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(Chest. 2003;123:1595-1602.)
© 2003 American College of Chest Physicians

Percutaneous Dilatational Tracheostomy in the ICU*

Optimal Organization, Low Complication Rates, and Description of a New Complication

Kees H. Polderman, MD, PhD; Jan Jaap Spijkstra, MD, PhD; Remco de Bree, MD; Herman M.T. Christiaans, MD; Harry P.M.M. Gelissen, MD; Jos P.J. Wester, MD, PhD and Armand R.J. Girbes, MD, PhD

* From the Departments of Intensive Care (Drs. Polderman, Spijkstra, Christiaans, Gelissen, Wester, and Girbes) and Otolaryngology/Head and Neck Surgery (Dr. de Bree), University Medical Center, Amsterdam, the Netherlands.

Correspondence to: Kees H. Polderman MD, PhD, Department of Intensive Care, University Medical Center, PO Box 7057, 1007 MB Amsterdam, the Netherlands; e-mail: k.polderman{at}tip.nl


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Study objectives: To assess short-term and long-term complications of bronchoscopy-guided, percutaneous dilatational tracheostomy (PDT) and surgical tracheostomy (ST) and to report a complication of PDT that has not been described previously.

Design: Prospective survey.

Setting: University teaching hospital.

Patients: Two hundred eleven critically ill patients in our ICU.

Interventions: PDT was performed in 174 patients, under bronchoscopic guidance in most cases. ST was performed in 40 patients.

Results: No procedure-related fatalities occurred during PDT or ST. The incidence of significant complications (eg, procedure-related transfusion of fresh-frozen plasma, RBCs, or platelets, malpositioning or kinking of the tracheal cannula, deterioration of respiratory parameters lasting for > 36 h following the procedure, or stomal infection) in patients undergoing PDT was 4.0% overall and 3.0% when bronchoscopic guidance was used. No cases of paratracheal insertion, pneumothorax, pneumomediastinum, tracheal laceration, or clinically significant tracheal stenosis occurred in patients undergoing PDT. We attribute this low rate of complications to procedural and organizational factors such as bronchoscopic guidance, performance by or supervision of all PDTs by physicians with extensive experience in this procedure, and airway management by physicians who were well-versed in (difficult) airway management. In addition, an ear-nose-throat surgeon participated in the procedure in case conversion of the procedure to an ST should become necessary. We observed a complication that, to our knowledge, has not been reported previously. Five patients developed intermittent respiratory difficulties 2 to 21 days (mean, 8 days) after undergoing PDT. The cause turned out to be the periodic obstruction of the tracheal cannula by hematoma and the swelling of the posterior tracheal wall, which had been caused by intermittent pressure and chafing of the cannula on the tracheal wall. In between the episodes of obstruction, the cannula was open and functioning normally, which made the diagnosis difficult to establish.

Conclusions:Bronchoscopy-assisted PDT is a safe and effective procedure when performed by a team of experienced physicians under controlled circumstances. The intermittent obstruction of the cannula caused by swelling and irritation of the posterior tracheal wall should be considered in patients who develop unexplained paroxysmal respiratory problems some time after undergoing PDT or ST.

Key Words: complications • critically ill • fiberoptic bronchoscopy • intermittent obstruction • organizational factors • percutaneous dilatational tracheostomy • posterior tracheal wall injury • tracheal wall injury with intermittent stoppage of the tracheostomy and episodes of dyspnea (TWISTED) syndrome


