Also in Group A, one patient had a tracheoesophageal fistula and there were six cases of hemorrhage.
Explore This IssueSeptember 2006
In Group B, we had one case of equipment malfunction with delayed cannulation, one accidental decannulation, one mild tracheitis, three accidental extubations on the anesthesiologist’s side, and zero cases of hemorrhage, Dr. Goldenberg said.
Contraindications and Advantages
Unlike open operative tracheotomy, he emphasized, PDT does have a set of contraindications which were strictly adhered to in the reported series-children, typically under the age of 13, and any abnormality that doesn’t allow the physician to assess the surgical landmarks through the skin. PDT may also be contraindicated for patients who have severe coagulopathy or patients with a history of difficult intubation. The indications were identical to those for open tracheotomy.
In our experience, we’ve found that the complication rate [of percutaneous dilation tracheotomy] drops significantly with experience, not only of the surgeon, but of the whole tracheotomy team. – -David Goldenberg, MD
The advantages of PDT compared with surgical tracheotomy, as we see it, are that it is a bedside procedure, there are diminished costs, and you do not have to transport or coordinate taking critically ill patients to the operating room, he said. But it is not without its disadvantages. If you lose the airway, for example, that can be very severe.
Complications Will Decrease with Time and Experience
When looking at potential complications and complication rates, Dr. Goldenberg pointed out that there are different definitions of complications, different definitions of severity, and the timing of complications that must be taken into consideration.
Another problem with assessing this in tracheotomy is that different disciplines are embracing this technique; you have intensivists and non-surgeons performing a surgical procedure, Dr. Goldenberg said. I’m sure that, as this gets looked at over time, as the kits get better, and as it becomes more mainstream, you will see complication rates coming down.
Another assessment limitation, he noted, is due to the fact that a large number of PDT patients are very ill and they do not survive; therefore, there are no controlled long-term studies for assessing long-term complications.
For institutions trying to get PDT up and running, Dr. Goldenberg reminds that there is a relatively steep learning curve and advises them not to get discouraged with initially high complication rates.
There’s always an initial enthusiasm about doing it, but often the first few have an unacceptably high complication rate or something catastrophic occurs and they want to fall back on open tracheotomy, he said. In reality, it’s not as much the technique as much as it is inadequate training and lack of familiarity with the technique that accounts for most complications. In our experience, we found that the complication rate for PDT is low and similar to that of the open technique.