Safety of bedside percutaneous tracheostomy in the critically ill: evaluation of more than 3,000 procedures

Abstract

Background: Bedside percutaneous dilational tracheostomy has been demonstrated to be equivalent to open tracheostomy. At our institution, percutaneous dilational tracheostomy without routine bronchoscopy is our preferred method. My colleagues and I hypothesized that our 10-year percutaneous dilational tracheostomy experience would demonstrate that the technique is safe with low complication rates, even in obese patient populations.

Study design: We conducted a retrospective review of all bedside percutaneous dilational tracheostomy performed by the Division of Trauma and Surgical Critical Care faculty from 2001 to 2011, excluding patients younger than 18 years of age. All major airway complications and procedure-related deaths were evaluated during the early (≤48 hours postprocedure), intermediate (in hospital), and late (after discharge) periods. Incidence of post-tracheostomy stenosis was also evaluated.

Results: There were 3,162 percutaneous dilational tracheostomies performed during the study period. Mean body mass index was 28 (16% with body mass index ≥35), mean Injury Severity Score was 32, and mean APACHE II score was 19. Major airway complications occurred in 12 (0.38%) patients, accounting for 5 (0.16%) deaths. Early major complications included 3 airway losses and 1 bleeding event requiring formal exploration with procedure-related deaths occurring in 3 patients. Intermediate major complications included 2 tube occlusion/dislodgement events with 2 related deaths. Late complications included 5 (0.16%) cases of tracheal stenosis requiring intervention without associated deaths.

Conclusions: Bedside percutaneous dilational tracheostomy is safe across a broad critically ill patient population. The safety of this technique, even in the obese population, is demonstrated by its low complication rate. Routine bronchoscopic guidance is not necessary. Specially trained procedure nurse and process improvement programs contribute to the safety and efficacy of this procedure.