Percutaneous Tracheostomy: Late Complications are Few
August 1, 1999 3 minutes read
Percutaneous Tracheostomy: Late Complications are Few
Abstract & Commentary
Synopsis: At six months follow-up of 80 patients undergoing percutaneous tracheostomy (PT), only one patient required treatment for symptomatic tracheal stenosis (repeat tracheostomy followed by successful decannulation). Several patients reported voice changes and one was referred for cosmetic surgery for a tethered scar.
Source: Leonard RC, et al. Chest 1999;115:1070-1075.
To determine the incidence and severity of late complications of percutaneous tracheostomy (PT), Leonard and associates followed up 80 patients who had undergone this increasingly popular and widely used ICU procedure. Of the 80 patients following PT using a Portex kit and tracheostomy tube, 54 survived for at least six months (68%). Forty-nine patients were neurologically intact and sent questionnaires regarding airway symptoms and scar appearance. Respondents were invited to present for flow-volume loops and tracheoscopy. Thirty-nine patients returned the questionnaire, two of whom were still intubated. Their average age was 52 years (range, 16-86). Of the 37 decannulated patients, none had severe stridor, although five reported some dyspnea, two had severe cough, and two reported ugly scars. Thirteen patients presented for evaluation. None of these had upper airway obstruction on spirometry. Ten underwent tracheoscopy and none was found to have significant pathology.
Comment by Charles G. Durbin, Jr., MD, FCCM
PT has become an accepted method of long-term airway management in the critically ill. PT compares favorably with open tracheostomy (OT) with respect to short-term complications. PT has a lower incidence of significant bleeding, infection, and inadvertent decannulations than OT. Since PT is performed in the ICU, costs are substantially reduced. Long-term complications are expected to be decreased as well, although it will take several years to accumulate the data necessary to make this assertion. This report, although limited to a few patients, is encouraging and adds to a growing body of data. The only significant problem identified in any patient, symptomatic tracheal obstruction, was probably not related to the PT but instead to the patient’s underlying airway problem. It was easily treated with placement of another tracheostomy, which, in turn, was followed by successful decannulation.
Even though only 13 patients of the original 54 were actually examined by the investigators, Leonard et al feel that due to the referral patterns in western Australia, where the study was performed, they would have been informed of any additional patients with clinically significant problems. They state that because the most symptomatic patients were evaluated and found to be free of pathology, the incidence of significant problems in the group must be small. This may be true, but it would be helpful in assessing the risk of PT to have a higher percentage of patients examined.
Another problem with this study is that the PT techniques and devices used have changed substantially. The Portex kit used in this study included a dilating forceps to create a stoma, whereas now only progressive dilation is used. Also, the paper does not state what type of tracheostomy tube was used. The Perfit tube included in newer Portex kits has a relatively high pressure (low profile) cuff, and the long-term effects of this cuff design on the trachea are unknown. With ongoing changes, incomplete follow-up, and lack of standards and definitions, it is unlikely that the true picture of risks and benefits of PT will soon be clear. What is needed to answer these questions is a large, prospective, multicentered registry with good follow-up information. How to establish and fund such a project is not clear.
Complications unique to percutaneous tracheostomy and not to open tracheostomy include:
a. increased pulmonary infection.
b. bleeding at the tracheostomy site.
c. post-decannulation tracheal stenosis.
d. laryngeal stenosis.
e. damage to the bronchoscope.
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