Use of postoperative chest x-ray after elective adult tracheotomy

Diagnosis by forensic autopsy of cannula malposition resulting in fatal tension pneumothorax after attempted percutaneous tracheostomy: A short communication

Percutaneous tracheostomy is commonly performed in the emergency department or intensive care unit to secure the airways of patients. This procedure is associated with a low incidence of complications; however, some of them, such as iatrogenic pneumothorax, can be fatal. Pneumothorax after percutaneous tracheostomy is most often caused by perforation of the tracheal wall or malposition of the cannula. A woman in her 80s was referred to the emergency department owing to persistent and prolonged coughing. Having speculated that she had acute epiglottitis, and having failed to achieve oral tracheal intubation, the physician performed a percutaneous tracheostomy to secure her airway. However, progressive percutaneous emphysema developed immediately thereafter, and the patient died shortly. Postmortem computed tomography showed bilateral pneumothorax. Forensic autopsy revealed that the tracheostomy cannula had failed to reach the trachea and was erroneously inserted into the right thoracic cavity via peritracheal route. Thus, it was determined that the patient's death was attributable to tension pneumothorax caused by cannula malposition during attempted tracheostomy. To the best of our knowledge, this is the first forensic autopsy case report on fatal tension pneumothorax caused by attempted percutaneous tracheostomy.

Our Experience with Percutaneous and Surgical Tracheotomy in Intubated Critically Ill Patients

Objective

Open surgical tracheotomy (OST) and percutaneous dilatational tracheotomy (PDT) are commonly used for securing airway in intubated critically ill patients. The purpose of this study was to compare the safety of OST and PDT, particularly in intubated critically ill patients.

Methods

The medical records of intubated critically ill patients who underwent tracheotomy between August 2006 and July 2017 were analyzed retrospectively. Minor and major complication rates were compared according to the tracheotomy technique. Preoperative intubation time, postoperative decannulation time, reason for hospitalization, and demographic data, including the Acute Physiology and Chronic Health Evaluation (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores, were evaluated.

Results

A total of 332 cases were enrolled into the study. The minor and major complication rates for both techniques were 27.2%, 8.8%, 9.7% and 3.2%, respectively. Minor and major complication rates were higher in the OST group (p=0.01, p=0.03, respectively). The rate of every single complication was also compared on groups' basis. Accidental decannulation (p=0.02) and pneumothorax (p=0.05) were found to be significantly frequent in the OST group. There was no impact of the preoperative intubation time on the minor (p=0.20) and major complication (p=0.29) rates found. There was no statistically significant difference regarding the postoperative decannulation time (p=0.32). Also, there was no statistically significant difference between two groups in terms of the APACHE II (p=0.69) and SOFA (p=0.37) scores. However, a statistically significant difference between the groups in terms of overall survival was found, in favor of PDT (p<0.001).

Conclusion

This study revealed that PDT is safer than OST, particularly in intubated critically ill patients.

Evaluation of the Clinical Utility of Routine Daily Chest Radiography in Intensive Care Unit Patients With Tracheostomy Tubes: A Retrospective Review

BACKGROUND

The utilization of imaging procedures is under scrutiny due to high costs and radiation exposure to patients and staff associated with some radiologic procedures. Within our institution's intensive care unit (ICU), it is common for patients to undergo chest radiography (CR) not only immediately following tracheostomy tube placement but also on a daily basis, irrespective of the patient's clinical status. We hypothesize that the clinical utility of performing routine daily CR on patients with tracheostomy tubes is low and leads to unnecessary financial cost.

METHODS

A retrospective medical chart review was done on 761 CRs performed on 79 ICU patients with tracheostomy from April 2010 to July 2011. We searched the radiology reports of the 761 CRs for the presence of new radiographically detected complications and reviewed medical records to determine which complications were clinically suspected and which radiology reports led to changes in patient management.

RESULTS

Of the 761 CRs, only 18 (2.3%) radiographs revealed new complications. All complications were clinically suspected prior to imaging. Only 5 (0.7%) complications resulted in a management change. The most common management changes were a change in antibiotic regimen (0.3%) and ordering of diuretics (0.3%).

