NIHR Signal Bedside tracheostomy may be at least as good as traditional surgical techniques

Published on 29 November 2016

Bedside tracheostomy procedures in intensive care units were at least as good as surgical tracheostomies, usually done in theatre.

A tracheostomy creates a hole in the windpipe (trachea) and is one of the most common procedures performed in intensive care to help critically ill patients breathe when they are connected to ventilators.

Surgical tracheostomies access the windpipe by cutting through the tissues and need to be done in an operating theatre. Percutaneous techniques are less invasive and use needles and plastic dilators to make the hole in the windpipe, tunnelling through the skin. They can be performed at the bedside or in the theatre and are potentially more convenient and cheaper.

This systematic review of trials found moderate quality evidence that wound infection rates up to two years later were three times lower with percutaneous techniques (43 per 1,000 procedures) compared with surgery (178 per 1,000).

Rates of death and serious harms were no different between procedures, but this was based on low quality evidence.

Percutaneous tracheostomy is generally assumed to be cheaper, but to perform this safely requires expertise and training costs need to be considered.

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Why was this study needed?

A tracheostomy is a procedure that creates a hole in the windpipe to help people breathe while connected to mechanical ventilators. It is one of the most common procedures performed in critically ill patients in intensive care. As many as 10% of patients requiring at least three days of mechanical ventilation will eventually receive a tracheostomy for prolonged mechanical ventilation or airway support.

Percutaneous techniques have been studied in trials compared to surgical tracheostomy since 1995 and are thought to have advantages over surgery. Despite this the evidence was not clear on who might benefit from which approach. This review aimed to identify and summarise the best-quality evidence to see how these techniques compared.

What did this study do?

The review systematically identified 20 trials (1,652 patients enrolled between 1990 and 2011) comparing the effectiveness and safety of non-emergency percutaneous tracheostomy with surgical tracheostomy in critically ill adults.

The trials varied in the type of patients studied, techniques used, procedure setting, and level of staff experience. This could make the review less likely to detect a difference in techniques if one existed.

The main outcomes of interest were deaths and life-threatening adverse events after the procedure, but few studies reported many of these events. With the exception of infection rate, the quality of evidence was low or very low for most outcomes, meaning conclusions aren’t very reliable and may change in the future.

Costs and patient satisfaction with the procedure were not looked at in this review. The country of origin for these studies was unclear, but they were mostly conducted in hospitals likely to be providing similar care to the UK.

What did it find?

  • Wound infection rates at up to two years were significantly lower with percutaneous techniques (43 per 1,000 procedures, 95% confidence interval 27 to 66) than surgical (178 per 1,000). This was based on moderate quality evidence from 12 trials including 936 people.
  • Unfavourable scarring up to 20 months was also rarer after percutaneous techniques (74 per 1,000 procedures) than surgical (296 per 1,000) based on low quality evidence from six trials including 789 people.
  • Low quality evidence from four trials found no significant difference in the rate of death directly related to either procedure.
  • Low quality evidence found no significant difference in the rates of serious life-threatening adverse events during or within 24 hours of the procedures.
  • Very low quality evidence suggested no difference in risk of major bleeding, tracheostomy tube blockage or obstruction, accidental tube removal, of difficult tube change.

What does current guidance say on this issue?

NICE provides guidance on one specific type of percutaneous tracheostomy, translaryngeal tracheostomy. It states that rates of bleeding, trauma and infection may be lower with this technique, compared with other percutaneous or surgical techniques.

Doctors wishing to perform translaryngeal tracheostomy are advised that they need specialised training and expertise, because carrying it out safely requires different skills from other percutaneous methods.

What are the implications?

This review implies percutaneous tracheostomy techniques are as good as, or better than, surgical alternatives, with advantages of lower infection rates and scarring.

The review was not able to say which percutaneous techniques worked best, but 2013 NICE guidance suggests translaryngeal tracheostomy may have advantages over other techniques.

The review did not address cost or cost effectiveness. Percutaneous techniques are assumed to be cheaper as they can be performed at the bedside rather than in the operating theatre, but are not always done there. The selection of suitable people for this will be important. However, training intensivists or anaesthetists or surgeons in percutaneous methods needs to be considered, as this may initially offset some of the potential savings.

Citation and Funding

Brass P, Hellmich M, Ladra A, et al. Percutaneous techniques versus surgical techniques for tracheostomy. Cochrane Database Syst Rev. 2016;7:CD008045.

This review was funded by the University of Cologne, Germany, and the Cochrane Anaesthesia Review Group, Denmark.

Bibliography

Durbin Jr, CG. Tracheostomy: why, when and how? Respiratory Care. 2010;55(8):1056-68.

NICE. Translaryngeal tracheostomy. Interventional procedure guidance 462. London: National Institute for Health and Care Excellence; 2013.

NHS Choices. Tracheostomy. London: Department of Health; 2015.

Why was this study needed?

