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TRANSCRIPT
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Abstract
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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
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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
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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 -
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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
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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
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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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.~
REFERENCES
1. Borm an J, Davidson JT: A history of trache-
ostom y: Si spiritim ducit vivit.
B r] A na es th
1963 ; 35 :388- 390
2. F rost E AM : Tracing the tracheostom y.
An n
O to /1 97 6; 8 5:6 18 -6 24
3. Jackson C : T racheùstom y.
Laryngoscope
1 90 9; 1 9: 28 5- 29 0
4. Jackson C: High tracheotomy and other er-
rors, the chief causes of chronic Iaryngeal
stenosis.
Surg Cynecol Obstet
1921; 32:
392-400
5. M acEw an W : C linical observations of intro-
duction of tracheal tubes by m quth instead
o f p er fo rm in g a tr ac he os tomy. B M ]
1880;
ii:122-124
6. O 'Dwyer JP: Two cases of croup treated by
tub ag e o f the glo ttis.
N Y S tate] Med 1885;
42:146-151
7. C arte BN, Giuseppi T: Tracheostom y, a use-
fuI procedure in thoracic surgery with par-
ticular reference to its employment in
crushing injury of the thorax.
]
T h o r a c
Surg
1951 ; 21 :495- 503
8. G allow ay TC : Tracheotom y in bulbar polio-
myelitis.
]AMA
1943 ; 128:1096 -1097
9. Lassen HCA: A prelim inary report on the
1 95 2 ep id em ic o f po liom yelitis in C op en ha-
gen w ith special reference to the treatm ent
of acu te respirato ry in su fficiency .
Lancet
1 95 3; i :3 7- 40
10. Head JM : Tracheostomy in the manage-
ment o f r es pi ra to ry p rob lems. N E n g l
]
M e d
1960 ; 264:587 -591
11. Watts JM : Tracheostomy in modern prac-
tice.
Br] Surg
1963 ; 50 :954- 975
12. Kodicek JM : The place and management of
trach eo sto my in resp iratory in sufficien cy .
]
O to l L aryn go /1 960 ; 74 :8 91 -9 18
13. Kamen JM, W ilkinson CJ: A new low-
pressure cuff for endotracheal tubes.
Anes-
thesiology
1971 ; 5 :482- 485
14. C hristensen K T, D uvall
Al :
T ra ch ea l s ten o-
sis from the cuffed tracheotom y tube.
Arch
O to la ry ng o/1 96 8; 8 7:2 79 -2 84
15. Heffner JE: Tim ing of tracheotomy in me-
c ha ni cal ly v en til at ed p ati en ts .
Am Rev Re-
spir D is
1993 ; 147:768 -771
16. Oliver P, Richardson JR , Clubb RW, et al:
T ra ch eo to my in c hild re n. N E n g l
]
Med
1962 ; 267:631 -637
17. Stauffer JL, O Ison DE, Petty TL: C om plica-
tions and consequences of endotracheal in-
tubation and tracheotom y: A prospective
study of 150 critically. ill adult patients.
A m ] M e d 1981; 70 :65-76
18. N icholls JC: The use of tracheostomy fol-
lowing major open cardiac surgery: A re-
view of 64 cases.
Thorax
1968 ; 23 :652- 656
19. Shelden CH, Pudenz RH, Tichy FY: Percu-
ta ne ou s tr ac he oto my .
]AMA
1957; 165:
2068-2070
20. Ciaglia P, Firsching R, Syniec C: Elective
.
percutaneous dilatational tracheostom y: A
new sim ple b ed sid e proced ure. P relim in ary
report.
Chest
1985 ; 87 :715- 719
21. Schachner A, Ovil Y , Sidi J, et al: Percuta-
1624
neo us trach eotom y-A . n ew m eth od .
Crit
Care
M e d 1989; 17 :1052-1056
22. Caldicott LO, Oldroyd GJ, Bodenham AR:
An evaluation of a new percutaneous tra-
cheo st omy k it .
A n e s t h e s i a
1995; 50 :49-51
2 3. T oy F J, W einstein JO : A p ercu tan eo us trach e-
o st omy d ev ic e.
Surgery
1969 ; 65 :384- 389
24. Cole lE : Elective percutaneous (Rapitrac)
tracheotom y: R esults of a prospective trial.
