Percutaneous Dilation Tracheotomy Can Be a Safe, Effective Nonsurgical Option

CHICAGO- Percutaneous dilation tracheotomy (PDT) is becoming an accepted and increasingly popular alternative to surgical, or open, tracheotomy, particularly in the treatment of critically ill patients requiring prolonged intubation and mechanical ventilation. There are, however, important contraindications to consider and a learning curve that must be overcome in order to reduce the risk of complications, according to David Goldenberg, MD, Associate Professor of Head and Neck Surgery and Oncology at the Milton S. Hershey Medical Center of Penn State College of Medicine in Hershey, Pa.

Dr. Goldenberg presented the results of a study looking at PDT complication rates to the Triological Society here at the 2006 Combined Otolaryngology Spring Meetings.

In our experience, we’ve found that the complication rate drops significantly with experience, not only of the surgeon, but of the whole tracheotomy team, Dr. Goldenberg said. We recommend adherence to contraindications and to a strict protocol, and emphasize that the learning curve is not just for the surgeon, but for the entire team that participates in performing these procedures.

Study Protocols

Dr. Goldenberg and his colleagues undertook a retrospective chart review of 318 consecutive PDTs performed in the intensive care unit between the years 2002 and 2005. Procedural and postoperative complications in an earlier group (Group A) were compared with those in the later group (Group B) for both frequency and severity.

All these procedures were done with the same method, using the Blue Rhino, Ciaglia method, single-pass percutaneous dilation tracheotomy set, Dr. Goldenberg said. All patients were intubated and their airway was under control by an experienced anesthesiologist during the procedure.

All patients underwent the procedure with local anesthetic and simultaneous video bronchoscopic visualization. For the majority of patients, the indication was prolonged intubation and mechanical ventilation, while a few were termed airway protection, pulmonary toilet, or partial obstruction.

Some Complications Reported

The overall complication rate was 5.9 percent, with severe complications being zero, Dr. Goldenberg reported. In Group A, which represented the first 159 patients in that series, there were 12 complications, whereas in Group B there were a total of seven complications.

In Group A, three patients experienced during surgery what we deemed equipment malfunction, which forced us to open another set, and cannulation was delayed, he said. There was one accidental extubation on the anesthesiologist’s side. There was one patient who had cardiopulmonary arrest during the procedure, although this was a very sick individual and it probably had nothing to do with the procedure itself.

Also in Group A, one patient had a tracheoesophageal fistula and there were six cases of hemorrhage.

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.

©2006 The Triological Society