Chest
Volume 118, Issue 5, November 2000, Pages 1412-1418
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Clinical Investigations in Critical Care
A Meta-analysis of Prospective Trials Comparing Percutaneous and Surgical Tracheostomy in Critically Ill Patients

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Study objectives

Tracheostomy is one of the mostcommonly performed procedures in the patient receiving long-termmechanical ventilation. While percutaneous dilational tracheostomy(PDT) is becoming increasingly utilized as an alternative toconventional surgical tracheostomy, most literature evaluating thesetwo techniques is neither prospective nor controlled. We performed ameta-analysis of available prospective controlled studies comparing PDTand surgical tracheostomy in critically ill patients to more fullyunderstand the relative benefits and risks of these two procedures inthis population.

Design

Meta-analysis usingMantel-Haenszel fixed effect model.

Interventions

Weperformed searches of MEDLINE, Current Contents, Best Evidence,Cochrane, and HealthSTAR databases from 1985 to present to identifyprospective controlled studies comparing PDT and surgical tracheostomyin critically ill patients. After establishing clinical and statisticalhomogeneity (Q statistic), studies were analyzed by aMantel-Haenszel fixed effect model. For each clinical end pointexamined, PDT and surgical tracheostomy were compared by calculatingeither absolute differences or odds ratios (ORs) with 95% confidenceintervals (CIs) for continuous or discrete variables,respectively.

Measurements and results

We pooled datafrom five studies (236 patients) satisfying our search criteria toanalyze eight clinical end points. Operative time was shorter for PDTthan surgical tracheostomy: absolute difference with 95% CI, 9.84 min(7.83 to 10.85 min). There was no difference comparing PDT and surgicaltracheostomy with respect to overall operative complication rates: ORwith 95% CI, 0.732 (0.05 to 9.37). However, relative to surgicaltracheostomy, PDT was associated with less perioperative bleeding (ORwith 95% CI, 0.14 [0.02 to 0.39]), a lower overall postoperativecomplication rate (OR with 95% CI, 0.14 [0.07 to 0.29]), as well asa lower postoperative incidence of bleeding (OR with 95% CI, 0.39[0.17 to 0.88]), and stomal infection (OR with 95% CI, 0.02 [0.01to 0.07]). No difference was identified in days intubated prior totracheostomy (absolute difference with 95% CI, 0.16 days [− 0.9 to1.22 days]), overall procedure-related complications (OR with 95% CI,0.73 [0.06 to 9.37]), or death (OR with 95% CI, 0.63 [0.18 to2.20]) comparing these two techniques.

Conclusions

Despite its popularity, there arecurrently only a limited number of small studies prospectivelyevaluating PDT and surgical tracheostomy. Our meta-analysis of thesestudies suggests potential advantages of PDT relative to surgicaltracheostomy, including ease of performance, and lower incidence ofperistomal bleeding and postoperative infection. If confirmed byadditional, adequately powered prospective trials, these findingssupport PDT as the procedure of choice for the establishment ofelective tracheostomy in the appropriately selected critically illpatient.

Section snippets

Materials and Methods

Using the search term percutaneous tracheostomy, weperformed searches of the MEDLINE, Current Contents, Best Evidence,Cochrane, and HealthSTAR databases from 1985 (the year that PDT wasinitially described4) to present to identify prospectivestudies comparing PDT and SCT. Our search was not restricted toEnglish-language articles. We limited the studies for analysis to thosethat prospectively compared PDT to SCT in populations of critically illpatients requiring prolonged mechanical ventilation.

Study Characteristics

Since 1985, 278 articles have been published on the technique ofPDT. Of these, we identified six prospective studies that compared PDTto SCT.181920212223 We excluded one study from our analysisbecause a large fraction of patients enrolled (60%) were notcritically ill, and were undergoing tracheostomy as part of an electiveprocedure (tumor resection).23 We included the remainingfive studies that enrolled 236 critically ill patients requiringtracheostomy for prolonged mechanical ventilation (115

Discussion

Since its description in 1985, PDT has gained widespreadacceptance as a method for creating an elective surgical airway in thepatient requiring long-term mechanical ventilation.9However, the benefits and risks of this technique, relative toconventional surgical approaches, have been determined largely fromstudies that are observational in design. In fact, our reviewidentified only five small (ranging in enrollment from 24 to 60patients) prospective studies comparing these two techniques

Conclusion

In summary, PDT has gained widespread acceptance despite thelimited number of studies comparing it to conventional surgicaltechnique. Our meta-analysis of prospective studies comparing PDT andSCT in critically ill patients suggests that PDT has some advantagesrelative to SCT, including ease of performance, and lower incidence ofperistomal bleeding and postoperative infection. Whether there is anyadvantage of PDT compared to SCT with respect to either long-termcomplications or cost requires

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