra-

cheostom y tract, keloids, and unaesthetic-

scarring). R arely described com plications

were not considered, unless they resulted in

se riou s o r fata l eve nts.

O nc e t he c ompli ca tio n li st w as e st ab li sh ed ,

the selected p ublica tion s w ere an aly ze d in de-

pendently by three investigators (PD , C G, and

J - C C ) a nd t he c omp li ca tio ns wer e ta bu la te d.

Discordant results were discussed, and the

publications were rechecked to achieve an

agreement.

Data Ana ly s is . T he frequency of each of the

3 2 c om plic ation s w as sum m ed ac ross pu blic a-

tions for each study group (SgT1960-1984,

SgT I98;;-1996' and PeT ), divided by the total

number of patients in each study group, and

expressed as events per 10,000 procedures.

C om plication rates per study group w ere com -

p ared u sin g th e Fish er's ex ac t test (h vo -sid ed ).

Two independent comparisons were per-

form ed: SgT l960-1984 ys.

SgT1985-1996 and

SgT1985-1996YS .P cT . We con si de re dp v al ue s o f

< .05 to b e sta tistically sign ifican t. T ho se rea d-

ers who wish to take the number of tests (62,

s in ce swit ch to s urg i c al te ch ni qu e i s, b y d ef -

inition, a com plication solely of PcT ) into ac-

count should consider as significant only p

values of < .00083, the w isdom of B onferroni

adjustments 1 0 1 being a m atter of cu rrent

debate (102, 103). ln addition, B onferroni ad-

justm ents assum e that ail tests are m utually

independent. This might not be the case for

po stop erativ e co mp licatio ns, w hich are o fte n

related and tend to occur in the sam e patients.

ln this situation, the use of B onferroni ad just-

ments would be too conservative_ -

T o sum marize findings, w e also com puted

totals of complications in each of six sub-

groups (serious, intermediate, and minor,

both peri- and postoperative). For each cate-

g or y o f c ompl ic ati on s (s eri ou s, in te rm ed ia te ,

an d m ino r), sub totals w ere ca lcu late d for eac h

publication and a weighted average was ob-

tained by taking into account the number of

patients in each publication (subjects at risk).

T he nu mb er of p erio pe ra tive , p os to pe ra tive ,

and total com plications per publication w ere

obtained by summing the subtotals for each

category of com plications. D ifferences be-

tween tracheostom y groups regarding these

sum mary variables w ere tested in m odels that

used the total com plications that could occur:

num ber of pati.ents tim es the num ber of pos-

sible com plications. H ow ever, these tests are

co rrect o nly if, in a give n p atie nt, e ve nts (co m-

plications) are m utually independent. If com -

p lica tion s w ere c lu ste re d in the sam e p atie nts,

the p values derived from this analysis w ould

be too extrem e, i.e., biased tow ard rejection of

the null hypothesis. U nfortunately, no data on

the ind ep en den ce o f co mp licatio ns w ere av ail-

a ble in the m ajo rity o f rev iew ed pu blicatio ns.

O ur analysis w as based on the prem ise that

published studies provide a systematic and

rep rese ntativ e picture of th e ge ne ral p rac tic e

of surgical and percutaneous tracheostom y.

Id eally , ail stu dies w ou ld in clud e s im ilar p op -

u la tio ns o f p ati en ts , th e p ro ce du re s p er fo rm ed

using the sam e technique, the com plications

C ri t C a r e M ed 1 9 9 9

V ol. 2 7, N o_ 8



SgT

1960-1984

Sg T

1985-1996

PcT

No. of studies 17 21

27

References

17, 18, 47, 85-98 26, 56, 57, 60, 64, 20, 21, 24-27,

65, 68, 71-84

49-69

No. of patients 4185 3512 1817

Mean age 51.2 : :: 11.5 64.5 : ::7.8 44.8 : :: 6.9

P ediatric cases (% )

6.5 : ::6 .6 0.0

0 .0 6 : :: 0.2

E me rg en cy ca ses

(% )

3 1.5 : :: 24

5.6: :: 7

1 .4 : :: 4. 7

D ay s o f i nt ub ati on

4.0 : ::3.6 12.7 : ::5.2 13.1 : ::3.9

D uration of procedure (m ins)

NA 26.9 : :: 16.5 .

