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Communications to the Editor |

Percutaneous Dilational Tracheostomy vs Open Tracheostomy Percutaneous Dilational Tracheostomy vs Open Tracheostomy FREE TO VIEW

Jeffrey D. Anderson, MD; Reuven Rabinovici, MD; Heidi L. Frankel, MD, FCCP
Author and Funding Information

Affiliations: Yale University School of Medicine New Haven, CT,  Washington University School of Medicine St. Louis, MO

Correspondence to: Heidi L. Frankel, MD, FCCP, Yale University School of Medicine, 333 Cedar Street LH 118, Department of Surgery, New Haven, CT 06520-8062;



Chest. 2001;120(4):1423-1424. doi:10.1378/chest.120.4.1423
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Published online

We read with interest the article by Dr. Freeman and colleagues in the November issue of CHEST,1 in which they compare percutaneous dilational tracheostomy (PDT) and standard open tracheostomy (ST). The authors concluded that their meta-analysis“ suggests potential advantages of PDT relative to surgical tracheostomy, including ease of performance and lower incidence of peristomal bleeding and postoperative infection.” Thus, this study supports the assertion that PDT is safer and that PDT should be the standard of care in appropriately selected patients.

We believe several factors cast doubt on the validity of this conclusion. First, the phrase “appropriately selected patients,” frequently used in the reviewed studies, should not be overlooked as it points to a major limitation in patient selection. As the meta-analysis indicates, patients were excluded from these studies for a variety of reasons including morbid obesity, obscure cervical anatomy, enlarged thyroid, short-thick necks, coagulopathy, previous tracheostomy or neck surgery, active infection, facial and cervical trauma and fractures, halo traction, and patients < 12 years of age. Since it is estimated that 25% of patients may be less than ideal candidates for PDT,2 it is not unexpected that PDT is considered faster, safer, and the procedure of choice for elective tracheostomy when a very liberal exclusion bias is applied.

Second, the authors report a higher incidence of perioperative and postoperative complications in patients undergoing ST. As reported by the study of Gysin et al3in 1999, the vast majority of these complications are clinically insignificant, consisting of nuisance bleedings and peristomal infections. On the other hand, life-threatening complications, although relatively infrequent, are more common in PDT. For example, the meta-analysis of Dulguerov et al4in 1999 showed a higher incidence of death and major cardiorespiratory events in patients undergoing PDT. A higher incidence of death, loss of airway, and hypoxia in patients undergoing PDT was also reported by Porter and Ivatury.5

Third, there are no solid data to support the purported advantages of bedside PDT, which include reduced costs, decreased procedure time, and avoidance of the significant risk of transfer to the OR. In fact, a recent comparison of PDT to bedside ST failed to demonstrate any significant advantage of PDT regarding costs, complications, and procedure time.

Taken together, these considerations suggest that PDT has a definite role in carefully selected patients. It should not be considered the procedure of choice for many critically ill patients for whom ST is the more appropriate procedure. Our current practice, therefore, is to perform PDT and ST at the bedside or in the OR, depending on the clinical circumstances and the physician’s preference and expertise.

Finally, we agree that Dr. Freeman’s meta-analysis demonstrates that a well-designed, prospective, randomized study to compare complications, costs, and final outcome is required for a definitive answer to the question of whether to use ST vs PDT.

Freeman, BD, Isabella, K, Lin, N, et al (2000) A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients.Chest108,1412-1418
 
Brookes, N, Howard, D Recent advances in intensive care: percutaneous tracheostomy may not be more effective than open technique.BMJ2000;320,1668-1669. [CrossRef]
 
Gysin, C, Dulguerov, P, Guyot, J, et al Percutaneous versus surgical tracheostomy: a double-blind randomized trial.Annu Surg1999;230,208-216
 
Dulguerov, P, Gysin, C, Perneger, TV, et al Percutaneous or surgical tracheostomy: a meta-analysis.Crit Care Med1999;27,1617-1625. [PubMed]
 
Porter, JM, Ivatury, RR Preferred route of tracheostomy—percutaneous versus open at bedside: a randomized prospective study in the SICU.Annu Surg1999;65,142-146
 