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Although the technique of minimally invasive percutaneous dilatational tracheostomy (PDT) is being used more and more widely in Europe and the United States, especially in ICUs, its exact role remains a matter for debate. Issues that remain controversial include whether PDT has more or fewer complications than traditional surgical tracheostomy (ST), how and by whom PDT should be performed, which if any precautions (such as bronchoscopic or ultrasound guidance) should be taken, and which categories of patients are suitable candidates for this procedure. Two meta-analyses have come to different conclusions. Dulguerov and colleagues1 analyzed 65 studies (38 dealing with ST and 27 dealing with PDT, published between 1960 and 1996) and concluded that PDT was associated with a higher prevalence of perioperative complications, perioperative deaths, and cardiorespiratory arrests. In contrast, Freeman and colleagues2 concluded from a meta-analysis of five prospective controlled studies involving 236 patients that PDT was easier to perform, produced fewer overall postoperative complications, had shorter operative times, less postoperative and perioperative bleeding, and fewer postoperative stomal infections than did ST. These authors concluded that their findings supported PDT as the procedure of choice for the establishment of elective tracheostomy in critically ill patients but that additional data were required.2 This view was reinforced in an accompanying editorial that stressed the heterogeneity of outcomes in the studies used for this meta-analysis.3

We studied the outcomes, short-term complications, and long term complications of PDT, as performed by intensivists or ear-nose-throat (ENT) surgeons, in a large series of patients in our ICU. All patients were carefully evaluated and followed up to assess the complications and adverse effects of PDT. In contrast to many previous studies, we assessed not only major complications such as procedure-related mortality, malpositioning, and tracheal stenosis, but also stomal infections, transfusion requirements (of RBCs, fresh-frozen plasma [FFP], and platelets), and changes in respiratory function and ventilator settings related to the procedure.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Patients and Material
All tracheostomies were performed with a kit (Portex; Hythe, Kent, UK) with curved dilating forceps. PDT was performed in 174 patients between 1996 and 2001 as a routine procedure (n = 168) or in emergency situations (n = 6) by an intensivist (n = 96 [including all emergency procedures]) or by ENT surgeons (n = 78). Since 1998, elective PDTs in our hospital have been performed under bronchoscopic guidance, and thus bronchoscopy was used in most procedures. The success rate, efficacy, safety, and outcome, as well as short-term and long-term complications, including site infection and bleeding, were carefully monitored. All PDTs were performed in the ICU. ST was performed in the operating room.

The indications for tracheostomy included the following: difficult weaning process (mostly patients with critical illness neuropathy and myopathy, and some patients with preexisting pulmonary disease); cerebral injury (usually severe traumatic head injury, postanoxic injury, or cerebral infarction); and other neurologic disorders (eg, spinal cord injury and Guillain-Barré syndrome).

Procedure and Follow-up
PDTs were performed by a team of three or four specialists (see below), with at least one ENT surgeon and one intensivist as part of the team. One physician was in charge of airway management, one performed the bronchoscopy, and one performed the actual tracheostomy. Sometimes this procedure was performed by two physicians, such as when the physician performing the PDT was inexperienced (ie, < 20 PDTs performed). In these cases, a more experienced physician supervised and guided the more inexperienced colleague.

Intensivists and ENT surgeons took turns performing each task (ie, bronchoscopy, airway management, or PDT itself). Low doses of the opiate fentanyl (0.05 to 0.20 µg/kg) and the short-acting sedative propofol (5 to 10 mg) were administered at the beginning of the procedure. Rocuronium bromide, a brief-acting muscle paralyzer, 50 to 100 mg, also was used in most patients. Local anesthesia (lidocaine, 3 to 10 mL, and a combination of lidocaine, 5 mg/mL, and epinephrine, 1:100.000) was administered to all patients. All short-term and long-term changes in the patients’ clinical conditions were carefully monitored, and all complications that were potentially related to the procedure were noted. These included deterioration in respiratory function, blood loss, transfusion requirement, circulatory problems, and neurologic deterioration. Long-term sequelae such as tracheal stenosis also were determined.