1 1. 7: : : 6 .5

Location: % in ICU 15.5 : ::24

6 5.9 : : :4 6

84. 3 : : :2 7 .6

Table 1. Characteristics of the studies included in the tracheostomy groups

SgT, surgi cal tracheostomy; PcT, percutaneous tracheostomy; ICU, intensive care unit; NA, not

applicable.

The averages and standard deviations for the pediatric cases, em ergency cases, days of intubation,

duration, and location of the procedure are not based on the entire population for each group, because

ce rtain s tu die s d id n ot g iv e a il th e v aria ble s

( s e e

t ex t f or d et ai ls ).

recorded using the sam e standard protocol,

and that the authors published ail available

inform ation. If this w ere true, w e w ould expect

studies in a given subgroup to provide sim ilar

results, w ith differences being attributable

only to chance. Results would be homoge-

neous, and statistical tests of heterogeneity

should be nonsignificant 95% of the time. O n

the contrary, if studies varied in their patient

p op ulatio ns, te ch nic al p ro ce du res , rec ord in g

of com plications, and reporting, w e w ould ex-

pect heterogeneity between studies in the

sam e subgroup. T his is clearly a m ore realistic

scenario. The problem with heterogeneity is

that averaging across heterogeneous studies

y ie ld s re su lts th at a re d iffic ult to in terp re t.

To exam ine the heterogeneity between

studies w ithin each group (PcT ,

SgTI960-198S'

SgT

1985-1996)'

w e com pared study-specific

com plication rates using a Fisher's exact test.

Because of the large number of studies in-

volved, w e used an approxim ation of the Fish-

er's exact test based on 10,000 Monte Carlo

simulations, as implemented in SPSS 6.0

(SP SS , Inc., C hicago, IL ). B ecause 94 hetero-

g en eity tes ts w ere p erfo rm ed , th e B on fe rro ni-

adjusted

p

value w ould be .00053.

To exam ine temporal changes in death

rates, we plotted death rates against study

publication years and exam ined trends, sepa-

rately for SgT and PcT , by m eans of nonpara-

m etric regression lines (104), w hich allow for

a com parison betw een tw o variables w ithout

imp os in g a s pe ci fic ( li ne ar ) r el ati on sh ip .

Sub se ts Anal ys is . Because it has been ar-

gued that PcT com plications could be influ-

enced by the particular PcT set used (24, 60),

a subset analysis w as perform ed on PcT stud-

ies. T he selected P cT publications w ere subdi-

vided in three groups: those using the pro-

gressive dilation technique (20), those using

the sam e progressive dilation technique and

perform ing the procedure under endoscopic

control (30), and those using other tracheos-

to my s ets. S im ila r d ata g ro up in g an d sta tis-

tical tests w ere used.

C ri t C a r e M e d 1 9 99 Vol. 2 7, N o. 8

RESULTS

Seven te en a rt ic le s publi shed between

1 96 0 a nd 1 98 4 an d an aly zin g trach eo s-

t omy compli ca ti ons in 4188 pat ient s con -

stitu te th e S gT l96 0-1 98 4 gro up (T ab le

1 ). ln th is g roup , th e number o f p e dia tr ic

tracheosto mies w as specified in eig ht

stud ies (17 , 47 , 85 -90) w ith an av erag e

ra te o f p ed iatric ca ses o f 6 .5% . The p er-

cen tag e o f em erg en cy trac heo stomies

was sp ecified in 1 2 p ub lica tio ns (1 7, 1 8,

47 , 85 , 8 7-9 4), for an av erag e of 3 1.5% .

On ly fou r s tud ie s i nd ic at ed the numbe r o f

in tub ation d ays (1 7, 18 , 8 5, 87 ) an d the

lo ca tio n o f t h e p ro ce du re ( 18 , 85 , 8 9, 9 0) ,

w ith av erag e nu mb ers of 4 days and 15 %

intens ive ca re unit ( lCU)t racheos tomies .

N o pu blicatio n in this g rou p ind icated

th e d uratio n o f th e p ro ced ure (T ab le 1 ).