Percutaneous Dilational Tracheostomy vs Open Tracheostomy

To the Editor:

We wish to respond to the points raised by Anderson et al regarding potential limitations of percutaneous dilational tracheostomy (PDT) and our analysis.1

First, Anderson et al question the generalizability of our results. As with any clinical study, the conclusions of our meta-analysis are constrained by the selection criteria used in the individual trials on which our study was based. These trials excluded patients with contraindications for PDT, such as distorted neck anatomy, morbid obesity, and uncorrectable coagulopathy. Surgically created tracheostomy (SCT) remains the preferred method of providing an artificial airway in these settings, and the conclusions of our meta-analysis do not apply. In contrast, for patients meeting the inclusion criteria of these individual studies, our meta-analysis suggests that PDT has advantages relative to SCT.1

Second, Anderson et al question the significance and frequency of complications associated with PDT vs SCT. We found that PDT was associated with a lower rate of perioperative and postoperative bleeding and peristomal infection.1We disagree that these complications, which potentially add to the expense and morbidity of patient care, are trivial. As Anderson et al point out, the findings of our meta-analysis conflict with those of Dulguerov et al,2 who reported a higher incidence of death and major cardiovascular complications associated with PDT. Differences in the nature of the studies included in these two analyses may explain their conflicting conclusions. Specifically, Dulguerov et al2 included both prospective and observational studies as well as those using a variety of techniques for performing PDT. In contrast, only prospective studies employing the method of Ciaglia et al3 were selected for our analysis.

Third, a recently completed prospective study, which demonstrates that PDT may be performed more quickly and at lower cost than SCT,4 refutes the argument that there are no solid data to support the purported advantages of PDT.

Finally, while meta-analysis remains a useful technique, we consider our findings preliminary. We agree with Anderson et al that additional, adequately powered studies comparing PDT and SCT are needed to completely answer the question as to the relative merits and limitations of these techniques.

References
Freeman, BD, Isabella, K, Lin, N, et al A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients.Chest2000;118,1412-1418. [PubMed] [CrossRef]
 
Dulguerov, P, Gysin, C, Perneger, TV, et al Percutaneous or surgical tracheostomy: a meta-analysis.Crit Care Med1999;27,1617-1625. [PubMed]
 
Ciaglia, P, Firsching, R, Syniec, C Elective percutaneous dilational tracheostomy.Chest1985;87,715-719. [PubMed]
 
Freeman, BD, Isabella, K, Cobb, JP, et al A prospective randomized study comparing percutaneous and surgical tracheostomy in critically ill patients.Crit Care Med2001;29,926-930. [PubMed]
 

Figures

Tables

References

Freeman, BD, Isabella, K, Lin, N, et al (2000) A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients.Chest108,1412-1418
 
Brookes, N, Howard, D Recent advances in intensive care: percutaneous tracheostomy may not be more effective than open technique.BMJ2000;320,1668-1669. [CrossRef]
 
Gysin, C, Dulguerov, P, Guyot, J, et al Percutaneous versus surgical tracheostomy: a double-blind randomized trial.Annu Surg1999;230,208-216
 
Dulguerov, P, Gysin, C, Perneger, TV, et al Percutaneous or surgical tracheostomy: a meta-analysis.Crit Care Med1999;27,1617-1625. [PubMed]
 
Porter, JM, Ivatury, RR Preferred route of tracheostomy—percutaneous versus open at bedside: a randomized prospective study in the SICU.Annu Surg1999;65,142-146
 
Freeman, BD, Isabella, K, Lin, N, et al A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients.Chest2000;118,1412-1418. [PubMed] [CrossRef]
 
Dulguerov, P, Gysin, C, Perneger, TV, et al Percutaneous or surgical tracheostomy: a meta-analysis.Crit Care Med1999;27,1617-1625. [PubMed]
 
Ciaglia, P, Firsching, R, Syniec, C Elective percutaneous dilational tracheostomy.Chest1985;87,715-719. [PubMed]
 
Freeman, BD, Isabella, K, Cobb, JP, et al A prospective randomized study comparing percutaneous and surgical tracheostomy in critically ill patients.Crit Care Med2001;29,926-930. [PubMed]
 
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