Laryngoscope
1994 ; 104:1271- 1275
25. Friedm an Y , M ayer A D: B edside percutane-
ous tracheostom y in critically ill patients.
Che s t
1993;
104:532-535
26. Graham JS, Mulloy RH, Sutherland FR , et
a l: P erc uta ne ou s v ers u s o pe n tra ch eo sto my :
A retrospective cohort outcome study.
]
Trauma
1996 ; 42 :245- 250
27. W ang MB, Berke GS, W ard PH, et al: Early
e xp erie nc e w it h p erc ut an eo us t ra ch eo to my .
Laryngoscope
1992 ; 102:157 -162
2 8. H utch inso n R C, M itch ell R D: L ife-threaten-
ing com plications from percutaneous dila-
t a tiona l t racheos tomy.
Cr it Ca re
M e d
1991;
19:118-120
29. M cC leliand R MA : C om plications of trache-
ostomy.
BM ]
1963 ; i i: 567 -569
30. Paul A, M arelli D , Chiu R CJ, et al: Percuta-
neous endoscop ic
tracheotomy.Ann
T h o r a c
S u r g 1989; 47 :314-315
31. A ass A S: C om plications to tracheostom y and
l on g-te rm in tu ba tio n: A fo llo w-u p s tu dy .
Acta
A na esth S ca nd
1975 ; 19 :127- 133
32. Austen RT: Tracheostomy and prolonged
intubation in the management of trauma.
Injury
1971 ; 2 :191- 198
33. Chendrasekhar A , Ponnapalli S, Duncan A:
P ercu tan eo us d ilatation al trach eos to my : A n
alternative approach to surgi cal tracheos-
tomy.
South M ed]
1995 ; 88 :1062 -1064
34. D 'Am elio LF, Hammond JS, Spain DA, et al:
Tracheostomy and percutaneous endo-
scopic gastrostomy in the management of
head-injured traum a patients.
Am Surg
1994 ; 60 :180- 185
35. Earl PD, Lowry JC: The percutaneous di la-
t at io na l s ub cr ic oi d t ra ch eo st omy .
Br] Oral
M axillo fa c S urg
1 99 4; 3 2: 24 -2 5
36. FischIer M P, Kuhn M , C antieni R, et al: Late
outcom e of percutaneous dilatational tra-
ch eosto my in inten sive care p atien ts.
Inten-
sive
C ar e M ed
1995; 21:475-481
37. Fisher EW , Howard DJ: Percutaneous tra-
cheostomy in a head and neck unit.
]
Otol
L ar yn go /1 99 2; 1 06 :6 25 -6 27
38. Gunawardana R H: Experience with trache-
ostom y in m edical intensive care patients.
P ostg ra d M ed ]
1992 ; 68 :338- 341
39. Jones W G, Madden M , Finkelstein J, et al:
T ra ch eo to mi es in b urn pa tie nts .
Ann Surg
1989 ; 109:471 -474
40 .
L esnik I, R appaport W , F ulginiti J, et al: The
raIe
of early tracheo sto my in b lu nt, m ultip le
o rg an t ra uma .
Am Surg
1992 ; 58 :346- 349
41 . L ord R : R ev iew o f 2 80 trach eo sto mies.
Aust
N Z
]
S u r g 1967; 36 :192-199
42. M anara A R: Experience w ith percutaneous
tracheostomy in intensive care: The tech-
n iq ue o f cho ice?
Br] O ral M axillofac Surg
1994 ; 32 :155- 160
43. Paloschi G, Lynn RB: Observations upon
e le cti ve a nd em er ge nc y t ra ch eo sto my .
Surg
CynecolObstet
1965 ; 120:356 -358
44. V on S chulthess G : T racheotom y: C om plica-
tio ns a nd la te se qu ela e. A r c h
Otolaryngol
1965 ; 82 :405- 408
4 5. B ierin g-S oren so n M , B ierin g-S oren so n F : T ra-
ch eo sto my in spinal co rd in ju red : F req uen cy
and fo llowup . P a r a p l e g i a 1992;30:656-660
46. Provan JL, Austen W G: The role of elective
tracheo sto my after o pen heart su rg ery .