Twenty -one publ ic at ions conce rn ing

3512 patients w ho underw ent SgT be-

tween 1985 and 1996 constitute the

SgT

1985-1996

ro up (T able 1 ). S ixteen of

these stud ies (26 , 56 , 5 7, 60 , 6 4, 6 5, 68 ,

71 , 7 3-7 8, 8 2, 84 ) clearly stated th at no

p ed ia tr ic c as es wer e in clu de d. The num-

ber of em ergency tracheostom ies w as

s pe cif ie d in 18 s tu die s ( 26 , 5 6 , 5 7, 6 0, 6 4,

65, 68, 71-74, 76, 77, 80-84) and aver-

aged 5.6% . T he num ber of intubation

d ays w as ind icated in nin e articles (2 6,

57, 65, 68, 71, 72, 76, 81, 82), with an

a ve ra ge o f 12.7 d ay s. The dur atio n o f th e

p ro ced ure was sp ecifie d in s ix p ub lica-

tio ns ( 56 , 57 , 6 0, 6 4, 6 8, 8 3) a nd a ve ra ge d

26.9 m ins. T he location of the surgery

w as in dicated in 17 articles (26 , 60 , 6 4,

65, 68, 71-75, 77-80, 82-84), and the

procedure w as perform ed in the IC U in

6 6% o f cas es (T ab le 1 ).

Twen ty -s ev en a rtic le s w ere p ub lis he d

betw een 1985 and 1996 on percutaneous

tracheostomies (PcT) in 1817 patients

(Table 1). The m ajority (26) of publica-

tions did not contain pediatric cases.

O nly o ne article (49 ) in dicated a p ediatric

PcT in one patient for an overall rate of

0.06% . T he num ber of em ergency trache-

ostom ies w as indicated in 24 articles (20,

21,24-27,49-51,54-57,59-69), for an

average of 1.44% . T he num ber of intuba-

tion days before tracheostom y w as speci-

fied in 12 articles (21, 25, 26, 50, 51, 53,

55,57, 65, 66, 68, 69) and the average was

13.1 days. The duration of the PcT was

indicated in 12 publications (21, 24, 53,

56, 57, 59, 60, 62, 64, 66, 68, 69), for an

average of 11.7 m ins. ln 19 publications

(21,24-26,50, 53-57, 59, 60, 62-66, 68,

69), the average num ber of ICU PcT was

84% (Table 1).

Per iope ra tiv e Comp lic at ions

T able 2

S er io us p er io pe ra tiv e c omp lic atio ns ,

i.e., p erio perative d eath , card io res pira-

tory arrest, pneum othorax, or pneum o-

mediastinum , were noted in 239 per

10,000 SgTl960-1984, in 86 per 10,000

Sg T

1985-1996'

and in 149 per 10,000 PcT.

The se d if fe re nc es a re s ta tis tic ally s ig nifi-

cant.

T he p erio perative d eath rates w ere ten

times higher for SgT1960-1984 and PcT

c ompa re d w ith S gT19 85 -1 99 6d ata Ip

=

.001).

Simi la rly, c ardioresp iratory a rres t r at es we re

the highest for the SgT l960-1984 group,

follow ed by the PcT group, and the low est

for the SgT

1985-1996

group. The death

r ate s a re a ls o d is pla ye d g ra ph ica lly in F ig -

ure l, to p le . Pe riope ra tive pneumotho -

rax was more frequent in the older SgT

group, w ith a similar frequency in the

SgT

1985-1996 nd the P cT groups. ln fact,

p erio perativ e pn eu mo tho rax accou nted

fo r ap pro xim ately o ne-h alf o f th e seriou s

com plications in the SgTl960-1984

group and for close to the total of the

Sg T

1985-1996

group.

