Tracheal stenosis following percutaneous dilatational tracheostomy using the single tapered dilator: an MRI study

Safety of percutaneous dilatational tracheotomy (PDT) with the rigid tracheotomy endoscope (TED): a 6-month follow-up multicenter investigation

Background

The rigid tracheotomy endoscope (TED) was recently introduced to improve the fiberoptic technique during percutaneous dilatational tracheotomy (PDT) in critically ill patients. The aim was to evaluate the long-term complications of PDT using TED equipment in a prospective multicenter investigation.

Methods

One hundred eighty adult patients underwent PDT using TED in four German hospitals. Patients who were alive or their guardians were contacted via telephone and interviewed using a structured questionnaire 6 months following the tracheostomy procedure. Patients with airway complaints were invited for outpatient clinical ENT examination. The incidence of adverse events related to PDT was registered.

Results

Of 180 patients who received tracheostomy, 137 (76.1%) were alive at the time of follow-up. None of the 43 lethal events was related to the PDT. Fifty-three (38.7%) patients were available for follow-up examination, whereas 14 (10.2%) were able to visit ENT physicians. Two (3.8%) out of 53 patients developed tracheocutaneous fistula with required surgical closure of tracheostoma. Dyspnea (7.5%), hoarseness (5.7%), stridor and swallowing difficulties (both with 3.8%) were the most common complaints. Tracheal stenosis was confirmed in 1 patient (1.88% [95% CI: 0.33; 9.93]).

Conclusion

The use of TED for PDT in the clinical setting is safe regarding adverse events at 6-month follow-up. The incidence of tracheal stenosis after PDT with TED is comparable with that of flexible bronchoscopy; however, its role for PDT at the intensive care unit should be clarified in further investigations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01264-2.

Short- and long-term complications of surgical and percutaneous dilatation tracheotomies: a large single-centre retrospective cohort study

Objectives

The aim of this study was to determine and compare the incidence of long- and short-term complications of percutaneous dilatation tracheotomies (PDT) and surgical tracheotomies (ST).

Design

A single-centre retrospective study.

Participants

305 patients undergoing a tracheotomy (PDT or ST) in the University Medical Center Groningen from 2003 to 2013 were included. Data were gathered from patient files.

Main outcome measures

Short-term and long-term complications including tracheal stenosis.

Results

The incidence of short- and long-term complications, including tracheal stenosis, was similar in both groups. Analysis of a small high-risk subgroup showed no difference in long-term complications.

Conclusions

The rate of short- and long-term complications, including tracheal stenosis, is equal in PDT and ST. PDT is a safe alternative for ST in selected patients.

The ultrasound neck imaging for tracheostomy study: A study prompting ultrasound screening prior to percutaneous tracheostomy procedures to improve patient outcomes

Introduction

Percutaneous tracheostomy procedures are commonplace in intensive care units worldwide. Haemorrhagic complications, though potentially fatal, are thought to be under-reported. Ultrasonography use has not established itself in these procedures. This study assesses the prevalence and characteristics of pre-tracheal blood vessels, to aid intensivists on potential procedural hazards.

Method

A retrospective, observational study was performed in the UK. Computed tomography angiograms from January 2012 to October 2014 were randomly retrieved and analysed for vessel data.

Results

A total of 343 adult patients were included (mean age: 65 (inter-quartile range 52-79), male: 63%). Forty-one percent of patients demonstrated a vessel overlying percutaneous tracheostomy insertion sites (C6-T1); veins were more common than arteries (69%, p = 0.001). Males were more likely to display veins (78 vs. 53%, p < 0.001).

Discussion

A substantial proportion of patients exhibited pre-tracheal vessels. Front-of-neck ultrasonography has huge potential to identify these. Based on these data, we believe ultrasonography may be an effective screening tool for percutaneous tracheostomy procedures to reduce complications. Further research is required to study outcomes.

Late complications of percutaneous tracheostomy using the balloon dilation technique

OBJECTIVE

The purpose of this study was to determine the late complications in critically ill patients requiring percutaneous tracheostomy (PT) using the balloon dilation technique.

DESIGN

A prospective, observational cohort study was carried out.

SCOPE

Two medical-surgical intensive care units (ICU).

PATIENTS

All mechanically ventilated adult patients consecutively admitted to the ICU with an indication of tracheostomy.

INTERVENTIONS

All patients underwent PT according to the Ciaglia Blue Dolphin^® method, with endoscopic guidance. Survivors were interviewed and evaluated by fiberoptic laryngotracheoscopy and tracheal computed tomography at least 6 months after decannulation.

VARIABLES

Intraoperative, postoperative and long-term complications and mortality (in-ICU, in-hospital) were recorded.