A tracheostomy is a procedure that creates a hole in the windpipe to help people breathe while connected to mechanical ventilators. It is one of the most common procedures performed in critically ill patients in intensive care. As many as 10% of patients requiring at least three days of mechanical ventilation will eventually receive a tracheostomy for prolonged mechanical ventilation or airway support.

Percutaneous techniques have been studied in trials compared to surgical tracheostomy since 1995 and are thought to have advantages over surgery. Despite this the evidence was not clear on who might benefit from which approach. This review aimed to identify and summarise the best-quality evidence to see how these techniques compared.

What did this study do?

The review systematically identified 20 trials (1,652 patients enrolled between 1990 and 2011) comparing the effectiveness and safety of non-emergency percutaneous tracheostomy with surgical tracheostomy in critically ill adults.

The trials varied in the type of patients studied, techniques used, procedure setting, and level of staff experience. This could make the review less likely to detect a difference in techniques if one existed.

The main outcomes of interest were deaths and life-threatening adverse events after the procedure, but few studies reported many of these events. With the exception of infection rate, the quality of evidence was low or very low for most outcomes, meaning conclusions aren’t very reliable and may change in the future.

Costs and patient satisfaction with the procedure were not looked at in this review. The country of origin for these studies was unclear, but they were mostly conducted in hospitals likely to be providing similar care to the UK.

What did it find?

  • Wound infection rates at up to two years were significantly lower with percutaneous techniques (43 per 1,000 procedures, 95% confidence interval 27 to 66) than surgical (178 per 1,000). This was based on moderate quality evidence from 12 trials including 936 people.
  • Unfavourable scarring up to 20 months was also rarer after percutaneous techniques (74 per 1,000 procedures) than surgical (296 per 1,000) based on low quality evidence from six trials including 789 people.
  • Low quality evidence from four trials found no significant difference in the rate of death directly related to either procedure.
  • Low quality evidence found no significant difference in the rates of serious life-threatening adverse events during or within 24 hours of the procedures.
  • Very low quality evidence suggested no difference in risk of major bleeding, tracheostomy tube blockage or obstruction, accidental tube removal, of difficult tube change.

What does current guidance say on this issue?

NICE provides guidance on one specific type of percutaneous tracheostomy, translaryngeal tracheostomy. It states that rates of bleeding, trauma and infection may be lower with this technique, compared with other percutaneous or surgical techniques.

Doctors wishing to perform translaryngeal tracheostomy are advised that they need specialised training and expertise, because carrying it out safely requires different skills from other percutaneous methods.

What are the implications?

This review implies percutaneous tracheostomy techniques are as good as, or better than, surgical alternatives, with advantages of lower infection rates and scarring.

The review was not able to say which percutaneous techniques worked best, but 2013 NICE guidance suggests translaryngeal tracheostomy may have advantages over other techniques.

The review did not address cost or cost effectiveness. Percutaneous techniques are assumed to be cheaper as they can be performed at the bedside rather than in the operating theatre, but are not always done there. The selection of suitable people for this will be important. However, training intensivists or anaesthetists or surgeons in percutaneous methods needs to be considered, as this may initially offset some of the potential savings.

Citation and Funding

Brass P, Hellmich M, Ladra A, et al. Percutaneous techniques versus surgical techniques for tracheostomy. Cochrane Database Syst Rev. 2016;7:CD008045.

This review was funded by the University of Cologne, Germany, and the Cochrane Anaesthesia Review Group, Denmark.

Bibliography

Durbin Jr, CG. Tracheostomy: why, when and how? Respiratory Care. 2010;55(8):1056-68.

NICE. Translaryngeal tracheostomy. Interventional procedure guidance 462. London: National Institute for Health and Care Excellence; 2013.

NHS Choices. Tracheostomy. London: Department of Health; 2015.

Percutaneous techniques versus surgical techniques for tracheostomy

Published on 21 July 2016

Brass, P.,Hellmich, M.,Ladra, A.,Ladra, J.,Wrzosek, A.