We also assessed complications in a smaller number of patients undergoing ST. However, a number of these patients were selected to undergo ST rather than PDT because of altered or difficult local anatomy. As this might have led to higher risk in these patients, the differences in complication rates between PDT and ST were not compared statistically. The reasons for performing ST rather than PDT were an inability to extend the neck sufficiently (n = 4) and significant enlargement of the thyroid gland or palpable vessels in the operative field that left insufficient space for PDT insertion (n = 3). The other patients undergoing ST were selected at random. The mean duration of follow-up for the assessment of tracheal stenosis was 14 months (range, 6 to 29 months)


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Overall Results and Incidence of Procedure-Related Complications
The results are shown in Table 1 . The correct position of the tracheal cannula (which is defined as a secure position within the trachea, preferably, but not necessarily, in midline) was achieved in all patients (100%). No procedure-related fatalities occurred during either PDT or ST. No occurrences of paratracheal insertion, pneumothorax, pneumomediastinum, or tracheal lacerations were observed. No perforation of or other injury to the posterior tracheal wall occurred during bronchoscopy-guided PDT. The overall rate of moderately severe complications (ie, bleeding requiring the transfusion of RBCs, deterioration in respiratory function lasting >= 48 h, malpositioning of the cannula, stomal infection or tracheal stenosis, coagulopathy requiring the transfusion of platelets or FFP) was 4%, and in patients undergoing PDT under bronchoscopic guidance it was 3.0% (Table 1) . Transient deterioration in respiratory parameters (for < 36 h) was seen in 2.3% of patients undergoing PDT, and in 1.5% of patients when bronchoscopic guidance was used.


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  		Table 1.. Data and Complications for Patients Undergoing PDT and ST*

 
Thus, the PDT insertion procedure was completely uneventful in 93.7% of all patients, and in 95.5% when bronchoscopic guidance was used. For patients undergoing ST, the total complication rate was 12.2%, with moderate-to-severe complications occurring in 7.3% of patients.

The complication rates between PDT performed by intensivists and PDT performed by ENT surgeons did not differ significantly. The placement of the tracheal cannula using PDT was successful in 99.4% of patients, although ST was later performed in two patients because of the development of a specific problem with the tracheal cannula (see below). Factors associated with lower complication rates of PDT were bronchoscopic guidance and the experience of the physician performing the procedure.

It is noteworthy that the seven patients selected for ST because of difficult anatomy did not have higher complication rates than the other patients who were randomly selected.

New Complication
We observed a problem that had not been reported previously in the literature in four patients in the weeks following PDT and in one patient who had undergone ST. The initial procedure was uneventful in all these patients, and at first no problems were encountered during weaning from the respirator. However, after a few days (mean [± SD], 8 ± 7.5 days; range, 2 to 21 days) they developed paroxysmal episodes of dyspnea and deterioration of blood gas levels during assisted spontaneous breathing or unassisted breathing on the airway humidifier (ICOR Instruments; Upplands Väsby, Sweden). These dyspneic episodes lasted for several minutes, despite therapy with extra oxygen and/or suction. Temporary improvements in oxygenation were sometimes achieved by lung recruitment (using the ventilator or by hand using a balloon), but a degree of dyspnea persisted, and dyspnea increased when normal ventilator settings or the airway humidifier were restored.

These episodes initially remained unexplained. In two patients, the obstruction of the tube by mucus or kinking was initially considered, however, bronchoscopic examination established that the tracheal cannula and the main bronchi were open (Fig 1 , top).



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  		Figure 1.. Bronchoscopic view of the posterior wall of the trachea in a patient with paroxysmal respiratory distress. These complaints had started several days after the placement of the tracheal cannula. After insertion of the bronchoscope through the tracheal cannula, the initial examination revealed no abnormalities (top). However, when the proximal part of the cannula (outside the patient) was moved downward, causing the tracheal part of the cannula to move upward, extensive bruising and abrasion of the posterior tracheal wall were observed (middle and bottom). Middle: the edge of the endotracheal tube is visible just above the abrasion. Bottom: the bronchoscope has been advanced somewhat to provide a clearer view of the posterior wall. The proximal portion of the tracheal cannula (outside the patient) has been pulled slightly downward to provide a better view of the posterior wall.

