Portal de Periódicos da CAPES

Percutaneous Dilatational Tracheostomy

2003; Elsevier BV; Volume: 123; Issue: 5 Linguagem: Inglês

10.1378/chest.123.5.1336

1931-3543

Luis F. Laos,

Esophageal and GI Pathology

In 175 ad, Galen inflated the lungs of a dead animal with a bellows, similar to that used to keep a fire alive. This was the beginning of mechanical ventilation. Marco Aurelio Severino (1580–1656) was one of the first to use the tracheostomy as an operation for obstructed air passages. With a trocar-like instrument, he was able to save innumerable lives during the diphtheria epidemic in Naples in 1610. Lorenz Heister (1683–1758) established the term tracheotomy for a windpipe incision.1Hæger K History of surgery. Bell Publishing Company, New York, NY1988Google Scholar From then on, many changes have occurred. With improvements in critical care, we now have patients receiving mechanical ventilation for years or even decades. For this reason, tracheotomies have become one of the most common surgeries performed in critically ill patients. Traditionally, surgeons have performed tracheostomies in the operating room. Ciaglia et al2Ciaglia P Firsching R Syniec C Elective percutaneous dilatational tracheostomy: a new simple bedside procedure; preliminary report.Chest. 1985; 87: 715-719Crossref PubMed Scopus (920) Google Scholar in 1985 demonstrated the feasibility and utility of the percutaneous dilatational tracheostomy (PDT). Since then, there have been a myriad of articles demonstrating that this technique is not only adequate, but has been touted by some to be the “procedure of choice” for performing tracheostomies.3Freeman BD Isabella K Lin N et al.A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients.Chest. 2000; 118: 1412-1418Abstract Full Text Full Text PDF PubMed Scopus (360) Google Scholar As usual, in medicine such as in life, what we think is clear can be confusing to others. For that reason, many questions remain to be answered. A major question is whether PDT is better than a surgical tracheostomy (ST). There have been several meta-analyses trying to answer this question. The meta-analysis done by Dulguerov and collaborators4Dulguerov P Gysin C Perneger TV et al.Percutaneous or surgical tracheostomy: a meta-analysis.Crit Care Med. 1999; 27: 1617-1625Crossref PubMed Scopus (296) Google Scholar concluded that PDT is associated with a higher prevalence of perioperative complications; particularly concerning was an increase in perioperative deaths and cardiorespiratory arrests. However, Freeman and collaborators3Freeman BD Isabella K Lin N et al.A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients.Chest. 2000; 118: 1412-1418Abstract Full Text Full Text PDF PubMed Scopus (360) Google Scholar came to a much different conclusion. They not only found that PDT was safe, but even suggested that PDT had a lower incidence in peristomal bleeding and postoperative infection. How can such different conclusions be reached? That is the inherent problem of meta-analysis. The conclusions reached are totally dependent on the quality of the data analyzed. They are most useful when the data analyzed are aggregate data from high quality, randomized, controlled trials. In the article by Dulguerov et al,4Dulguerov P Gysin C Perneger TV et al.Percutaneous or surgical tracheostomy: a meta-analysis.Crit Care Med. 1999; 27: 1617-1625Crossref PubMed Scopus (296) Google Scholar included were both prospective and observational studies that utilized several PDT techniques. In contrast, the article by Freeman et al3Freeman BD Isabella K Lin N et al.A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients.Chest. 2000; 118: 1412-1418Abstract Full Text Full Text PDF PubMed Scopus (360) Google Scholar analyzed only prospective studies that employed the Ciaglia procedure. This fact makes the latter analysis more sound, but it is still not conclusive. Cheng and Fee5Cheng E Fee Jr, WE Dilatational versus standard tracheostomy: a meta-analysis.Ann Otol Rhinol Laryngol. 2000; 109: 803-807Crossref PubMed Scopus (73) Google Scholar did a similar meta-analysis, reaching the conclusion that PDT is a safe procedure for elective tracheostomy in carefully selected patients and that standard STs had a fivefold rate of complications over that of PDT in this patient group. At present, there are multiple prospective trials that reach a similar conclusion. The article by Melloni et al6Melloni G Muttini S Gallioli G et al.Surgical tracheostomy versus percutaneous dilatational tracheostomy: a prospective-randomized study with long-term follow-up.J Cardiovasc Surg (Torino). 