l nte rmedi at e per ioperat ive t ra cheos-

tomy comp lic atio ns , i.e ., d es atu ra tio n

o r h yp oten sio n, le sio ns o f th e p os te rio r

tra ch eal w all, m isp lacemen t o f th e tra -

c he ostomy ca nn ula, asp iratio n d urin g

th e su rgery, and sw itchin g to th e su rgi-

cal technique, were noted in 84 per

1 0,0 00 S gT19 60 -1 98 4, in 4 6 p er 1 0,0 00

SgT1985-1996,nd in 254 per 10,000 PcT

Ip < .05) .De sa tu ra tio n a nd hypote ns io n

d id not a pp ea r in th e SgT1960 -1984 pub -

lic atio ns , p roba bly b ec au se o f under re -

1619



14 0

140

12 0

erloperatlve

120

ostoperative

100

100

80

80

60

60

40

40

20

20

0

SgT1960-S5

SgT 1986-96

Pe T

SgT1960-85

S gT 1 98 6.9 6

Pe T

t ra cheo stomy . Int raoper at iv e mort al it y,

w hich m ay reflect technical problem s

w ith the procedure, indeed decreased

du rin g th e firs t y ea r when p erc ut an eous

tracheostom y w as perform ed (Fig. 2,

t o p . ln contrast,postoperativemortality

w as virtually ni from the start (F ig. 2,

bottom). O n the other hand, postopera-

t ive mor ta li ty after surg ica l t racheostomy

h as d ec re as ed f rom > 1% to z ero b etween

1970 and 1990.

PcT C om plications w ith

D ifferent Techniques Table

4

C om pariso n o f d ifferen t P cT m eth od s

revealed that techniques not using the

progressive dilation technique had the

hig hest com plication rates, both peri op -

eratively and posto peratively . A Iso , th e

lowest complication rates were found

when e nd osco pic co ntro l w as u sed d urin g

the progressive dilation technique. The

d if fe renc e r ea ched s ta ti st ic al s igni fi canc e

for the in term ediate and m inor perio per-

a tiv e c omp lic atio n g ro up s.

In div id ua l c omp lic atio ns th at re ac he d

statistical significance betw een the PcT

groups include desaturation, cannula

m isp la cem en t, d ifficu lt tu be p lac em en t,

and false passage for the perioperative

com plications and pneum othorax as the

only pos tope ra ti ve comp li ca ti on .

gT

1986-96

cT

gT

1960.85

00

50 0

40 0

30 0

20 0

10 0

o

1400

cT

1200

1000

DISCUSSION

Surgi c al tracheostomy is a time-

e st ab li shed p rocedu re . The adven t o f the

p erc uta neou s tra ch eo stomy te ch ni qu e

requires a critical exam ination of the

publ ished data to CO l lparethese t ',vo t ra-

cheostom y techniques. A dvantages of

PcT , according to PcT advocates , i nc lude

smal le r skin inc is ion (20 , 25, 49, 55-58 ),

and Jessdi ssec tion and t is sue t rauma (20 ,

21, 24, 49, 55-57, 67, 68), w hich Jead to

less hem orrhage (20, 24, 25, 49, 54, 57,

5 8, 6 1, 6 8, 6 9), fewe r in fe ctio ns (2 0, 2 4,

2 5, 4 9-5 1, 5 4-5 8, 6 1, 6 5, 6 8), fewe r t ra-

cheal problem s (21, 49, 51, 57, 59, 69),

a nd f ewe r cosme tic d ef orm itie s (2 4, 2 5,

5 0,5 1,5 5- 57 ,5 9- 62 ,6 8) . The p ro cedu re

ca n b e p erfo rm ed a t th e b ed sid e (2 0, 2 5,

26, 51, 53-64, 66-69), decreasing the

ris k and cos t o f p atie nt tra nspo rta tio n to

the ope ra ting room (105, 106 ).PcT i sa l so

said to be faster (21, 24, 25, 49-51, 56,

5 7,5 9-6 2, 6 4-6 9) an d ea sier to p erfo rm

(20,21,25,49,50,53,57,59,60,62-64),

to re qu ire le ss p er so nn el (2 5, 4 9, 6 2) a nd

equ ipmen t (25 ,49 , 60, 69) , and the re fo re ,

is a ss oc ia te d w ith lower cos t (5 0, 5 3- 55 ,

64, 66, 67, 69). Furthermore, PcT is

600

400

200

Figure 1. Bar plots of the mortality top , Id an d righ ) and com plication rates middle an d bottom)

in the tracheostom y literature. The data are grouped in term s of perioperative top Id an d middle) an d

postoperative t op rig h an d bottom) events. The complications have been subdivided into serious,

intermediate, and m inor (see Tables 2 and 3). Sgl, s urgi ca l t racheo st omy ; PcT, p er cu ta ne ou s tra ch e-

ostomy.

