Percutaneous versus surgical tracheostomy

Given that this is a very ICU-oriented procedure, the topic of percutaneous tracheostomy has come up several times in the exam. Specifically, in  Question 10 from the first paper of 2014 and Question 6 from the first paper of 2002 the candidates were expected to weight the risks and benefits of this procedure as compared to surgical tracheostomy, as well as on its own merits. 

The answer to  Question 6 may act as a good short summary of advantages and disadvantages. For the majority of the ensuing discussion, the Ciaglia technique will be used as the default percutaneous tracheostomy technique.

In short

Advantages of percutaneous tracheostomy

Safety advantages

• Less "postprocedural" complications. This seems to come from the much-cited article by Friedman et al (1996). This early study was an RCT comparing percutaneous and surgical techniques where n=53. Postprocedural complication rate was 12% for the percutaneous technique, and 41% for the standard surgical approach. The authors' idea of "complication" was accidental decannulation,  bleeding in excess of 25ml and wound infection.  Subsequent meta-analysis by Dulguerov et al (1999) had found some support for this assertion, but on close inspection the bulk of the difference in complications was in minor complications. The only exceptions were death and cardiac arrest. More on that below.
• Less bleeding risk: the incision is smaller, and the width of the tracheostomy holds pressure on the dilated tract, preventing significant blood loss. Even if you puncture the isthmus of the thyroid, it's not the end of the world.

• Lower incidence of tracheal stenosis: the hole is smaller, and therefore there is less granulation tissue and scarring
• Lower incidence of tracheal infection - again from Dulguerov et al (1999) we can see that the rate of minor tracheal infections is lower in the percutaneous group.
• The cosmetic effect is better: although the cosmetic effect of any tracheal stoma cannot be described as ravishingly beautiful, nor is this much of a concern in the critical care environment.

Pragmatic advantages

• Cheaper:  one does not need an anaesthetist, surgeon, or a fully staffed operating theatre.
• Faster: with the Ciaglia single-dilator technique, it can be done in 10-15 minutes
• More easily available in the ICU: Operating theatre time is precious, and it may not be possible to get timely surgical/anaesthetic cooperation. 
• Logistically easier (no need to transfer to OT)- the patient is spared the risks of transfer.
• Decreases length of stay in ICU: specifically, this point refers to early tracheostomy, which was a fleeting fad, and is no longer practiced. Certainly, a meta-analysis by Griffiths  et al (2006) had confirmed that early tracheostomy means early ICU discharge.

Disadvantages of percutaneous tracheostomy

• Inadequate backup for major complications or difficult anatomy: the surgical approach is still the gold standard for difficult tracheostomy.
• Much of the technique is essentially blind: from the skin incision to the appearance of the needle tip on the bronchoscope screen, the Ciaglia technique does not permit the visualisation of traversed anatomy.
• More intraoperative complications, specifically cardiac arrest and death.
• Diathermy is not available: minor bleeding cannot be easily controlled. On the plus side, there is no risk of airway fires.
• Cardiothoracic surgical support is lacking: bleeding complications eg. innominate artery perforation cannot be immediately controlled
• Bronchoscopy is required for safety (and this is not available everywhere). Even if you have a bronchoscope and a skilled operator, you endanger your bronchoscope by stabbing in its vicinity with large needles.
• The cost savings may be an illusion: the disposable percutaneous kits cost more than the tracheostomy tube alone, and so a bedside surgical tracheostomy is still cheaper.
• There is a greater risk of death and cardiac arrest. The already mentioned  meta-analysis by Dulguerov et al (1999) had revealed that percutaneous tracheostomy was associated with a greater incidence of perioperative death (0.44% vs. 0.03%) and serious cardiorespiratory events (0.33% vs. 0.06%).

Modern evidence comparing percutaneous and surgical tracheostomy

In terms of immediate and early complication rates

"With regard to rates of mortality, intraoperative hemorrhage, and postoperative hemorrhage, there was no statistically significant difference between the two techniques" - this was the conclusion of the meta-analysis by Johnson-Obaseki et al (2016). The same authors found that the post-procedure infection rate was lower with the percutaneous technique. The difference between this meta-analysis and the meta-analysis by Dulguerov et al (1999) probably reflects how the safety of the percutaneous technique has improved over time, thereby decreasing the intraoperative complication rate. The comparatively lacklustre performance of the surgical technique can perhaps be attributed to the fact that these days only the most technically difficult tracheostomies are being performed surgically.

In terms of resource utilisation

The abovementioned meta-analysis from Johnson-Obaseki et al (2016) found that the procedure time was faster for the percutaneous technique.

In terms of late complications

The risk of tracheal stenosis was found to be higher for surgical tracheostomy - though only as a trend, rather than a firm association (Dempsey et al, 2016)