An n
T ho rac S urg
1966 ; 2 :358- 367
47 . R ogers L A: C om plicatio ns o f trach eo sto my .
South M ed]
1969 ; 62 :1496 -1501
48. G audet P T, Peerless A , S asaki C T, et al: P edi-
atric trach eo stom y an d asso ciated co mplica-
tions.
Laryngoscope
1978; 88 :1633-1641
49. Toye FJ, W einstein JO : C linical experience
with percutaneous tracheotom y and crico-
th yro id oto my in 1 00 p atie nts.
]
T r a u m a
1986 ; 26 :1034 -1040
50 . H azard P B, G arett H E, A dam s JW , et aJ: B ed sid e
tra ch eo st om y: E xp er ie nce w ith 5 5 e le cti ve p ro -
cedures.A n n T h o r a c S u r g 1988;46:63-67
5 1. C oo k P D, C aJ la na n V I: P erc uta ne ou s d ila ti on aJ
trach eosto my techn iq ue an d ex perien ce.
A n -
a es th I n te ns iv e C a r e 1989; 17:456-457
52. Holtzman RB: Percutaneous approach to
tracheostomy.
C rit C are M ed
1 98 9; 1 7:5 95
53. M arelli D , Paul A, M anolidis S, et al: Endo-
sco pic g uid ed p ercu tan eou s tracheo stom y:
Early results of a consecutive trial.
]
T r a u m a 1990; 30 :433-435
54. Bodenham A, Diament R, Cohen A, et al:
P ercutaneous dilatational tracheostom y: A
bedside procedure in the intensive care
unit.
Anesthesia
1991 ; 46 :570- 572
55. Delany S, Stokes J: Percutaneous dilata-
tio nal trach eosto my: O ne y ear's ex perience.
N Z M e d ] 1991 ; 104:188 -189
56. Griggs W M, M yburgh
lA ,
W orthley LIG: A
prospective com parison of a percutaneous
tracheostom y technique w ith standard sur-
g ic al t ra ch eo st omy .
Intensive Care M e d
1991 ; 17 :261- 263
57. Hazard P, Jomes C , Benitone J: Compara-
tive clinical trial of standard operative tra-
cheostomy w ith percutaneous tracheos-
tomy. Crit C a r e M ed 1991; 19 :1018-1024
58. C iaglia P, G raniero KD: Percutaneous di la-
tationaI tracheostomy: Results and long-
t er m f ol low -u p.
Chest
1991 ; 101:464 -467
59. Ivatury R, Siegel JH, Stahl \VA, et al: Per-
cutaneous tracheostomy after trauma and
cr it ical i llness . ] T r a u m a 1992; 32:133-140
60. Leinhardt DJ, Mughal M , Bowles B. et al:
A ppraisal of percutaneous tracheostom y.
Br] Surg
1992 ; 79 :255- 258
61. G aukroger M C, Allt-G raham J: Percutane-
ou s d ilatatio nal tracheo to my .
Br
]
Oral
Maxillofac
S u r g 1994; 32:375-379
62. W inkler W B, Karnik R , Seelmann 0, et al:
B ed sid e p er cu tan eo us d ila tat io nal tra ch eo s-
to my w ith en dosco pic g uid ance: E xp erien ce
w ith 7 1 IC U p atie nts.
Intensive
C a re M e d
1994 ; 20 :476- 479
C ri t C a r e M e d 1 9 9 9 V o l . 2 7 , N o . 8
8/16/2019 Dulguerov et al 1999.pdf
http://slidepdf.com/reader/full/dulguerov-et-al-1999pdf 10/10
63. V an H eerden PV , W ebb SA R, Pow er BM , et al:
.
Percu taneous d i la tat ional t racheostomy-A
clinical study evaluating two systems.
An -
ae sth Inte nsive C are
1996 ; 24 :56 -59
64 . B arba C A, Ang ood P B, K auder D R, et al: B ron-
cho scop ie guidance m akes p ercutaneous tra-
cheostom y a safe, cost -effective, and easy to
t ea ch p roc edu r e.
Surgery
1995; 118:879 -883
65. Crofts SL, Alzeer A , McGuire PG, et al: A
comparison of percutaneous and operative
tracheostomies in intensive care patients.
