The use of tracheostomy for prolonged ventilation
Dr Pete Watkinson DICM MRCP FRCA
Advanced Trainee Intensive Care Medicine
Focus on the use of tracheostomy for prolonged ventilation
The use of tracheostomy in prolonged ventilation is controversial. The perceived advantages include increased patient comfort (with consequent decreased sedation), reduced dead space and airway resistance and a reduced risk of glottic trauma.
Balanced against this are the risks of the procedure. These risks are summarised in Table 1.
Table 1. Risks associated with tracheostomy formation
Laryngeal nerve damage
Vessel erosion causing secondary haemorrhage
There are normally two decisions to be made with regard to tracheostomy insertion on the intensive care unit:
- Firstly, should a percutaneous or surgical approach be undertaken
- Secondly, should the tracheostomy be formed ‘early’ or ‘late’
Focus on percutaneous or surgical techniques
Whilst various percutaneous techniques have been employed, the most common is that of Ciaglia. This originally involved insertion between the cricoid cartilage and the first tracheal ring. It has since been found that insertion between the first and fourth costal cartilage decreases the risk of tracheal stenosis from high insertion and bleeding from low insertion. The technique has been modified recently by the introduction of a single "Blue Rhino" dilator (Cook Critical Care) to replace the sequential dilators in the original technique. This seems to speed up the technique, and may possibly increase safety.
There have been two recent meta-analyses comparing the relative safety of the surgical versus the percutaneous approach.
Dulguerov et al showed that percutaneous techniques were associated with small increases in peri-operative death and serious cardiorespiratory events (which achieved statistical significance). However, the studies included were somewhat heterogeneous, and a disproportionate number of the percutaneous tracheostomy patients were performed on the ICU, and therefore might reasonably be expected to have a higher peri-operative complication rate. Importantly, no assessment of the pre-operative level of illness was made. Moreover the different percutaneous techniques were not separated.
In contrast, Freeman et al, who restricted their meta-analysis to prospective studies, and only included Ciaglia’s percutaneous dilational technique, found no statistical difference. There was a trend towards greater safety with the percutaneous technique. However, the inclusion criteria pertaining to this meta-analysis resulted in only five studies (containing a total of 326 patients) contributing to the findings. However, both studies note significantly decreased peri-stomal bleeding and infection rates associated with the percutaneous technique. Neither study took into account the risks associated with transferring a patient to and from the ICU inherent with the surgical approach, which are well documented, nor the delay that may occur. Discussion subsequent to the publication of these papers suggested that the percutaneous technique could probably be made safer by use of continual bronchoscopic surveillance during the procedure, a point emphasised in Dulguerov’s paper. The combination of these factors would suggest that there is little to choose between the two techniques with regard to major peri-operative complications.
Focus on the timing of the tracheostomy
In 1989, the National Association of Medical Directors of Respiratory Care recommended translaryngeal (endotracheal) intubation only for those requiring less than ten days of artificial ventilation and that a tracheostomy should be placed in patients who still require artificial ventilation twenty-one days after admission.
These guidelines demonstrate the uncertainty that exists with regard to the timing of tracheostomy placement. A recent meta-analysis by Griffiths and colleagues suggests that ‘early tracheostomy’, (defined as between days one and four of ICU admission) may reduce the duration of artificial ventilation and ICU stay when compared to ‘late tracheostomy’ (defined as after day ten of ICU admission). However, the studies included in this systematic review are small and heterogeneous which limits the conclusions that can be made. The question of what effect the timing of tracheostomy placement has on patient outcome will hopefully be answered by the UK TRACMAN trial – a large, multi centre randomised controlled trial that has already recruited over 500 patients.
Key learning points
Tracheostomy placement is commonly encountered on a modern day ICU
Percutaneous and surgical techniques appear to be associated with similar levels of risk
The effect that the timing of tracheostomy has on patient outcome is uncertain but current evidence favours the ‘early’ approach
The effect that the timing of tracheostomy has on patient outcome is currently being addressed by a large, multi center UK trial.
Griffiths J, Barber VS, Young JD.
Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation.
BMJ 2005; 330: 1243-1248.
Eggert SM, Jerwood C.
BJA CEPD review 2003; 3(5):139-42
Freeman BD, Isabella K et al.
A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients.
Chest 2000; 118:1412-8
Dulguerov P, Gysin C et al.
Percutaneous or surgical tracheostomy: a meta-analysis.
Crit Care Med 1999; 27:1617-25
Plummer AL, Gracey DR.
Consensus conference on artificial airways in patients receiving mechanical ventilation.
Chest 1989; 96(1):178-80 (No Pubmed abstract available)
Ciaglia P, Fisching R, Syniec C.
Elective percutaneous dilational tracheostomy.
Chest 1985; 87:715-9