 
The diagnoses that were considered in these and the other three patients to explain the paroxysmal respiratory problems included intermittent mitral valve insufficiency, pulmonary embolism, cardiac failure caused by a decrease of positive end-expiratory pressure, and plugging of the tube by mucus retention. In most patients, extensive diagnostic procedures were initiated to assess pulmonary and cardiac function as a possible explanation for the intermittent respiratory problems. When these procedures failed to provide an explanation, comprehensive (ie, repeat) bronchoscopy via the tracheal cannula (Fig 1 , middle and bottom ) and via the upper airways was performed.

In this way, we were ultimately able to establish the diagnosis. Bronchoscopic examination revealed extensive swelling, bruising, and abrasion of the posterior tracheal wall (Fig 1 , middle and bottom), which had been caused by rasping and the pressure of the tracheal cannula. The resultant swelling of the tracheal wall had subsequently caused the intermittent obstruction of the tracheal tube (Fig 3 ), which had begun days or weeks after the placement of the tracheal cannula. In this regard, it is particularly noteworthy that in two patients the initial bronchoscopic examination had not revealed the abnormality, because it was located slightly above the distal lumen of the tracheal cannula. The reason for this is depicted in Figure 4 . Normally, during bronchoscopy the cannula is placed in a straight position, and some upward pressure on the outside section of the cannula may occur during the insertion of the bronchoscope (Fig 4) . This positioning and upward pressure on the proximal section of the cannula during the first bronchoscopy may have pushed the distal section downward in the trachea, past the lesion that had been causing the intermittent obstruction (Fig 4) . Thus, during bronchoscopy the tube and airways appeared to be open, and no abnormalities were seen. Only when the diagnosis was already suspected, and the cannula was positioned in such a way as to reveal a large section of the posterior tracheal wall, was the diagnosis finally established. On the other hand, when tubing was attached to the tracheal cannula while the patient was in sitting position, the weight of this tubing pulled the proximal section of the cannula downward, causing the distal section to move upward inside the trachea, allowing the obstruction to "reassert" itself (Fig 3) .



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  		Figure 3.. When the proximal portion of the cannula (outside the patient) moves downward, the distal portion (inside the trachea) moves upward, and rubs back and forth against the posterior tracheal wall. The attachment of tubing to the cannula can induce this phenomenon. Continuous rasping and pressure of the tracheal cannula can cause bruising and swelling of the tracheal wall, leading to intermittent obstruction and blockage of the tracheal tube.

 


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  		Figure 4.. For bronchoscopy, the respiratory tubing is removed, the patient is in a supine position, and the cannula is placed in a straight position. While the bronchoscope is inserted, some upward pressure is exerted on the outside (proximal) section of the cannula, pushing the distal section further downward and past the lesion of the tracheal wall. No abnormalities are seen during bronchoscopy, because the lesion is located higher in the trachea.

 
The respiratory problems resolved in all patients following the exchange of the regular tracheal cannula for a cannula with a longer distal section that was less perpendicular to the tracheal wall. In the first three patients, we elected to replace the cannula under controlled circumstances (ie, in the operating room). This allowed the optimal inspection of the tracheal wall. The replacement procedure was uneventful in all three patients. Having thus observed that the problem could be quite easily corrected by the insertion of a long-necked tracheal cannula, we chose to perform the cannula replacement percutaneously in the next two patients. These procedures also were performed uneventfully.


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
In this study, we observed that significantly lower complication rates were associated with PDT than have been reported in previous studies. We attribute our low complication rates to our insertion procedure, in which PDT was performed in the ICU under bronchoscopic guidance by a team of experienced physicians. This issue is discussed in more detail below.