Ca n
]
Anaesth
1995 ; 9 :7 7 5- 779
66. Cobean R, BeaIs M , M oss C, et al: Percuta-
neous dilatational tracheostomy: A safe,
c os t- ef fe ct iv e b ed si de p ro ce du re .
A rc h Surg
1996 ; 1 31 :2 65 -2 71
.
67. Fernandez L, Norwood S, Roettger R, et al:
Bedside percutaneous tracheostomy wi th
bronchoscopie guidance in critically ill pa-
tients.
Arch Surg
1996 ; 1 31 :1 29 -1 32
68: Friedman Y, Fildes J, M izock B, et al: Com-
parison of percutaneous and surgical tra-
cheostomies.
Chest
1996 ; 1 10 :4 80 -4 85
69. Hill BB, Zweng TN, M aley RH, et al: Percu-
taneous dilatational tracheostom y: Report
of 356 cases.
]
Trauma
1996; 40 :238 -244
70. Toursarkissian B, Fowler CL, Zweng TN, et
al: P erc utan eo us d ila tatio nal trach eo sto my
in children and teenagers.
]
P edia tr Surg
1994; 29 :1421-1424
71. Dayal YS, El Masri W : Tracheostomy in in-
tensive care settin g.
Laryngoscope 1986;
96:58-60
72. Stock M C, W oodward CG, Shapiro BA, et al:
Perio perative com plication s of elective tra-
cheostom y in critically il p atients.
Crit
C are M ed
1986 ; 1 4: 86 1- 863
73. W aldron J, Padgham ND, Hurley SE: Com-
plications of em ergency and elective trache-
ostomy: A retrospective study of 150 con-
s ec ut iv e c as es .
Ann R Coll Surg Engl1990;
72:218-220
74. Upadhyay A, M aurer J, Turner J, et al: Elec-
tive bedside tracheostom y in the. intensive
c are u ni t.]
Am Coll Surg
1996; 1 8 2: 51 -5 5
75. W ease GL, Frikker M , Villalba M, et al: Bed-
si de tracheostomy in the intensive care
unit.
A rch Surg
1996 ; 1 31 :5 52 -5 55
76. Zeitouni AG, Kost MK: Tracheostomy: A
retrospective rev iew of 281 cases.
]
Otolar-
y ng o1 19 94 ; 2 3:6 1-6 6
C rit C a r e M e d 1 99 9 Vol. 27 , N o. 8
77. Malata CM, Foo lTH, Simpson KH, et al: An
audit of Bjork flap tracheostom ies in head
and neck p lastic surgery .
Br] Oral M axil-
l or ac S ur g
1996 ; 3 4 :4 2 -4 6
78. Hawkins ML, Burrus EP, Treat RC, et al:
Tracheostom y in the intensive care unit: A
s afe a lte rn ativ e to th e o pe ra tin g r oom .
South M ed]
1989; 82 :1096-1099
79. F utran N D, D utcher PO , R ob erts JK : T he safety
a nd e ff ic ac y o f b ed si de t ra ch eo tomy.
Otolaryn-
gol H ead N eck Surg
1993; 109 :707 -711
80. G oldstein SI, Breda SD , Schneider K L: Sur-
g ic al co mp lica tio ns o f b ed sid e trach eo to my
in an otolaryngology residency program .
Laryngoscope
1987 ; 97 :1407 -1409
81. Boyd SA, Benzel EC: The role of early tra-
cheostomy in the management of the neu-
r os ur gi ca l p at ie nt .
Laryngoscope
1 99 2; 1 02 :
5 59 - 562
82. A strachan D I, K irchner JC , G oodw in W J: Pro-
lo ng ed in tu ba ti on v s. tr ac he oto my : C om pl ic a-
tio ns , p rac tical a nd p sy ch olo gic al co ns id er-
ations.
Laryngoscope
1988; 98 :1165 -1169
83 . Pogu e M D, Pecaro B C: Safety and efficien cy
of elective tracheostomy performed in the
in te nsiv e c are u nit.
]
O ra l M ax illo ra c S ur g
1995 ; 5 3: 89 5- 897
84. Castling B, Telfer M , A very BS: Com plica-
tions of tracheostomy in major head and
neck cancer surgery: A retrospective study
of 60 consecutive cases.