SgT

1985-1996

group, and 18 of 32 in the

PcT group. By using the Bonferroni ad-

justed

p

v alu e o f .0 00 55 , th e co rresp on d-

ing numbers were 12 of 31, 20 of 31, and

27 of 32, respectively. Thus, there was

m ore heterogeneity in the older studies,

and m ore in studies reporting on surgical

rather th an on percutaneous tracheos-

tom y. C ontrary to our expectations, seri-

ous complications w ere not reported in a

m ore hom ogeneous w ay (14/39 tests con-

firm ed hom ogeneity using the 0.05 crite-

rio n) th an in te rm ed iate (1 1/2 5) an d m i-

nor (9 /30) complica tions .

Variations in M ortality over

Time

One p oss ib le e xp la nation fo r d iffer-

ences betw een studies is that the inter-

vention technique and other aspects of

health care m ay change over tim e. T his

m ay be particularly true of recently de-

v elo ped me th od s, s uch a s p erc uta neou s

C ri t C a r e M ed 1999 Vol. 27, No. 8

1621



T ab le 3 . P os t o p er a tiv e c o m p lic a tio ns , c la ss i f ie d a s s e rio u s, in te rm e d ia te , a nd m in o r , in th e th re e t r a ch e os to m y g r o up s

S g T

1960-1984

y s . S g T

] 9 8 5 - ] 9 9 6

P o sto pe ra tiv e C o m pl i c a t io n s

S g T

1 9 6 0 - 1 9 8 4

S g T 1 9 8 5 _ 1 9 9 6

S g T

1 9 8 5 - 1 9 9 6

Y S . P c T P c T

S e r io us ( t o ta l)

8 4 5

< O . O O O O l a

2 5 6

O . 7 2 a

2 7 8

D e a t h

1 2 4

0 . 0 0 0 0 1

1 4

1 .0

1 1

T ra ch eo es op ha ge a l f i s tu la

3 1 0 .0 0 0 4 0 0 0 . 0 3 9 6 0

1 7

M e d ia s t in i t is 1 2 0 .0 6 7 0 0

S e p s i s

2 4 0 .0 0 2 6 4 6

0 . 3 4 1 6

H em o rr h ag e, in tr a tr a ch ea l

8 8 0 .0 0 0 0 1

7 1 0 . 0 0 9 4 7 3 9

P n e u m o th o r a x 7 0 .0 0 0 0 1

0 0 . 0 0 8 2 4 1 7

C a n n u la o b s t r u c t io n 2 5 1 0 .0 0 0 0 1

4 8 0 . 6 7 3

3 9

C a n n u la d is p la c e m e n t 1 4 8 0 .0 2 8 1 8

9 1 0 . 1 3 5 5 0

T r a c h e a l s t e n o s is 1 6 0 0 .0 0 0 0 1

26

0 . 0 0 0 7 3 9 9

1 nte rm e d ia te ( t o ta l)

1 0 6 3

< O . O O O O l a

1 4 6

0 . 0 5 2 a

7 8

P n e u m o n i a

6 5 0

0 .0 0 0 0 1 1 3 1 0 . 0 0 0 0 1 0

A t e l e c t a s i s .

2 6 3 0 .0 0 0 0 1 3 1 . 0 6

A s p i r a t i o n

7 4 0 .0 0 0 0 1 9 0 . 5 5 6 0

T ra c h ea l c a r t i l a g e le s io n

7 6 0 .0 0 0 0 1 3 0 .0 0 0 0 1 7 2

M in o r ( t o t a l )

1 3 7 2

< O . O O O O l a

5 6 1

0 . 0 0 0 6 4 a

3 4 2

H em o r r h ag e , e x t e r n al

2 3 7

0 . 6 5 7 2 5 3 0 .1 8 0 1 9 3

W o un d in fe ct io n

5 5 9

0 . 0 0 0 0 1 2 7 1 0 .0 0 0 0 2

9 9

T r a c h e it is 4 8 0 0 . 0 0 0 0 1 2 3 0 .4 1 3 3 9

Delayed

c u ta n e ou s c lo s u re 3 8 0 . 0 0 0 0 6 0 0

K e l o i d

22 0 . 0 0 4 9 9

0

0 .3 4 1 1 1

U na e s th e t ic s c a r

3 6

0 . 0 7 4

1 4

1 .0

0

T o t a l p o s t o p e r a t iv e c o m p l i c a t io n s 3 2 8 0

< O . O O O O l a

9 6 3

0 . 0 0 2 4 a

6 9 8

'.0

~ ~ . 5

0 .0

' 9 6 0

S gT , s u r g i c a l t r a c h e o s t o m y ; P cT , p e r c u t a n e o u s t r a c h e o s to m y .

