Question 6

Compare and contrast percutaneous and surgical tracheostomy.

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College Answer

Surgical tracheostomy is the time-honoured approach. Best operating conditions (coping with complexities of anatomy), best control of bleeding and airway. Requires operating time and staff, and transport to operating theatre. Lower incidence of peri-operative complications. Higher incidence of tracheal stenosis, postoperative bleeding and stomal infection.

Percutaneous tracheostomy refers to a number of different techniques. In particular the gradual dilatation [Ciaglia], forceps dilation [Griggs], Rhino and translaryngeal techniques. Most comparative data is for the Ciaglia technique. Blind external technique (which can be bronchoscopy assisted to improve visualization/placement) which seems to be significantly operator dependent. Some neck anatomy problems provide relative contraindications. Permits smaller incision, but lesser exposure and not usually performed with diathermy available. Only require intensive care staff, though airway maintenance is probably more critical, with respiratory acidosis and loss of airway more likely. No delays due to theatre requirements, no transport required, and takes less time to perform. Higher incidence of anterior tracheal wall injury and posterior wall perforation. Lower incidence of postoperative haemorrhage, infection and tracheal stenosis.

Discussion

This question lends itself well to a tabulated answer.

	Surgical tracheostomy	Percutaneous tracheostomy
Advantages	Gold standard for difficult anatomy Better control of bleeding Fewer intraoperative complications	Less postprocedural complications such as accidental decannulation, bleeding and wound infection. (Dulguerov et al, 1999) Less bleeding risk (smaller hole) Lower incidence of tracheal stenosis Lower incidence of tracheal infection Johnson-Obaseki et al (2016) The cosmetic effect is better No transfer, thus no risks of transfer Cheaper Faster (10-15 minutes) More easily available in the ICU Decreases length of stay in ICU (if early tracheostomy: Griffiths et al, 2006)
Disadvantages	More postprocedural complications Higher incidence of tracheal stenosis Higher incidence of stomal infections Expensive; requires the operating theatre to be fully staffed Takes longer to roganise Exposes patients to risk of transfer	Inadequate backup for major complications or difficult anatomy. Much of the technique is essentially blind. Diathermy is not available in ICU Cardiothoracic surgical support is lacking Bronchoscopy is required for safety The bronchoscope may get damaged Disposable percutaneous kits cost more than a bedside surgical tracheostomy There is a greater risk of death and cardiac arrest. (Dulguerov et al, 1999) Some intraoperative complications are unique to percutenous technique (eg. knotted guide wire)

References

Durbin, Charles G. "Indications for and timing of tracheostomy." Respiratory care 50.4 (2005): 483-487.

Kilic, Dalokay, et al. "Article When is Surgical Tracheostomy Indicated? Surgical “U-shaped” versus Percutaneous Tracheostomy." Ann Thorac Cardiovasc Surg 17.1 (2011): 29-32.

De Leyn, Paul, et al. "Tracheotomy: clinical review and guidelines." European Journal of Cardio-thoracic Surgery 32.3 (2007): 412-421.

Friedman, Yaakov, et al. "Comparison of percutaneous and surgical tracheostomies." CHEST Journal 110.2 (1996): 480-485.

Dulguerov, Pavel, et al. "Percutaneous or surgical tracheostomy: a meta-analysis." Critical care medicine 27.8 (1999): 1617-1625.

Duann, Chi‐Wei, et al. "Successful percutaneous tracheostomy via puncture through the thyroid isthmus." Respirology Case Reports 2.2 (2014): 57-60.

Friedman, Yaakov, et al. "Comparison of percutaneous and surgical tracheostomies." CHEST Journal 110.2 (1996): 480-485.

Dulguerov, Pavel, et al. "Percutaneous or surgical tracheostomy: a meta-analysis." Critical care medicine 27.8 (1999): 1617-1625.

Griffiths, John, et al. "Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation." Bmj 330.7502 (2005): 1243.

Johnson‐Obaseki, Stephanie, Andrea Veljkovic, and Hedyeh Javidnia. "Complication rates of open surgical versus percutaneous tracheostomy in critically ill patients." The Laryngoscope (2016).

Dempsey, Ged A., et al. "Long-Term Outcome Following Tracheostomy in Critical Care: A Systematic Review." Critical Care Medicine (2016).

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