Meta-Analysis Comparison of Open Versus Percutaneous Tracheostomy

Department of Otolaryngology-Head and Neck Surgery, Sunnybrook Health Sciences Centre-University Toronto, Ontario, Canada.
The Laryngoscope (Impact Factor: 2.14). 04/2007; 117(3):447-54. DOI: 10.1097/01.mlg.0000251585.31778.c9
Source: PubMed


Multiple studies have been performed to characterize differences in complications and cost-effectiveness of open and percutaneous tracheostomy; however, large enough studies have not been performed to determine a clearly superior method. Our primary objective was to compare complication rates of open versus percutaneous tracheostomy in prospective, randomized-controlled trials using meta-analysis methodology. Secondary objectives included cost-effectiveness and procedure length analyses.
From 368 abstracts, 15 prospective, randomized-controlled trials involving nearly 1,000 patients were reviewed to extract basic demographic data in addition to complications, case length, and cost-effectiveness. Pooled odds ratios (OR) with confidence intervals (CI) were calculated in addition to subgroup analyses and meta-regression.
Pooled OR revealed statistically significant results against percutaneous tracheostomy for the complication of decannulation/obstruction (OR 2.79, 95% CI 1.29-6.03). There were significantly fewer complications in the percutaneous group with respect to wound infection (0.37, 0.22-0.62) and unfavorable scarring (0.44, 0.23-0.83). There was no statistically significant difference for complications of false passage (2.70, 0.89-8.22), minor hemorrhage (1.09, 0.61-1.97, P = .77), major hemorrhage (0.60, 0.28-1.26), subglottic stenosis (0.59, 0.27-1.29), death (0.70, 0.24-2.01), and overall complications (0.75, 0.56-1.00). However, the overall complications trended toward favoring the percutaneous technique. Percutaneous tracheostomy case length was shorter overall by 4.6 minutes, and costs were less by approximately $456 USD.
Our meta-analysis illustrates there is no clear difference but a trend toward fewer complications in percutaneous techniques. Percutaneous tracheotomies are more cost-effective and provide greater feasibility in terms of bedside capability and nonsurgical operation.

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    • "Long-term complications include phonetic or respiratory problems. Additionally, PDT is commonly used in the ICU environment [8]. Advantages to percutaneous techniques include speed of procedure, less personnel, smaller skin incision, less tissue trauma, lower wound infection, and peristomal bleeding . "
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    ABSTRACT: This case is a patient with amyotrophic lateral sclerosis who was unable to be separated from mechanical ventilator support and required a tracheostomy. The patient underwent an initial open tracheostomy utilizing flexible fiberoptic tracheoscopy (FFT) in the operating room (OR). Subsequently, he developed recurrent leaks in the tracheal tube cuff requiring multiple trips back to the operating room. The recurrent cuff leak occurred following each tube placement until the etiology of the leak was discovered during the fourth procedure. In the fourth procedure, the wound was explored more extensively, and it was found that there was a sharp, calcified, aberrant fragment of a tracheal cartilage ring protruding into the tracheal lumen, which was damaging the cuff of each tube. This fragment was not visible by multiple FFTs, nor was it visible in the wound by the surgeons until wider exploration of the wound occurred. The cartilage fragment was ultimately excised and the patient had no further cuff leaks. Aberrant tracheal cartilage should be on the differential diagnosis for cuff leaks subsequent to surgical tracheostomy (ST) or percutaneous dilatational tracheostomy (PDT).
    08/2015; 2015(5):379397. DOI:10.1155/2015/379397
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    • "Higgins et al.17 in a meta-analysis on about 1000 patients, concluded that PDT is cost-benefit, available bedside, and does not require an operating room. It lasted 4.6 minutes and its expense was 456$. "
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    ABSTRACT: Introduction: Following advances of Intensive Care medicine and widespread administration of mechanical ventilation, tracheostomy has become one of the indispensable surgical procedures. During this research we tried to assess and compare two main strategies for doing tracheostomy: Surgically Created Tracheostomy (SCT) and Percutaneous Dilatational Tracheostomy (PDT). Methods: In a randomized clinical trial, 60 cases of patients who were admitted in Intensive Care Unit (ICU) and needed tracheostomy during their stay were enrolled. Patients were randomly divided into two groups. SCT technique was considered for the first group and PDT for the second one. Demographic characteristics, associated and underlying diseases, type and duration of procedure, duration of receiving mechanical ventilation and ICU stay, expenses and complications of tracheostomy including bleeding, subcutaneous emphysema, pneumothorax, stomal infection and airway loss were all recorded during study and compared between both groups. Results: There were significant differences between two groups of patients in terms of duration of receiving mechanical ventilation (P=0.04), duration of tracheostomy procedure (P=0.001) and procedure expenses (P=0.04). There was no significant difference between two groups in terms of age and gender of patients, duration of ICU stay and complications of tracheostomy including copious bleeding, stomal infection, subcutaneous emphysema and airway. Conclusion: According to the results of our study and similar researches, it can be concluded that PDT can be considered as the preferred procedure in cautiously selected patients during their ICU stay.
    03/2014; 6(1):43-46. DOI:10.5681/jcvtr.2014.008
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    • "In a further 11 patients, the tracheal cannula accidentally dislocated postprocedurally. While the surgical approach allows easy reinsertion of the tracheal cannula, airway complications such as accidental decannulation or tube obstruction are well-described problems of the percutaneous technique [70]. Some researchers have proposed that fixing the tracheal cannula to the skin with sutures for the first postprocedural week may decrease cannula-related complications such as accidental decannulation and postoperative bleeding [71,72]. "
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    ABSTRACT: Since the introduction and widespread acceptance of percutaneous techniques in the intensive care unit (ICU) setting, the number of critically ill patients undergoing tracheostomy has steadily increased. However, this procedure can be associated with major complications, including death. The purpose of this study is to estimate the incidence and analyze the causes of lethal complications due to percutaneous dilatational tracheostomy (PDT). We analyzed cases of lethal outcome due to complications from PDT including cases published between 1985 and April 2013. A systematic literature search was performed and unpublished cases from our own departmental records were retrospectively analyzed. 71 cases of lethal outcome following PDT were identified including 68 published cases and 3 of our own patients. The incidence of lethal complications was calculated to be 0.17%. Of the fatal complications, 31.0% occurred during the procedure and 49.3% within seven days of the procedure. The main causes of death were: hemorrhage (38.0%), airway complications (29.6%), tracheal perforation (15.5%), and pneumothorax (5.6%). We found specific risk factors for complications in 73.2% of patients, 25.4% of patients had more than one risk factor. Bronchoscopic guidance was used in only 46.5% of cases. According to this analysis, PDT-related death occurs in 1 out of 600 patients receiving a PDT. Careful patient selection, bronchoscopic guidance, and securing the tracheal cannula with sutures are likely to reduce complication rates.
    Critical care (London, England) 10/2013; 17(5):R258. DOI:10.1186/cc13085 · 4.48 Impact Factor
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