R es u l ts a r e e x p r e s s e d a s e v e n t s p e r 1 0 , 0 0 0 p r o c e d u r e s .

a p V a lu e s w e r e c o m pu te d a s s u m in g a n in d e p e n d e n c e b e tw ee n c o m pl ic a t io n s w it h in e a c h c a t e g o r y . If th is h y p o t h e s is w e r e in c o r r e c t , p

v a lu e s w o u Id

b e b ia s e d t o w ar d r e je c t io n o f t h e n u l l h y p o t h e s i s .

Perioperat ive death

00

Postoperativedeath

Year o f s t ud y p u b l; œ t io n

F i g u r e 2. T em p o r a l t r e n d s in d e a th r a t e s , p e r io p e r -

a t i v e t o p a n d p o s to p e ra tiv e b o t t o m a fte r s u rg ic a l

s oM l in e a n d p e rc u ta n eo u s d as he d l in e t r a c h e -

o s to m y , b a s e d o n t h e 6 5 a n a l y z e d s t u d ie s a n d

w e ig h te d b y s tu d y s a m ple s iz e . T r e n d s a r e r e p r e -

s e n t e d b y n o n p a r a m e t r i c r e g r e s s io n l in e s .

claim ed to resu lt in fewer o perat iv e an d

long- te rm compli ca ti ons (20 , 21, 49-51 ,

53, 54, 56, 57, 59, 60, 62, 64, 66-69).

F in ally , P cT can b e p erfo rm ed b y p hy si-

1 6 2 2

'

cians w ith ou t prev io us surgi cal training

(54, 56, 58, 60, 63, 64). .

Our m eta-analysis confirm s that PcT

.

is a faster procedure than SgT (11. 7 Ys.

26.9 mins). AIso, a large number of PcT

procedures were performed in the lCU,

w hich confirm s that the procedure can be

p erform ed safely at the bedside and pro b-

ably argues that PcT is easy to perform.

SgT procedures have been performed at

the bedside since 1962 (107) and were

do ne in the ICU in 66% of SgT

1985-1996

cases. Therefore, the location of the op-

eration remains largely a matter of per-

sonal choice on behalf of the physician.

A com pariso n o f percutaneous trach e-

ostomy with surgical tracheostomy

(1 96 0- 19 84 ) p ub lica tio ns c le arly d emon -,

strates that the frequency of most com-

plication s is low er w ith percutan eo us tra-

cheostomy. As previously stated, the

com parison is probably unfair because of

the advances in medical care and, more

specifically, in the design of the trache-

ostom y tubes and cuffs. SgT procedures

performed

.

during the last 10 yrs

(SgT

1 985 -19 96 )are also associated w ith

lower rates of peri- and postoperative

complications.

The c ompar is on o f PcT w it h SgT1985-1996

com plication rates is less clear cut. Our

re su lts s ug ges t th at p erio pe ra tiv e comp li-

cations are more frequent with PcT,

whereas postopera tive compl icat ions s ti ll

occur m ore often w ith SgT . ln general,

th e bulk o f th e d iff er en ce c once rn s c om-

plica tions we c lass if ied as minor (Tables2

a nd 3 ). ln te rms o f p er io pe ra tiv e c omp li-

cat ions, s ignif icant d if fe rences a re found

in trach eo stomy tu be p lacemen t, n oted

a s e it he r ope ra tive d if fi cu lt y o r t ube fals e

p as sa ge .Th is is to b e e xpec te d, b ec au se a

SgT p ro ce du re p ro ce ed s under d ir ec t v i-

sion to the anterior tracheal wall,

whereas PcT remains a b lind operat ion .

ln addition, the m ost frequently used

com mercial PcT set uses a series of 10

d il ato rs o f p rogres sively l arge r d iamet er

to create a passage of the appropriate

s iz e, a llow ing for th e in tr oduc tio n o f th e

tr acheos tomy cannu la . These nume rous

manipu la ti ons may l ead to d ispla cemen t

of the guidew ire tip in the pretracheal

ti ssue s and the c re at ion o f a fals e pas sage .