Cochrane Database Syst Rev Volume 7 , 2016

BACKGROUND: Tracheostomy formation is one of the most commonly performed surgical procedures in critically ill intensive care participants requiring long-term mechanical ventilation. Both surgical tracheostomies (STs) and percutaneous tracheostomies (PTs) are used in current surgical practice; but until now, the optimal method of performing tracheostomies in critically ill participants remains unclear. OBJECTIVES: We evaluated the effectiveness and safety of percutaneous techniques compared to surgical techniques commonly used for elective tracheostomy in critically ill participants (adults and children) to assess whether there was a difference in complication rates between the procedures. We also assessed whether the effect varied between different groups of participants or settings (intensive care unit (ICU), operating room), different levels of operator experience, different percutaneous techniques, or whether the percutaneous techniques were carried out with or without bronchoscopic guidance. SEARCH METHODS: We searched the following electronic databases: CENTRAL, MEDLINE, EMBASE, and CINAHL to 28 May 2015. We also searched reference lists of articles, 'grey literature', and dissertations. We handsearched intensive care and anaesthesia journals, abstracts, and proceedings of scientific meetings. We attempted to identify unpublished or ongoing studies by contacting manufacturers and experts in the field, and searching in trial registers. SELECTION CRITERIA: We included randomized and quasi-randomized controlled trials (quasi-RCTs) comparing percutaneous techniques (experimental intervention) with surgical techniques (control intervention) used for elective tracheostomy in critically ill participants (adults and children). DATA COLLECTION AND ANALYSIS: Three authors independently checked eligibility and extracted data on methodological quality, participant characteristics, intervention details, settings, and outcomes of interest using a standardized form. We then entered data into Review Manager 5, with a double-entry procedure. MAIN RESULTS: Of 785 identified citations, 20 trials from 1990 to 2011 enrolling 1652 participants fulfilled the inclusion criteria. We judged most of the trials to be at low or unclear risk of bias across the six domains, and we judged four studies to have elements of high risk of bias; we did not classify any studies at overall low risk of bias. The quality of evidence was low for five of the seven outcomes (very low N = 1, moderate N = 1) and there was heterogeneity among the studies. There was a variety of adult participants and the procedures were performed by a wide range of differently experienced operators in different situations.There was no evidence of a difference in the rate of the primary outcomes: mortality directly related to the procedure (Peto odds ratio (POR) 0.52, 95% confidence interval (CI) 0.10 to 2.60, I(2) = 44%, P = 0.42, 4 studies, 257 participants, low quality evidence); and serious, life-threatening adverse events - intraoperatively: risk ratio (RR) 0.93, 95% CI 0.57 to 1.53, I(2) = 27%, P = 0.78, 12 studies, 1211 participants, low quality evidence,and direct postoperatively: RR 0.72, 95% CI 0.41 to 1.25, I(2) = 24%, P = 0.24, 10 studies, 984 participants, low quality evidence.PTs significantly reduce the rate of the secondary outcome, wound infection/stomatitis by 76% (RR 0.24, 95% CI 0.15 to 0.37, I(2) = 0%, P < 0.00001, 12 studies, 936 participants, moderate quality evidence) and the rate of unfavourable scarring by 75% (RR 0.25, 95% CI 0.07 to 0.91, I(2) = 86%, P = 0.04, 6 studies, 789 participants, low quality evidence). There was no evidence of a difference in the rate of the secondary outcomes, major bleeding (RR 0.70, 95% CI 0.45 to 1.09, I(2) = 47%, P = 0.12, 10 studies, 984 participants, very low quality evidence) and tracheostomy tube occlusion/obstruction, accidental decannulation, difficult tube change (RR 1.36, 95% CI 0.65 to 2.82, I(2) = 22%, P = 0.42, 6 studies, 538 participants, low quality evidence). AUTHORS' CONCLUSIONS: When compared to STs, PTs significantly reduce the rate of wound infection/stomatitis (moderate quality evidence) and the rate of unfavourable scarring (low quality evidence due to imprecision and heterogeneity). In terms of mortality and the rate of serious adverse events, there was low quality evidence that non-significant positive effects exist for PTs. In terms of the rate of major bleeding, there was very low quality evidence that non-significant positive effects exist for PTs.However, because several groups of participants were excluded from the included studies, the number of participants in the included studies was limited, long-term outcomes were not evaluated, and data on participant-relevant outcomes were either sparse or not available for each study, the results of this meta-analysis are limited and cannot be applied to all critically ill adults.

Tracheostomies can be surgical or percutaneous.

Surgical tracheostomies take place in an operating theatre under general anaesthetic. They involve cutting away skin and muscle layers in the throat to expose the windpipe, and then cutting through this to insert a breathing tube.

Percutaneous – meaning “through the skin” – tracheostomies are less invasive and can be done at the hospital bedside. There are many techniques but generally they involve inserting a needle into the windpipe before instruments called dilators are used to widen the hole just enough so that a breathing tube can be inserted.

Expert commentary

Tracheostomy is a commonly planned procedure for mechanically ventilated patients in intensive care to help improve their comfort and facilitate weaning of sedation when longer periods of ventilation are anticipated. Tracheostomy procedures conducted at the bedside are part of standard care for carefully selected patients and should be performed by trained operators with appropriate equipment. Surgical tracheostomies in operating theatres are reserved for patients deemed unsuitable for a percutaneous procedure.

Reviewing randomised controlled clinical trials comparing these procedures only in patients who would have been deemed safe for both procedures, reveals that there are likely to be short term patient benefits from percutaneous tracheostomy: although longer term and patient reported outcomes have not been studied. This review supports current standard care but does not provide evidence to help decide which critically ill patients would benefit most from which procedure.

Paul Dark, Professor of Critical Care Medicine, University of Manchester; NIHR CRN National Research Lead for Critical Care, King's College London; Honorary NHS Consultant in Critical Care Medicine, Salford Royal NHS Foundation Trust

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