Discussed in Oxford on 16/01/15 – report by Abigail Ash Follow @Abs_Fab
Percutaneous and surgical tracheostomy in critically ill adult patients: a meta analysis. Critical Care 2014, 18:544. C Putensen, N Theuerkauf, U Guenther, M Vargas and P Pelosi.
Background
Percutaneous tracheostomy (PT) and surgical tracheostomy (ST) are performed in critical care for a variety of indications. Three previous meta-analyses had demonstrated mixed results with limited data on survival and long term complications. With the introduction of newer PT techniques, the authors felt further analysis was warranted.
Warning! This study uses multiple abbreviations which I have listed at the end of this review.
Aim
The aim of this study was to conduct a meta-analysis to determine whether percutaneous tracheostomy techniques are advantageous over surgical tracheostomy and if one percutaneous technique is superior to the others.
Methods
The authors searched CENTRAL, MEDLINE and EMBASE databases for RCTs and also society meetings for unpublished data between 1966 – 2013. Their search had no language restrictions and included adult, mechanically ventilated patients. They excluded non RCTs, cross over studies, emergency airways, paediatrics and non-critically ill/home ventilated patients. Primary outcomes during the procedure included major and minor bleeding, technical difficulties, false route, subcutaneous emphysema, pneumothorax and oxygen desaturation, and post procedure included major and minor bleeding, stoma inflammation or infection, tracheomalacia and tracheal stenosis. Secondary outcomes included length of procedure and hospital survival.
Results
11625 citations were screened, 108 were retrieved for more detailed evaluation. Of these, 22 citations were included in the meta-analysis. 16 of these were a mixed patient population with one trauma, one surgical and four not described. Most ST were performed by surgical specialties (surgeons (10) and ENT (3)) and PT by intensivists (12), surgeons (4) and ENT (3). All PT occurred in ICU. Bronchoscopy was used regularly in 9 studies.
Percutaneous Vs Surgical
973 patients in 14 RCTs: PT had reduced odds for major bleeding (OR, 0.39; 95% CI, 0.15 to 0.97 (p=0.04)), stoma inflammation (OR, 0.38; 95% CI, 0.19 to 0.76 (p=0.006)) and infection (OR, 0.22; 95% CI, 0.11 to 0.41 (p<00001)) and increased odds for procedural technical difficulties (OR, 4.58; 95% CI, 2.21 to 9.47 (p<0.0001)). No difference in hospital survival.
Multiple Dilator Trache Vs Surgical
719 patients in 10 RCTs: MDT had reduced odds for stoma inflammation (OR, 0.25; 95% CI, 0.09 to 0.65 (p=0.005)) and infection (OR, 0.18; 95% CI, 0.08 to 0.38 (p<0.0001)) but increased odds for procedural technical difficulties (OR, 5.45; 95% CI, 2.47 to 12.01 (p<0.0001)). No difference in survival.
Pooled MDT +SSDT Vs pooled GWDF + RDT +BDT
700 patients in 8 RCTs: MDT +SSDT had reduced odds for intraprocedural technical difficulties (OR, 0.3; 95%CI, 0.12 to 0.8 (p=0.02)) and major bleeding (OR, 0.29; 95% CI, 0.10 to 0.85 9p=0.02)) with no difference in survival or duration.
Pooled MDT + SSDT Vs GWDF
560 patients in 6 RCTs: MDT +SSDT reduced odds for intraprocedural major bleeding (OR, 0.29; 95% CI, 0.1 to 0.85 (p=0.02)).
Strengths
This meta-analysis is relevant to our current practice. This study has clearly defined objectives and conducted a comprehensive literature search seeking out non published RCTs with no language restrictions. Inclusion and exclusion criteria are defined and appropriate. Data extraction is detailed along with how disagreements were resolved and evaluation of publication bias. Multiple PT techniques are explored which may be of particular interest in institutions that use certain techniques exclusively.
Weaknesses
Other outcomes that may have been of interest include tracheostomy blockage, accidental decannulation and re-intubation rates. There is no information on the length of stay of patients and the duration of mechanical ventilation (pre procedure and total). The authors stated that this meta-analysis would be useful given the introduction of newer PT techniques, yet ultrasound is not commented on.
One study accounted for 39% of the weight in the pooled effects of Pt Vs ST. This study used a TLT technique but we had not heard of, seen, or used this technique.
The majority of I2 values for pooled PT Vs ST outcomes are 0%. This raised some discussion amongst our audience given the apparent heterogeneity of the RCTs in the brief descriptions provided in the appendices. Most studies excluded patients in whom a surgical tracheostomy would have probably been first choice, due to the presence of contraindications to the PT technique, and it is difficult to know how this affected the results.
Will this change my practice?
This meta-analysis does not provide a clear benefit of PT over ST to alter current practice locally. The RCTs included are not wholly representative of current practice and therefore I would have concerns about the external validity of this paper. However, this meta-analysis raised important questions about the role of PT and ST, including patient selection, technique, and more broadly, training opportunities.
PT abbreviation guide
MDT – Multiple dilator tracheostomy
GWDF – Guide wire dilating forceps
TLT – Translaryngeal tracheostomy
SSDT – Single step dilation tracheostomy
RDT – Rotational dilation tracheostomy
BDT – Balloon dilation tracheostomy
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