CONCLUSIONS

Routine daily imaging of patients with tracheostomy in an ICU provides little clinical utility, and CR in this population should be performed selectively based on the patient's clinical status.

Is routine chest X-ray after surgical and percutaneous tracheostomy necessary in adults: a systemic review of the current literature

BACKGROUND

For many years, routine post-tracheostomy chest X-ray has been the standard of care for patients in many countries. However, recent evidence suggests that this is unnecessary and cost-ineffective.

OBJECTIVE

To review the current literature and examine the role of routine post-tracheostomy chest X-ray in adult patients.

TYPE OF REVIEW

Systemic review.

SEARCH STRATEGY

Electronic databases (PubMed, EMBASE, Cochrane) were searched using the keywords 'chest X-ray/radiography/radiograph' and 'tracheostomy/tracheotomy' in various permutations. Search period ranged from 1960 to 2012. Inclusion criteria included systematic reviews, meta-analyses, randomised control trials, prospective and retrospective case series. Paediatric and non-English articles were excluded. Abstracts and subsequently full text articles were screened by two of the authors independently. References from obtained articles were also examined.

EVALUATION METHOD

Specific outcome measures were collated to evaluate the usefulness of post-tracheostomy chest X-ray: Chest X-ray detected (tracheostomy-related) complication rates Proportion of cases requiring significant intervention Potential predictors of complications

RESULTS

Routine post-tracheostomy chest X-ray is of a low yield, and its findings had limited impact on patient management. Complication detection rates for surgical and percutaneous tracheostomy are 2.2% and 3.2%, respectively. Only 0.7% and 1.8% of chest X-rays performed in surgical and percutaneous tracheostomy cases, respectively, required intervention. Certain groups of patients, however, are at higher risks of complications, and may benefit from post-tracheostomy chest X-ray. For surgical tracheostomy, these groups include those with post-operative signs and symptoms of complications or had emergent or 'difficult' tracheostomies. For percutaneous tracheostomy, high-risk patients include trauma cases (unspecified), patients with post-procedural signs and symptoms of complications, patients who have high ventilatory requirements, difficult tracheostomy cases or tracheostomy cases performed without bronchoscopic guidance.

CONCLUSION

The practice of routine post-tracheostomy chest X-ray is debatable owing to its low yield and minimal impact on clinical management. However, certain groups of patients appear to be at higher risks of post-tracheostomy complications; currently, there is insufficient evidence to conclude the absolute need for routine chest X-ray in these groups of patients, although it may be prudent to do so based on available evidence in the literature and logical clinical reasoning.

Chest X-ray after tracheostomy is not necessary unless clinically indicated

BACKGROUND

Chest radiography is routinely used post-tracheostomy to evaluate for complications. Often, the chest X-ray findings do not change clinical management. The present study was conducted to evaluate the utility of post-tracheostomy X-rays.

METHOD

This retrospective review of 255 patients was performed at a single-center, university, level I trauma center. All patients underwent tracheostomy and were evaluated for postprocedure complications.

RESULTS

Of the 255 patients, 95.7% had no change in postprocedure chest X-ray findings. New significant chest X-ray findings were found in 4.3% of patients, including subcutaneous emphysema, pneumothorax, and new significant consolidation. Only three of these patients required change in clinical management, and all changes were based on clinical presentation alone.

CONCLUSIONS

Routine chest X-ray following tracheostomy fails to provide additional information beyond clinical examination. Therefore radiographic examination should be performed only after technically difficult procedures or if the patient experiences clinical deterioration. Significant cost savings and minimization of radiation exposure can be achieved when chest radiography after tracheostomy is performed exclusively for clinical indications.

Utility of routine postoperative chest radiography in pediatric tracheostomy

OBJECTIVES

Routine chest radiography following pediatric tracheostomy is commonly performed in order to evaluate for air-tracking complications. Routine chest radiography affords disadvantages of radiation exposure and cost. The primary objective of this study was to determine the utility of routine postoperative chest radiography following tracheostomy in pediatric patients. Secondary objectives were to compare the rates of postoperative complications by various patient and surgeon characteristics.

