Percutaneous vs Surgical Tracheostomy
13/9/10
PY Mindmaps
Percutaneous tracheostomy = reference to a number of different techniques to insert a tracheostomy (gradual dilation, forceps dilation, rhino and translaryngeal techniques)
Surgical tracheostomy = surgical dissection down to trachea, creation of window in trachea with insertion of tracheostomy tube for ventilation.
Percutaneous Surgical
Benefits - no transport required - dissection under direct vision
- can be performed earlier - can avoid aberrant vessels
- tighter fit - better for the challenging patient
- less expensive - time honoured
- trend toward reduced VAP - best control of airway
- trend toward reduced ICU LOS - lower complication rate
- less cosmetic deformity
- less infection
- less bleeding
- quicker
Disadvantages - requires bronchoscope for safety - transport out of ICU
- no visualisation of tissues traversed - higher tracheal stenosis
- risk damage to bronchoscope - more bleeding
- same pneumothorax risk
Safety/Complications - 8% complication rate - 9% complication rate
- operator safety is volume dependent
- occlusion by posterior tracheal membrane
Evidence
PDT = Ciaglia Technique
1999 – Dulguerov et al, Critical Care Medicine
- open vs perc.
-> PDT+ Bronch = lowest complication rate in percutaneous group
- percutaneous group = lower post op but higher perioperative complication rate
2000 – Cheng et al, Ann Otol Rhinol Laryngol
- meta-analysis (including 4 RCT’s)
- open vs PDT
-> PDT = lower risk of infection and bleeding
-> PDT + Bronch as safe as open tracheostomy
2000 – Freeman et al, Chest
- meta-analysis (including 5 RCT’s)
- open vs PDT
-> no overall difference in mortality rate
-> PDT: quicker, lower post op complications, less bleeding
2006 - Delaney et al, Crit Care Med
- large meta-analysis (17 studies)
- PDT vs open
-> PDT: lower wound infection,
-> no difference in bleeding and complication rates
2007 – Higgins et al, Laryngoscope
- PDT vs open
- meta-analysis (15 studies)
- PDT: less infection, less scarring, trend towards lower complication rate, faster, cheaper, lower conversion rate
- PDT: higher accidental decannulation, no difference in bleeding, subglottic stenosis, death
Jeremy Fernando (2011)