RESULTS

A total of 114 patients were included. The most frequent perioperative complication was minor bleeding (n=20) and difficult cannula insertion (n=19). Two patients had severe perioperative complications (1.7%) (major bleeding and inability to complete de procedure in one case and false passage and desaturation in the other). All survivors (n=52) were evaluated 211±28 days after decannulation. None of the patients had symptoms. Fiberoptic laryngotracheoscopy and computed tomography showed severe tracheal stenosis (>50%) in 2patients (3.7%), both with a cannulation period of over 100 days.

CONCLUSIONS

Percutaneous tracheostomy using the Ciaglia Blue Dolphin^® technique with an endoscopic guide is a safe procedure. Severe tracheal stenosis is a late complication which although infrequent, must be taken into account due to its lack of clinical expressiveness. Evaluation should be considered in those tracheostomized critical patients who have been cannulated for a long time.

Tracheotomy-Related Deaths

BACKGROUND

Tracheotomies are frequently performed on ventilated patients in intensive care and sometimes lead to fatal complications. In this article, we discuss the causes and frequency of death associated with open surgical tracheotomy (OST) and percutaneous dilatational tracheotomy (PDT) on the basis of a review of the pertinent literature.

METHODS

We systematically searched the PubMed, EMBASE, and Cochrane Library databases and the Karlsruhe Virtual Catalog for publications (1990-2015) on tracheotomy-related deaths in adults, using the search terms "tracheotomy" and "tracheostomy." 39 relevant dissertations were included in the analysis as well.

RESULTS

109 publications were included. Of the 25 056 tracheotomies described, there were 16 827 PDTs and 7934 OSTs; for 295 tracheotomies, the technique used was not stated. 352 deaths were reported, including 113 in patients treated with PDT, 49 in those treated with OST, and 190 deaths related to a tracheotomy without specification of the method used. The frequency of death among patients with OST and those treated with PDT was similar: 0.62% for OST (95% confidence interval [0.47; 0.82]) and 0.67% for PDT ([0.56; 0.81]). The most common causes of death and their frequencies, as a percentage of all tracheotomies, were hemorrhage (OST: 0.26% [0.17; 0.40], PDT: 0.26% [0.19; 0.35]), loss of airway (OST: 0.21% [0.13; 0.34], PDT: 0.20% [0.14; 0.28]), and false passage (OST: 0.11% [0.06; 0.22], PDT: 0.20% [KI 0.15; 0.29]).

CONCLUSION

Bias in the data cannot be excluded, as these were not epidemiologic data and the documentation was found to be incomplete. The likelihood of a fatal complication seems to be the same with both tracheotomy techniques as far as can be determined from the available evidence. Tracheotomy-related deaths can be avoided in several ways: by thorough training under the leadership of experienced physicians, by the use of the World Health Organization's Surgical Safety Checklist regardless of where the tracheotomy is performed, and by the continuous vigilance of nursing staff.

Long-Term Outcome Following Tracheostomy in Critical Care: A Systematic Review

OBJECTIVES

The prevalence and impact of longer-term outcomes following percutaneous tracheostomy, particularly tracheal stenosis, are unclear. Previous meta-analyses addressing this problem have been confounded by the low prevalence of tracheal stenosis and a limited number of studies.

DESIGN

Embase, PubMed-Medline, and the Cochrane Central Register of Clinical Trials were searched to identify all prospective studies of tracheostomy insertion in the critically ill. To reflect contemporary practice, the search was limited to studies published from 2000 onward. We scrutinized the bibliographies of returned studies for additional articles. Meta-analyses were undertaken to estimate the pooled risk difference of tracheal stenosis, bleeding, and wound infection comparing different techniques.

MEASUREMENTS AND MAIN RESULTS

We identified a total of 463 studies, 29 (5,473 patients) of which met the inclusion criteria. Nine were randomized controlled trials, six were nonrandomized comparative studies, and 14 were single-arm cohort studies. Risk of wound infection was greater for the surgical tracheostomy than for the Ciaglia multiple dilator technique, pooled risk difference 0.12 (95% CI, 0.02-0.23). We did not identify significant risk differences in other meta-analyses. Pooling across all studies according to the random-effects proportion meta-analysis suggests a higher prevalence of tracheal stenosis, wound infection, and major bleeding for surgical tracheostomies.

CONCLUSIONS

Considering comparative data, there was no significant difference in the prevalence of tracheal stenosis or major bleeding between percutaneous and surgical tracheostomy. In relation to wound infection, we have found a reduction associated with the original Ciaglia technique when compared with that with the surgical tracheostomy. Considering all published data reporting long-term outcomes pooled proportion meta-analysis indicates a trend toward a higher rate of tracheal stenosis and an increased risk of major bleeding and wound infection for surgical tracheostomies. This finding may be biased as a result of targeted patient selection, and further, high-quality long-term comparative data are needed to confirm these findings.