Tracheostomy

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• surgical
• percutaneous dilational
  • Ciaglia technique
    • sequential multiple dilators
    • single progressive dilator
  • Griggs dilational forceps
  • PercuTwist
  • Fantoni translaryngeal method
• optimal technique (surgical or percutaneous) unclear
  • Surgical vs Ciaglia multiple dilators
    • RCT
    • 200 patients ≥16 years old
    • hypercapnia and moderate/severe wound infection at 7 days more common in surgical group. No significant differences in other short term outcomes
  • Surgical (72 patients) vs Fantoni technique (67 patients)
    • major post-operative bleeding more common in surgical group. No significant differences in other short term outcomes
    • 8-9% incidence of bacteraemia following both procedures
  • No good comparative long term outcome data. The number of patients undergoing long term follow up in the two studies above was low
  • Surgical technique probably preferable for patients with coagulopathy or significant thrombocytopaenia, with abnormal cervical anatomy or requiring high inspired oxygen concentration or high PEEP. Percutaneous technique probably preferable for those for whom tracheostomy wound infection would pose greater risk than usual
• optimal percutaneous dilational technique also unclear
  • Ciaglia single dilator vs Griggs
    • small RCT
    • difficult cannulation, moderate bleeding (11-50 ml), over-dilation of trachea more common with Griggs technique. Fracture of tracheal or cricoid cartilage restricted to Ciaglia group
  • Fantoni vs Griggs
    • small RCT
    • Fantoni technique associated with longer duration of procedure, technical difficulty, significant drop in PaO₂ and loss of airway (with significant hypoxia in 3/7 patients in whom airway was lost).

• upper airway obstruction
• to reduce duration of orotracheal intubation
  • increases patient comfort
  • spares further direct laryngeal injury
  • facilitates nursing care
  • improves patient’s ability to communicate
  • facilitates oral intake of food, thus providing psychological benefit
  • provides more secure airway and thus may facilitate ICU discharge
• aid weaning
  • data limited but early tracheostomy appears to be associated with shorter duration of mechanical ventilation
• facilitate tracheal suction

Contra-indications

• soft tissue infection of neck
• grossly abnormal anatomy of neck

Percutaneous tracheostomy

• coagulopathy or severe thrombocytopaenia
• difficult intubation
• severe intracranial hypertension

Timing

• controversial. Data is limited.
• meta-analysis suggests that early tracheostomy associated with shorter duration of ventilation and length of ICU stay. Definition of "early" variable, but in general <7 days after intubation. Only one study truly randomized.

• bleeding
• paratracheal insertion
• pneumothorax
• subcutaneous emphysema
• hypoxia
• hypotension
• loss of airway
• death

• bleeding } most common
• infection }
• tube displacement
• obstruction
• cuff leakage
• tracheal erosion
• tracheoesophageal fistula
• tracheoarterial fistula
• death

• cosmetic deformity. Cosmetic results good in 94% and moderate in 6% following PDT
• laryngeal stenosis
• tracheal granuloma and stenosis. Latter occurs in 6% (of whom 1/3 are symptomatic) following PDT
• tracheomalacia

Griffiths J et al. BMJ, doi:10.1136/bmj.38467.485671.EO

Durbin CJ.

© Charles Gomersall December 1999

©Charles Gomersall, September, 2008 unless otherwise stated. The author, editor and The Chinese University of Hong Kong take no responsibility for any adverse event resulting from the use of this webpage.
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