In recent years, the placement of a tracheostomy has gained popularity as a means of facilitating the weaning of patients from the respirator, as it reduces pulmonary dead space, provides access for the clearing of pulmonary secretions under various pathologic conditions, and improves the patient’s comfort. The appropriate timing of the tracheostomy in intubated patients is yet to be defined, and which technique should be preferred (ie, PDT or ST) remains controversial. In theory, PDT has a number of advantages compared to ST, including procedure time, less immediate bleeding, smaller skin incision, less dissection, and less risk of perforation of the wall of the posterior trachea.4 Some authors5 have found that PDT is relatively safe, with acceptable complication rates, but have recommended that (only) surgeons perform the procedure in case conversion of the procedure to an open ST becomes necessary. Others6 have reported major complications including difficulty with dilatation, excessive bleeding, false passage of the tracheal cannula, and death. A number of other studies6 7 8 9 and a meta-analysis by Dulguerov and colleagues1 confirmed the observation that PDT had significantly higher complication rates than ST. However, a number of studies and another meta-analysis of prospective and mostly randomized studies2 10 11 12 13 arrived at an opposite conclusion, namely, that PDT was safer, cheaper, and more effective than ST. Some studies have suggested that the safety of the procedure may be enhanced by the use of ultrasound14 15 or by bronchoscopic guidance,16 17 18 although this remains controversial. Our observations confirm the value of bronchoscopic guidance.

The complication rates reported in most previously published large studies and meta-analyses1 2 were significantly larger than those observed in our study, ranging from 8.9 to > 30%. In addition, there were procedure-related fatalities in most of these studies, in contrast to our observations. We attribute this to a combination of the timing of the procedure, bronchoscopic guidance, and the fact that PDT was performed or supervised by physicians with extensive experience in this procedure. Moreover, an ENT physician participated in the procedure, providing the option of conversion of the procedure to a classic ST should this be deemed necessary. The airway was guarded by an intensivist with experience in (difficult) airway management. Thus, each PDT procedure was performed by an experienced team of physicians under optimized circumstances. We think that these logistical factors contributed to the low incidence of complications and the absence of procedure-related fatalities in our patients. Although in our study only one patient required the conversion of PDT to ST, the presence of an ENT surgeon may have helped to decrease the tension surrounding the procedure, and in this way contributed to optimal circumstances.

To the best of our knowledge, we have reported for the first time a complication that may occur frequently but often may go undetected. We observed the occurrence of intermittent respiratory problems caused by repeated trauma of the posterior tracheal wall by the tracheal tube motion (Fig 1 2 3 4) . As chronic irritation of the posterior wall led to increased swelling and edema, the patients developed respiratory symptoms, but only during those relatively brief periods of time when the lumen of the cannula was obstructed by the bloated and inflamed tissue of the posterior tracheal wall. When the bottom end of the cannula was in a position below this lesion, the patient experienced no symptoms, and the cannula was open and functioned normally. What is more, when bronchoscopy was performed and the bronchoscope was inserted through the tracheal cannula, the outside part of the cannula was pushed upward in the direction of the patients’ face, leading to a slightly deeper and forward position (away from the posterior wall) of the internal part of the cannula (Fig 4) . Thus, the lesions of the posterior wall were initially not visible during endoscopy, and indeed the diagnosis was initially missed in two patients. Only when bronchoscopy was repeated while the tracheal cannula was slightly withdrawn was the diagnosis finally established.



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  		Figure 2.. The tracheal cannula has been inserted and is positioned in the trachea.

 
Interestingly, when seen in retrospect the weight of the tubing attached to the tracheal cannula may have precipitated some episodes of dyspnea when the patients were in a sitting position by pulling the proximal part of the cannula forward and downward, leading to the obstruction of the distal part of the cannula (Fig 3) . When the patients developed respiratory problems, they were usually taken off the ventilator and received manual ventilation. In most cases, the problems were (temporarily) resolved, only to recur when the tubing was reconnected. When the patients were put in a supine position the problems diminished. In retrospect, all these observations can be explained by the above-mentioned mechanism.

