STANFORD, CALIF--Many physicians have avoided performing percutaneous dilatational tracheostomy because of safety concerns about the new procedure and greater familiarity with standard tracheostomy. However, a recent meta-analysis may help to change their minds about the percutaneous method.[1]

"For patients who require an elective tracheostomy, this is an excellent technique," Willard E. Fee, Jr, MD, one of the authors, told PULMONARY REVIEWS. In the meta-analysis, the percutaneous method took less than half as long to complete as standard tracheostomy. Moreover, standard tracheostomy had an almost fivefold higher rate of postoperative complications, especially minor bleeding and stomal infection, and these complications were often more severe.

"Be aware, though, that the patients who entered these studies were carefully selected," cautioned Dr. Fee, a Professor of Otolaryngology at the Stanford University Medical Center in California. That is, most of them were not obese and, thus, had normal-sized necks.

A QUICKER PROCEDURE

Using the keywords "dilatational tracheostomy," "percutaneous tracheostomy," and "endoscopic tracheostomy," the authors performed a MEDLINE search that yielded 256 relevant papers published through January 31, 1999. "We wanted randomized, prospective studies comparing percutaneous dilatational tracheostomy with standard tracheostomy, and only four of the papers met these criteria," said Dr. Fee.

The four studies had a total of 212 patients. Of these, 103 underwent percutaneous dilatational tracheostomy and 109 had a standard tracheostomy. In each of the four studies, the two groups of patients were well matched in terms of their demographic characteristics (eg, age, sex, and number of days intubated) and indications for the procedure. Most often, the procedure was indicated for pulmonary disease, such as pneumonia, respiratory failure, or chronic obstructive pulmonary disease; however, in almost one third of cases, neurologic disorders were the indication for surgery.

Percutaneous dilatational tracheostomy was the faster procedure; it required only eight minutes, on average, to perform--versus about 21 minutes for standard tracheostomy. During surgery, the patients who underwent the percutaneous procedure experienced a smaller drop in arterial oxygen saturation (SaO2) than did the standard tracheostomy group (mean lowest intraoperative SaO2, 96.8% vs 93.7%).

The percutaneous group also had a lower rate of minor bleeding during surgery (9% vs 25%).

FEWER POSTOP COMPLICATIONS

Overall, only 14% of the patients who underwent the percutaneous procedure experienced postoperative complications, compared with 60% of the standard tracheostomy group. The most common of these complications--minor bleeding and stomal infection--occurred in 7% and 4%, respectively, of the percutaneous group--versus 18% and 29%, respectively, of those with standard tracheostomies.

Most other postoperative complications (eg, major bleeding, pneumothorax, subcutaneous emphysema, atelectasis, aspiration, and cuff leak) occurred with similarly low frequency in either group. For example, major bleeding affected 2% of each group. Cuff leaks developed in none of the patients who underwent the percutaneous procedure and in 2% of those who received standard tracheostomies.

Decannulation was slightly more likely to be successful in the percutaneous group. These patients also required tracheostomy for a shorter period (mean duration, 22 days vs 27 days in the standard tracheostomy group).

Three postoperative deaths occurred, all in the patients with standard tracheostomies. Death was related to accidental decannulation in two cases and to massive hemorrhage from a tracheoinnominate fistula in one case.

"For patients who do not need an emergency airway, percutaneous dilatational tracheostomy has similar risk and complications as standard tracheostomy," concluded Dr. Fee.

He and his coauthor recommend the percutaneous procedure for elective tracheostomy in such patients, especially those with normal-size necks. However, they suggest performing standard tracheostomy or cricothyroidotomy for patients with abnormal neck anatomy and for those who need emergency airway access.

--Timothy Begany

Reference
1. Cheng E, Fee WE Jr. Dilatational versus standard tracheostomy: a meta-analysis. Ann Otol Rhinol Laryngol. 2000;109:803-807.

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