Anoth er m inor p er io pe ra tiv e c omp lic a-

ti on , r epor ted with a s igni fi cant ly h ighe r

f requency wi th PcT , i s subcu timeous em-

physem a. T his could be attributable to

th e tig ht fit o f th e d issected p retrach eal

ti ssue a round the t ra cheostomy cannu la ,

wh ic h p re ve nts th e e sc ap e o f tra ch ea l a ir

th rough th e s kin in cis io n.

T he tig ht fit o f th e trach eo stomy can -

nula to the surgi cal tract probably ex-

G ri t G a r e M e d 1 9 9 9 V o l . 2 7 , N o . 8



P D T - P c T

with

Endoscopie

Fischer's

PDT-PcT

Control O ther PcT Exact Test

No . o f s tu di es 17 5 5

References

2 0, 2 5- 27 , 5 0- 52 ,

53, 62-64, 67 21, 24, 49,

54, 55, 57, 58, 56,59

60, 61, 65, 66,

68,69

No. of patients 1123 373 321

Serious perioperative

12 5

107 281

0.12a

1ntermediate perioperative 205

134

561

0.0013a

Minor perioperative 534 241

1401

<O.OOO1a

Total perioperative complications 864 482 2243

<O.OOOla

Serious postoperative 294 134 374

O.lIa

1n te rmed ia te postope ra tive

89

27 125

0.29a

Minor postoperative 392 375 156

0.10a

Total postoperative complications 775 536 655

0.29a

_h

Table 4. Peri- and postoperative com plications, classified as serious, interm ediate, and m inor, in the

three percutaneous tracheostomy (pcT) groups

PO T, progressive d ilation technique; PcT , percutaneous tracheo sto my.

Results are expressed as events per 10,000 procedures.

a p Valu es w er e c omp ute d a ss um in g a n i nd ep en de nc e b etw ee n c omp li ca tio ns w it hin e ac h c at eg or y.

If this hyp othesis w ere incorrect, p values w ould be biased tow ard rejection of the null hypothesis.

p la in s th e d if fe re nc e in m inor pos to pe ra -

tive complications favoring the PcT

tech niq ue. T he tampo nad e o f sm all v es-

sels reduces extern al hem orrh age, and

th e le ss er tis su e d is se ctio n a nd e xposur e

in the tracheostomy wound might ex-

p la in the lowe r rat es o f wound infec ti ons.

T herefo re, o ur an aly sis ten ds to su pp ort

c la ims tha t PcT cause s le ss t is sue t rauma ,

wou nd in fectio ns, an d b le ed in g. ln co n-

tr as t, fewer tr ac he al p roblems ( tr ac he al

sten osis an d trach ea l c artilag e lesio ns)

o ccur in Sg T

1985-1996ata rela t ive to PcT.

P robab ly the most troubl esome d if fe r-

ences betw een PcT and SgT

198 5-1996re

in s er io us p erio pe ra tiv e c omp lic atio ns .

Significant differences are present in

term s o f o pe rativ e mortality a nd card io -

resp irato ry arrest, w ith totals of 77 p er

10,000 for PcT and 9 per 10,000 with

SgTI985-1996'Wheth er th e le ar nin g c urve

o f a n ew tech niq ue, as sh own in F ig ure 2 ,

top, is th e only e xp la na tio n r ema in s to b e

d emons tr ate d. Con tr ib utin g f ac to rs may

inc lude a fal se passage , poster ior t racheal

wa ll ie sions wi th resul ti ng t ra cheoesoph -

ag ea l fistu las, an d th e b lin d n atu re o f

P cT d is se ctio n. Howeve r, p atie nts in th e

ICU,who ten d to b e in clu ded more o ften

in PcT a rt ic le s, p robab ly have inheren tl y

h igher compli ca ti on rat es .

