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Correspondence |

Just Because We Can Does Not Mean We ShouldCombined PEG and Tracheostomy Insertion: A Perspective on Combined Tracheostomy and Percutaneous Endoscopic Gastrostomy Tube Insertion FREE TO VIEW

Eoin Slattery, MD; David S. Seres, MD
Author and Funding Information

From the Division of Preventive Medicine and Nutrition, Columbia University Medical Center-New York Presbyterian Hospital.

Correspondence to: Eoin Slattery, MD, Division of Preventive Medicine and Nutrition, Columbia University Medical Center-New York Presbyterian Hospital, 630 W 168th St, New York, NY 10032; e-mail: Slattery.eoin@gmail.com


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(2):421-422. doi:10.1378/chest.13-2134
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Published online
To the Editor:

We read with interest the article from Yarmus et al1 in CHEST (August 2013) about the feasibility of percutaneous endoscopic gastrostomy (PEG) tube insertion by interventional pulmonologists. For reasons that are unclear, a combination procedure of PEG and tracheostomy has been advocated by some. In the current work, more than one-half of the patients (n = 41) underwent a combined procedure. There is some historic observational data on the feasibility of this approach2,3; however, efficacy and safety of this approach has not been previously studied in prospective randomized trials.

Consensus guidelines would suggest that PEG tube insertion be considered for patients who are likely to have a requirement for enteral nutrition of > 30 days.4 PEG, while safe and reasonably well tolerated, is not a frivolous procedure. Thirty-day mortality after PEG tube insertion has been noted to range between 10% and 26% in some series, largely driven by poor patient selection.4,5 Indeed, in one of the largest published series, a 1-week mortality of 43% was seen in a national confidential inquiry into patient deaths in the National Health Service, of which 19% of procedures were deemed futile upon expert review.6 It is with this knowledge that the selection of critically ill patients undergoing tracheostomy as suitable subjects for PEG tube insertion needs to be questioned. By virtue of their complex critical illness, patients undergoing tracheostomy insertion are sick and not optimal subjects. Reported 30-day mortality rates after tracheostomy insertion alone vary but have been reported to be on the order of 30%.6-8 For similar reasons, the policy of placing PEG tubes in patients early in the course of their critical illness (as early as 4 days in the current report) and prior to declaration of medical stability is questionable.

In the current series, Yarmus et al1 reported mortality at 30 days of 11%. The mortality in the group that underwent simultaneous PEG and tracheostomy tube insertion was not reported; we would be interested to see these data.

PEG tubes were removed in 73% of surviving patients within a median of 76 days (range, 24-611 days). This would seem to suggest that PEG tube insertion (and all of its attendant risks) may have been avoided completely in some patients by deferring simultaneous insertion.

Nasogastric feeding tubes are widely regarded as safe and should be the preferred option for short-term nutrition delivery. We feel that the policy of simultaneous PEG and tracheostomy tube insertion should not be advocated until it has been proven to be superior to a watch-and-wait approach in prospective randomized trials.

References

Yarmus L, Gilbert C, Lechtzin N, Imad M, Ernst A, Feller-Kopman D. Safety and feasibility of interventional pulmonologists performing bedside percutaneous endoscopic gastrostomy tube placement. Chest. 2013;144(2):436-440. [CrossRef] [PubMed]
 
Vaughan JR, Scott JS, Edelman DS, Unger SW. Tracheostomy. A new indication for percutaneous endoscopic gastrostomy tube placement. Am Surg. 1991;57(4):214-215. [PubMed]
 
Moore FA, Haenel JB, Moore EE, Read RA. Percutaneous tracheostomy/gastrostomy in brain-injured patients—a minimally invasive alternative. J Trauma. 1992;33(3):435-439. [CrossRef] [PubMed]
 
Terragni PP, Antonelli M, Fumagalli R, et al. Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: a randomized controlled trial. JAMA. 2010;303(15):1483-1489. [CrossRef] [PubMed]
 
Leeds JS, McAlindon ME, Grant J, Robson HE, Lee FK, Sanders DS. Survival analysis after gastrostomy: a single-centre, observational study comparing radiological and endoscopic insertion. Eur J Gastroenterol Hepatol. 2010;22(5):591-596. [CrossRef] [PubMed]
 
Johnston SD, Tham TC, Mason M. Death after PEG: results of the National Confidential Enquiry into Patient Outcome and Death. Gastrointest Endosc. 2008;68(2):223-227. [CrossRef] [PubMed]
 
Combes A, Luyt CE, Nieszkowska A, Trouillet JL, Gibert C, Chastre J. Is tracheostomy associated with better outcomes for patients requiring long-term mechanical ventilation? Crit Care Med. 2007;35(3):802-807. [CrossRef] [PubMed]
 
Young D, Harrison DA, Cuthbertson BH, Rowan K; TracMan Collaborators. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial. JAMA. 2013;309(20):2121-2129. [CrossRef] [PubMed]
 

Figures

Tables

References

Yarmus L, Gilbert C, Lechtzin N, Imad M, Ernst A, Feller-Kopman D. Safety and feasibility of interventional pulmonologists performing bedside percutaneous endoscopic gastrostomy tube placement. Chest. 2013;144(2):436-440. [CrossRef] [PubMed]
 
Vaughan JR, Scott JS, Edelman DS, Unger SW. Tracheostomy. A new indication for percutaneous endoscopic gastrostomy tube placement. Am Surg. 1991;57(4):214-215. [PubMed]
 
Moore FA, Haenel JB, Moore EE, Read RA. Percutaneous tracheostomy/gastrostomy in brain-injured patients—a minimally invasive alternative. J Trauma. 1992;33(3):435-439. [CrossRef] [PubMed]
 
Terragni PP, Antonelli M, Fumagalli R, et al. Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: a randomized controlled trial. JAMA. 2010;303(15):1483-1489. [CrossRef] [PubMed]
 
Leeds JS, McAlindon ME, Grant J, Robson HE, Lee FK, Sanders DS. Survival analysis after gastrostomy: a single-centre, observational study comparing radiological and endoscopic insertion. Eur J Gastroenterol Hepatol. 2010;22(5):591-596. [CrossRef] [PubMed]
 
Johnston SD, Tham TC, Mason M. Death after PEG: results of the National Confidential Enquiry into Patient Outcome and Death. Gastrointest Endosc. 2008;68(2):223-227. [CrossRef] [PubMed]
 
Combes A, Luyt CE, Nieszkowska A, Trouillet JL, Gibert C, Chastre J. Is tracheostomy associated with better outcomes for patients requiring long-term mechanical ventilation? Crit Care Med. 2007;35(3):802-807. [CrossRef] [PubMed]
 
Young D, Harrison DA, Cuthbertson BH, Rowan K; TracMan Collaborators. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial. JAMA. 2013;309(20):2121-2129. [CrossRef] [PubMed]
 
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