Our protocol for performing PDT involved the performance of bronchoscopy during and immediately following PDT to check the final position of the tracheal cannula. For this reason, we can be reasonably certain that the problems of edema and abrasions of the posterior tracheal wall developed well after the placement of the cannula in our patients. Moreover, the insertion procedure itself was quick and uncomplicated in all five patients (PDT, four patients; ST, one patient) who subsequently developed this complication.

As outlined above, significant damage to the posterior tracheal wall as well as (intermittent) clinical and respiratory deterioration may result from this problem. Although the occurrence of direct damage to the posterior tracheal wall during the insertion of the cannula (ie, during the performance of PDT) has been reported previously,19 20 to our knowledge this is the first time that the specific problem of chronic irritation of the posterior tracheal wall following PDT, leading to intermittent tracheal obstruction of the cannula days or weeks after the performance of PDT, has been described. In our opinion, the development of such undetected tracheal lesions may explain some cases of respiratory failure after the removal of the tracheal cannula and may contribute to the development of tracheal stenosis.

Regarding the long-term sequelae of PDT, there were no cases of clinically significant tracheal stenosis in our patients. In general, PDT appears to be a less traumatic procedure than ST. For example, cartilage rings usually remain more or less intact during PDT, while most surgeons incise one or more tracheal cartilage rings at operation during ST. In a study21 using MRI to assess tracheal stenosis after PDT, no postoperative stenosis was found after PDT. In a larger study using CT scanning to assess the tracheal lumen, a narrowing of > 10% was observed in 26% of patients, none of whom had clinical symptoms such as dyspnea. The risk of stenosis was shown to be operator-dependent in that study. The authors concluded that the risk of significant tracheal stenosis following PDT was low compared to conventional tracheostomy.22 In contrast, Norwood and colleagues23 observed a high rate (31%) of > 10% tracheal stenosis in critically ill patients after they had undergone PDT, with symptomatic stenosis (manifested by subjective respiratory symptoms) present in 6% of patients. It is possible that the complication now reported in our article may have played a role in the development of tracheal stenosis. Although we observed no cases of clinically significant tracheal stenosis in our PDT group, we cannot rule out that some cases of subclinical stenosis may have occurred. Diagnostic procedures including CT scanning, MRI, and bronchoscopy were performed only in patients with respiratory complaints and/or clinical signs and symptoms such as inspiratory wheezing.

In conclusion, we studied the efficacy, safety, and the short-term and long-term complications of PDT. We report a significantly lower rate of serious complications and mortality compared to previous studies, which we attribute largely to logistic and organizational factors. In addition, we describe a complication that has not been reported previously in the literature, namely, chronic irritation of the posterior tracheal wall by the tracheal cannula, leading to bloating and abrasion of the trachea and to intermittent obstruction of the tracheal tube. We suggest the name TWISTED (ie, tracheal wall injury with intermittent stoppage of the tracheostomy and episodes of dyspnea) for this syndrome. Physicians treating patients with tracheal cannulas should be aware of this potentially serious, but easily correctable, problem. Despite this new complication, we conclude that PDT is a safe, highly effective, and minimally invasive procedure that should be performed in selected critically ill patients requiring prolonged mechanical ventilation. Bronchoscopic guidance during the procedure may help to bring down complication rates even further. PDT should be performed or supervised by a team of physicians with extensive experience in this procedure, and this team should include intensivists with experience in (difficult) airway management and at least one ENT surgeon.


   Acknowledgements
 
The authors thank J.M. Luursema for providing the drawings accompanying this manuscript, and A. Vincent for his critical appraisal of our manuscript.


   Footnotes
 
Abbreviations: ENT = ear-nose-throat; FFP = fresh-frozen plasma; PDT = percutaneous dilatational tracheostomy; ST = surgical tracheostomy

Received for publication November 29, 2001. Accepted for publication August 26, 2002.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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