METHODS

All infants and children 18 years of age or less (n=421) who underwent tracheostomy at a single tertiary-care medical center from January 2000 to April 2009 were included in the study. A combination of data obtained from billing and administrative systems and review of electronic medical records were recorded and compiled in a database for statistical analysis.

RESULTS

Three air-tracking complications (2 pneumothoraces and 1 pneumomediastinum) were identified in our population of 421 pediatric patients, for an incidence of 0.71% (95% CI: 0.1-2.0%). No significant relationships were found between the incidence of air-tracking complication and surgical specialty, patient age, or type of procedure (elective, urgent/emergent).

CONCLUSIONS

Our study identified a low rate of pneumothorax and pneumomediastinum following pediatric tracheostomy. In all three cases, the pneumothorax was suspected clinically. This finding suggests that postoperative chest radiography should be reserved for cases where there is suspicion of a complication on the basis of intraoperative findings or clinical parameters.

Tracheostomy in the critically ill: indications, timing and techniques

PURPOSE OF REVIEW

Tracheostomy is one of the most common procedures performed in the intensive care unit. Indications, risks, benefits, timing and technique of the procedure, however, remain controversial. The decision of when and how to perform a tracheostomy is often subjective, but must be individualized to the patient. The following review gives an update on recent literature related to tracheostomy in the critically ill.

RECENT FINDINGS

Surprisingly, few data are available on the current practice of tracheostomy in the intensive care unit setting. Very few trials address this issue in a prospective, randomized fashion (randomized controlled trial). Most reports include small numbers representing a heterogeneous population, describing contrary results and precluding any definite conclusions. Evidence seems to suggest that early tracheostomy, however, might be preferable in selected patients.

SUMMARY

Due to increased experience and advanced techniques, percutaneous tracheostomy has become a popular, relatively safe procedure in the intensive care unit. The question of appropriate timing, however, has not been definitely answered with a randomized controlled trial. Instead, a number of retrospective studies and a single prospective study have shed some light on this issue. Most reports favor the performance of tracheostomy within 10 days of respiratory failure.

Acute complications of artificial airways

In conclusion, though there has been a dramatic reduction in the acute complications of artificial airways in the last hundred years, it remains crucial for the intensivist/anesthesiologist to have an implicit understanding of the anatomy and physiology of the process of ETI. As new techniques such as PDT are introduced, we must investigate their utility compared with the current standard of care in the most rigorous fashion. Additionally, as many of the complications of ETI can lead to increases in morbidity and mortality, prompt diagnosis and management are essential.

Routine Chest Radiograph is not Indicated after Open Tracheostomy: A Multicenter Perspective

Obtaining a chest radiograph (CXR) after open tracheostomy has been standard practice for many surgeons. We hypothesized that routine CXR after uncomplicated open tracheostomy is unnecessary. A prospective multicenter protocol was carried out on adult surgical patients undergoing uncomplicated tracheostomy. CXR was not routinely ordered in the immediate postoperative period but was obtained only for clinical indications. Preoperative and subsequent postoperative CXRs were reviewed for evidence of complications. Twenty-two surgeons at four institutions performed 151 tracheostomies. Posttracheostomy CXR was not diagnostic in four patients with potential tracheostomy-related complications (i.e., tachypnea, tachycardia, desaturation, and elevated peak airway pressure). In the 147 patients without clinical indications for CXR subsequent CXR revealed no significant new findings. In this era of cost containment the need for CXR after tracheostomy must be questioned. Routine CXR is not indicated or cost effective after uncomplicated open tracheostomy in adults.

Lack of utility of postoperative chest radiograph in pediatric tracheotomy

OBJECTIVE

To assess the incidence of pulmonary complications after nonemergent pediatric tracheotomy and to determine whether obtaining a routine postoperative chest radiograph is warranted.