B r] O ral M ax illo -
r ac S ur g
1994 ; 3 2 :3 -5
85. James OF, Moore PG: Tracheostomy in the
m an ag em en t o f c hest in ju ries: Its u se an d co m-
plications.
Aust N Z] Surg
1981; 51:598- ':602
86. Skaggs JA: Tracheotomy: Management,
mo rt al it y, c omp li ca ti on s.
Am
]
Surg 1969;
35:393-396
87. Arola M K: Tracheostom y and its com plica-
tions: A retrospective study of 794 trache-
o to mized p atien ts.
Ann Chir Gynaecol
1981 ; 7 0 :9 6 -1 06
88. Marshall RD: A review of the management
of 140 elective tracheostom ies follow ing
ope n- he ar t s ur ge ry .
Thorax
1969; 24 :78 -83
89. M ulder D S, Rubush JL: Com plications of tra-
cheosto my : R elatio nship to long term v enti-
la tory assis tance .]
Trauma
1969; 9 :389 -402
90. Stowe DG, Kenan PD, Hudson W R: Compli-
c at io ns o f t ra ch eo to my .
Am
]
Surg 1970;
36:34-38
91. Dane TEB, King EG: A prospective study of
complications after tracheostomy for as-
s is te d vent il at ion .
Chest
1975 ; 6 7: 39 8 -4 05
92. Glas W W, King
OJ ,
Lui A : Com plications of
tracheostomy.
A rc h .su rg
1962 ; 8 5: 56 -6 3
93. Yarington CT, Frazer JP: Complications of
tracheotomy.
Arch Surg
1965 ; 9 1: 65 2 -6 55
94. Schusterman M , Faires RA, Brown D, et al:
L oca l co mp lica tio ns an d m orta Iity o f a d ult tra -
cheostomy.]
K en t M ed A sso c
1983; 25:885-888
95. Dugan DJ, Samson PC: Tracheostomy:
Present day ind ications and tech nics.
Am
]
Surg
1963; 1 0 6: 29 0- 306
96. Chew JY, Cantrell RW : Tracheostom y: Com-
p lic atio ns an d m an ag em en t.
A rch O tola r-
y ng oI 19 72 ; 9 6:5 38 -5 45
97. M iller JO , Kapp JO: Complications of tra-
cheostom ies in neurosurgical patients.
S urg N eu rol1984 ; 2 2:18 6-18 8
98. Meade JW : Tracheotomy-Its complica-
tions and their management: A study of 212
cases.
N Engl] Med
1961 ; 2 6 5: 51 9- 523
99. M yers EN , Carrau RL: Early complications
of tracheotomy: Incidence and manage-
ment.
C lin C hest M ed
1991 ; 1 2: 58 9- 595
10 0. W ood D E, M athisen
DJ :
La te compl ic at ions
o f t ra cheo tomy .
Clin Chest Med
1991; 12:
597-609
101. G odfrey K : Com paring the m eans of several
groups.
N Engl] Med
1985 ; 313:1450 -1456
1 02 . S av itz D A, O lsh an AF : M ultip le c om paris on s
and related issues in the interpretation of.
e pi de mio lo gic d at a.
Am
]
E pid em io l 1995;
142:904-908
.'
103. Rothman KJ: No adjustments are needed
for m ultiple com pariso ns.
Epidemiology
1 99 0; 1 :4 3- 46
104. Cleveland W S: Robust locally weighted re-
g re ssio n an d sm oo th in g sc atterp lo ts .
]
Am
S ta t A ss oc
1979 ; 7 4: 82 9- 836
1 05 . W ad dell G : M ov em en t o f c ritically il pa tien ts
w ith in th e h os pitaL
BM ]
1975; 2 :417 -419
106. Sm ith l, Flem ing S, Cernainu A: M ishaps
during transport from the intensive care
unit.
C rit C are M ed
1990; 18:278-281 .
107. R oe B B: B edside tracheo stom y.
Surg Gy-
necolObstet
1962 ; 1 1 5: 23 9- 241
108. Gysin C, Dulguerov P, Chevrolet JC, et al:
Percutaneous vs. surgical tracheostom y: A
d ou ble -b lin d ran do mize d tria l. n n S urg ln
Press
6 25