P ub lis he d s tu die s on c omp lic atio ns o f

t racheos tomy exhibi ted subs tantial he te r-

o gen eity , ev en w ith in g ro up s o f stu dies

th at rep orted o n sim ilar p ro ced ures . Ad-

equate data to explain betw een-study

var ia tio ns wer e not a va ila ble . P la us ib le

hypo theses i nc lude d if fe rences i n pat ient

G r i t G a r e M e d 1 99 9 Vo l. 27 , No .8

p op ula tio ns , in te rv en tio n tec hn iq ue , s ur -

g ical sk ills, effectiven es s o f s up po rtive

services, choice of relevant com plica-

tion s, m etho ds to ass es s co mp licatio n oc-

cu rren ce, repo rting fo rm at, an d selectiv e

publication. The sam e variables that en-

g end er h etero gen eity m ay also cau se co n-

founding in comparisons of the three

s tu dy g ro up s. T hus , ail results p resented

in this analysis should be taken with cau-

tion because the heterogeneity analysis

sug ges ts th at n ot ail o bserved d ifferen ces

were attributable to intervention tech-

nique.

For example, the subset analysis of

d iff ere nt P cT s howe d d if fe re nt c omplic a-

tio n rates. T he 1 0w est co mp licatio n rates

were obtained w ith the progressive diIa-

tion m ethod (20) perform ed under endo-

scop ic con tro l (5 3). N on pro gres siv e dila-

tion PcT techniques had the highest

nu mb er o f co mp licatio ns. N ev ertheless,

even w h en the PcT technique associated

with the lowest complication rates,

nam ely the endoscopically controlled

progressive dilation technique, is com -

pared with SgT

1985-1996

data, the trend

d is cu ss ed ea rlie r is c on firm ed : lowe r p eri-

operative complications with SgT and

low er postoperative com plication rates

w ith P cT .

D esp ite this hetero gen eity of the stu d-

ies included in each group, the claim s of

low er com plication rates with PcT rela-

tive to SgT found in numerous publica-

tions (20, 21, 49-51, 53, 54, 56, 57, 59,

60, 62, 64, 66-69) seem unwarranted,

w h en studies conducted during the sam e

time f rame a re c ompar ed . On ly p ro~pec -

tive random ized trials, w ith a blinded

ev alu atio n o f th e in div id ual comp lica-

tio ns can d efin itiv ely an swer th is q ues-

tio n. S uc h tr ia ls a re a s y e t to b e pub lis he d

( l0 8) . P re vious c ompar ativ e s tu die s a re

re tr os pe ctiv e ( 26 , 60) , n on ra ndom iz ed

(24 , 26, 5 6, 6 0, 6 4) , o r not e va lu ate d bya n

obs er ve r b lin de d a s to th e s ur gi c a l te ch -

nique (57, 65, 68). H ow ever, because

c omp lic atio ns o f tr ac he os tomy a re r ar e,

th e s iz e o f s uc h a tr ia l may be p rohib itiv e.

E ven th ou gh its su perio rity o ver S gT

is not e sta blis he d, P cT is b eing r epor te d

and pro bab ly u sed w ith increasing fre-

quency . The repo rted compli ca ti on rate s

in 27 studies of alm ost 2,000 patients

w ho h ave u nderg on e the procedure are

no t p rohibitive an d com pare fav orab ly

wi th compli ca ti on rat es o f SgT publi shed

only 10 yrs ago. M ost of the studies use

on e com m ercial PcT set, and futu re im -

provem ents in the devices used m ight

r ende r th e te chnique e ve n s af er .

ln c on clu sio n, th e a va ila ble d ata s ug -

gest the fo llo win g: a) P cT is no t clearly

su perio r to S gT when rece nt stu dies are

compared ; b ) PcT is a ssoc ia ted wi th more

per ioperat ive compli ca tions th an SgT in

th e p ub lish ed articles; c) P cT c ompa re s

f avor ab lyw i th SgT in te rms o f pos to pe r-

a tiv e p roblems. Howeve r, th es e c on clu -

sion s shou ld b e accep ted w ith caution

b ecau se o f th e h etero gen eity o f stu dies

pubI ished and because o f t he d if fi cu lt y i n

det eè ting rea l d if fe rences when the p rev-

alence of complications is low. The

choice of the tracheosto my techn iq ue

s hould b e b as ed on pers on al e xp er ie nc e,

u ntil c ompellin g e vid en ce f avor in g one

technique becomes avai IabIe .

1 6 2 3



.~

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6 25

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