2002; 43: 113-121PubMed Google Scholar is of particular interest because it is not only prospective but also randomized, and evaluates long-term follow-up. The authors conclude that PDT is a simpler, quicker procedure and has a lower rate of postoperative complications. They found that late tracheal complications were more prevalent in the PDT group, but these did not reach statistical significance. In the past, multiple patients were excluded from having PDTs for multiple reasons; now we have information that PDT can be safely performed in patients with a history of prior tracheostomy, obesity, short neck, coagulopathy, and bleeding diatheses.7Susanto I Comparing percutaneous tracheostomy with open surgical tracheostomy.BMJ. 2002; 324: 3-4Crossref PubMed Google Scholar Still, with all this information we can say that, at best, both techniques are comparable with regard to safety. However, if both techniques are equal in regard to safety and complication rates, is there an economic incentive to do one technique over the other? In this new world of medical economics, we need more “bang for the buck.” Bowen et al8Bowen CP Whitney LR Truwit JD et al.Comparison of safety and cost of percutaneous versus surgical tracheostomy.Am Surg. 2001; 67: 54-60PubMed Google Scholar did a retrospective medical chart review to define the safety and cost of PDT vs ST. The average charge per patient in an uncomplicated case, including professional fees, inventory, bronchoscopy (if performed), and operating room charges was $1,753.01 and $2,604.00 for PDTs and STs, respectively. Also, Freeman et al9Freeman BD Isabella K Cobb JP et al.A prospective, randomized study comparing percutaneous with surgical tracheostomy in critically ill patients.Crit Care Med. 2001; 29: 926-930Crossref PubMed Scopus (204) Google Scholar did an economic analysis that showed that the total patient charges for PDT were $1,569 ± 157 vs $3,172 ± 114 for ST. “Across the pond,” Heikkinen et al10Heikkinen M Aarnio P Hannukainen J Percutaneous dilational tracheostomy or conventional surgical tracheostomy?.Crit Care Med. 2000; 28: 1399-1402Crossref PubMed Scopus (123) Google Scholar did a similar economic analysis. They found that the mean cost for PDT (in US dollars) was $161 vs $357 for ST. Aside from the dramatic difference of the cost of medicine in our country when compared to other systems, it is clear that PDT is cost-effective. The major difference, in cost, is the operating room (OR) time charge. What if the ST is done at bedside in the ICU? Grover et al11Grover A Robbins J Bendick P et al.Open versus percutaneous dilatational tracheostomy: efficacy and cost analysis.Am Surg. 2001; 67: 297-301PubMed Google Scholar addressed this question. They analyzed three groups: ST in the OR, ST in the ICU, and PDT in the ICU. ST in the OR increased costs by $2,194 and charges by $2,871 over the same bedside procedure. ST at bedside reduced cost by $180 and charges by $658 when compared to PDT in the ICU. Massick et al12Massick DD Yao S Powell DM et al.Bedside tracheostomy in the intensive care unit: a prospective randomized trial comparing open surgical tracheostomy with endoscopically guided percutaneous dilational tracheostomy.Laryngoscope. 2001; 111: 494-500Crossref PubMed Scopus (149) Google Scholar also documented that PDT incurred an additional patient charge of $436 per bedside procedure when compared to ST in the ICU. With this information, we can safely say that ST in the OR is more expensive than PDT. ST in the ICU has been proven to be safe and does not lead to an increase in the rate of infectious complications. This had led some authors to consider that it should be the standard of care in bedside tracheostomy.12Massick DD Yao S Powell DM et al.Bedside tracheostomy in the intensive care unit: a prospective randomized trial comparing open surgical tracheostomy with endoscopically guided percutaneous dilational tracheostomy.Laryngoscope. 2001; 111: 494-500Crossref PubMed Scopus (149) Google Scholar The next question that arises is, who should do the PDT? Multiple articles have addressed this question. Polderman et al in this edition of CHEST (see page 1595) tackles the issue in a very simple and clear manner. In their institution, a team of four specialists performs PDTs, with at least one ear, nose, and throat surgeon and one intensivist as part of the team. With this you can ensure a rapid surgical airway in case the need arises or a quick endotracheal intubation in case of airway loss. This approach is an excellent way to end the never-ending argument of who should do the procedure: surgery or medicine? It can be both, in a team approach, allowing the best interests of the patient to be served. In addition to these findings, these same authors describe another very interesting observation. How many times have we been called to the bedside of a patient with a tracheostomy for an acute respiratory decompensation? We suction the airway with no significant mucous plugging noted. Then, suddenly with no clear explanation, the patient settles down and we are happy but at the same time puzzled by these events. Now, Polderman et al challenges our knowledge with a very interesting explanation/observation for some of these mysterious events. They describe a complication that refers to irritation of the posterior wall of the trachea secondary to chronic irritation by the tracheostomy cannula that causes an intermittent obstruction of the tracheal tube. Polderman et al suggest the acronym TWISTED (tracheal wall injury with intermittent stoppage of the tracheostomy and episodes of dyspnea). It is important for all of us who care for tracheostomized patients to be aware of this potential problem, and to learn how to manage it. Finally, after the sad events of the last year, I can honestly say that we live in a TWISTED world.