STUDY DESIGN

Retrospective review of the records of 107 consecutive patients (age 1 month to 18 years) who underwent tracheotomy from October 1994 to June 2000. Main outcome measures included frequency of pulmonary complications and use of information obtained from postoperative chest radiograph for intervention.

SETTING

Tertiary care university children's hospital.

RESULTS

No pneumothoraces or significant pulmonary complications were detected in the immediate postoperative period. No management changes were undertaken as a result of information obtained from any chest radiograph in this period.

CONCLUSIONS

The incidence of significant pulmonary complications after pediatric tracheotomy is low. Little information is obtained from chest radiograph after tracheotomy, and this information does not change management.

SIGNIFICANCE

Routine postoperative chest radiograph after pediatric tracheotomy is not indicated in all patients.

The role of postoperative chest radiography in pediatric tracheotomy

A postoperative chest radiograph has traditionally been obtained after tracheotomies to evaluate for the presence of a pneumothorax and to assess tube position. Several recent studies in adults have questioned the usefulness of routine postoperative chest radiography in uncomplicated cases, but the role of post-operative chest radiography in pediatric patients has not been previously reviewed. We performed this study to examine the clinical utility of post-tracheotomy chest radiography in pediatric patients and determine if this routine practice impacts patient management enough to merit continued usage. A retrospective review was performed of 200 consecutive pediatric patients who underwent tracheotomies by the otolaryngology service in a tertiary care pediatric hospital from January 1994 to June 1999. All patients received postoperative chest radiographs. Five of 200 patients had a new postoperative radiographic finding, with three requiring interventions. Two patients required chest tube placement for pneumothorax, and one patient required tracheostomy tube change for repositioning. Fifty-one patients, including both pneumothoraces, exhibited clinical signs of pneumothorax (decreased breath sounds or oxygen saturation) in the immediate postoperative period. Chest X-ray ruled out a pneumothorax in the remaining 49 patients. The majority of these 51 patients were less than 2 years old (94%, P=0.002) or weighed less than 17 kg (89%, P=0.004). Postoperative chest X-rays yielded clinically relevant information in 168 patients that fell into one or more of four high risk categories: age less than 2, weight less than 17 kg, emergent procedures, or concomitant central line placement. Avoiding chest X-rays in the remaining 32 patients would have resulted in potential savings of $5000, which does not reflect the actuarial cost of a missed complication. Since the majority of our patients (84%) fell into a high-risk category, we feel it would be prudent to continue obtaining postoperative chest radiographs following all pediatric tracheotomies.

Chest radiographs after dilatational percutaneous tracheotomy: are they necessary?

BACKGROUND

The efficacy of routinely obtaining chest radiographs after standard open tracheotomy has been questioned. Recent literature would suggest that after a routine, uncomplicated tracheotomy, chest radiography is a low-yield procedure that incurs unnecessary expense. Percutaneous dilatational tracheotomy (PDT) is rapidly replacing open tracheotomy as the intensive care unit procedure of choice for airway management. Complication rates are equivalent between the two procedures.

OBJECTIVE

We examined the value and cost-effectiveness of routine postoperative chest radiographs in patients undergoing PDT.

STUDY DESIGN AND SETTING

The study was a prospective analysis of 54 consecutive PDTs performed at a tertiary care academic institution.

RESULTS

Eighteen (33%) patients had chest radiographs obtained within 1 hour of PDT (6 at the request of the otolaryngology service); 35 (66%) underwent radiography more than 2 hours later at the request of the intensive care unit for reasons other than PDT. There were no incidents of pneumothorax, pneumomediastinum, or tracheotomy tube malposition in any patient. Patients undergoing chest radiography within 1 hour of the PDT also had chest radiographs within 12 hours at the request of ICU staff for their underlying disease.

CONCLUSIONS

Routine chest radiography after PDT is of low yield. Because most of these patients require chest radiographs for their underlying disease within 12 hours, a cost savings of approximately $13,500 would be realized in this patient population.

SIGNIFICANCE

Routine chest radiography after PDT is unwarranted in most cases.