title: Long term outcomes following percutaneous dilatational tracheostomy in the critically ill
Creators: name: Dempsey, Ged
Publisher: name: University of Liverpool Repository
Year: 2016

description: Background: Percutaneous procedures are now the predominant tracheostomy technique within the critical care setting. Complication rates for various techniques appear to be equivalent to those achieved with surgical tracheostomy. There is a paucity of data when comparing percutaneous procedures, particularly when considering late complications (tracheo-innominate artery fistulae (TIF), tracheooesophageal fistulae (TOF) and tracheal stenosis (TS). Given the severity of illness and associated mortality in many of these patients the incidence of these complications remains difficult to define. Confounding factors present in survivors of critical illness may present difficulties in diagnosis such that underlying tracheal pathology may go undiagnosed. Aims: To determine: The incidence of common early and late complications of percutaneous dilatational tracheostomy (PDT) in relation to surgical tracheostomy (ST). The role of peri-operative events that may contribute to the aetiology of late complications of TS, TIF and TOF. The incidence of early and late complications in relation to percutaneous tracheostomy to define the safest percutaneous technique. The utility of adjunctive techniques (bronchoscopy &amp; ultrasound scanning) in reducing complications of PDT. The prevalence of sub-clinical TS following PDT using the single tapered dilator technique (STD). Aetiological factors for sub-clinical TS. Whether sub-clinical TS may present atypically in critical illness survivors. Methods: We have conducted a systematic review of all prospective studies reporting late complications after tracheostomy performed in the critically ill. We have also extracted data to assess the role of peri-operative events and monitoring in causing or preventing late complications. We have undertaken an eleven-year review of all PDTs performed within our unit to define the incidence of complications arising within our own population. Finally, a prospective study to identify the prevalence of sub-clinical TS and identify atypical presenting features in survivors of critical illness has been performed. Results: All surgical and percutaneous techniques are broadly similar in terms of early and late complications. There is a higher incidence of wound infection when comparing ST to the multiple dilator PDT. There are few studies assessing late complications between percutaneous techniques. The TS rate varies from 2.8 to 0.6% for ST and the STD technique respectively. Due to limited data we were unable to identify peri-operative events that may lead to late complications. There is a very low rate of complications attributed to the STD technique with only 9 significant late adverse events. The rate of sub-clinical TS is low with doubtful clinical significance. Conclusions: We have not found a significant difference in the incidence of TS between PDT and ST. Our pooled proportions meta-analysis may indicate a tendency toward a higher rate of stenosis for ST. The reported complication rates presented within our cohort study may indicate that the STD PDT is one of the safer techniques available. The rate of sub-clinical stenoses following STD PDT is low and of doubtful clinical significance. Further work is required to define the role for percutaneous tracheostomy outside the critical care setting and to gather qualitative data to assess the patient’s perception of tracheostomy in the critical care setting.