Title: Analysis of Critical Care Patients Requiring Tracheostomy:
Indications and Outcomes
Chester Royals, M.D. Resident
UF Jacksonville College of Medicine
655 West 8th Street Jacksonville Florida 32209
Tel: (904-244-0411) E-mail: Chester.Royals@jax.ufl.edu
Co-Author(s) Iman Naseri, M.D., Andrew Kerwin, M.D., Indermeet Bhullar, M.D.,
Abubakr Bajwa, M.D.
UF Jacksonville College of Medicine
Type of Paper: Clinical Science.
Background: Critically ill patients in a tertiary care hospital setting often require intubation
for acute airway management. Many of these patients subsequently require surgical
tracheotomy performed either open versus percutaneously. Percutaneous dilatational
tracheotomy (PDT) is often performed at the bedside and has proven to be a safe and costeffective alternative to standard open surgical tracheotomy and is routinely performed in the
intensive care setting. Despite the criteria and the ease of use in performing open and
percutaneous tracheotomies, peri- and postoperative morbidity is undeniably prevalent. This
morbidity can stem from many factors, including predisposing medical and surgical history,
which can be combined with tracheostomy-related complications. Although both open and
percutaneous modes of the tracheotomy procedure carry their own complications and risks,
higher rates have been reported for PDT.
Objective: Objective: Tracheotomy performed either by open or percutaneous technique
(PDT) is a common procedure required for definitive airway management of critically ill
intensive care unit patients. Although both tracheotomy techniques are associated with unique
complications and risks, higher rates have been reported for PDT. We evaluated a group of
long-term ICU survivors with tracheal stenosis or vocal cord paralysis to determine the
relationship of incidence and severity to tracheostomy technique.
Methods: We retrospectively reviewed all Tracheotomies preformed at our facility from July
2008 to June 2011 looking for an outcome of tracheal stenosis or vocal cord paralysis.
Routine demographics were recorded. We focused on several variables: the service
performing the procedure, difficulty during procedure, and length of intubation prior to
tracheostomy.
Results: 1125 patients had tracheostomy. 485 were done using an open technique in the
operating room while 640 were done using PDT in the ICU. Of the 38 patients reviewed with
proven vocal cord paralysis and tracheal stenosis, 20 (53%) of these patients have their
tracheotomy preformed with open procedure and 18 (47%) with a percutaneous procedure.
The incidence of symptomatic tracheal stenosis was 4% for the open group and 3% for the
PDT group. The mean duration from intubation to tracheostomy in the open group was 13
days while in the PDT group it was 15 days. This was not significantly different between the
two groups. The Duration of intubation for this cohort of patients ranged from 1-28 days. 18
patients had a history of GERD. Patients were then analysed for incidence of tracheal stenosis
based on timing of tracheostomy. Patients were divided into early tracheostomy (<7 days) and
late tracheostomy (>7 days). The incidence of tracheal stenosis in the early group was 25%
for open and 33% for PDT. In the late group the incidence was 45% for open and 44% for
PDT
Conclusions
Our data shows that the incidence of tracheal stenosis following tracheotomy is low. The
method of performing the tracheostomy is not related to the development of tracheal stenosis.
Duration of intubation prior to tracheostomy does not affect the development of tracheal
stenosis. Given the similar incidence of tracheal stenosis following tracheostomy, the PDT
technique is safe while providing all of the benefits of an ICU bedside procedure.