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(Chest. 2004;125:1173-1174.)
© 2004 American College of Chest Physicians

Routine Chest Radiographs After Endoscopically Guided Percutaneous Dilatational Tracheostomy

Isabel Gonzalez, MD and Stephen Bonner, MD

The James Cook University Hospital Middlesborough, UK

Correspondence to: Isabel Gonzalez, MD, Intensive Care Unit, The James Cook University Hospital, Marton Rd, Middlesborough TS4 3BW, UK; e-mail: img{at}doctors.org.uk

To the Editor:

We read with great interest the article by Datta et al (May 2003)1 analyzing chest radiographs after bronchoscopically guided percutaneous dilational tracheostomy (PDT). While we may instinctively agree with their conclusion that it is not necessary to perform a chest radiograph after an uneventful PDT, if guided by direct vision via bronchoscopy, we do not think that the conclusion can be safely made on the basis of only 60 chest radiographs that were retrospectively analyzed.

The authors acknowledge that the incidence of pneumothorax after PDT has been reported as 0 to 3%, and paratracheal placement as 0 to 6%. Any study would therefore need several hundred patients to convincingly exclude the usefulness of a postprocedure chest radiograph. Their own study found two significant complications (3.3%), one tension pneumothorax, and one pneumomediastinum, both suspected clinically, but diagnosed radiologically.

We performed a similar retrospective audit in 2001. Preprocedure and postprocedure chest radiographs were analyzed in 221 patients who underwent bronchoscopically guided PDT performed between 1996 and 2001 in the James Cook University Hospital ICU. We found that the overall complication rate (Table 1 ) for PDT was low (8.59%). The chest radiograph itself detected only the following four complications (Table 2 ): tube malrotation in one case; a self-limiting pneumomediastinum that had been noticed clinically before the radiograph had been performed and did not require treatment; and two areas of consolidation that required bronchoscopy, but which may have not been related to the PDT. There were no pneumothoraces observed during the study period.


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  		Table 1.. All Recorded Complications After PDT*

 

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  		Table 2.. Complications After PDT Detected Only by Chest Radiograph

 
Studies of non-endoscopically guided PDT have shown the incidence of pneumothorax, pneumomediastinum, and paratracheal tube insertion to be up to 12%,2 3 compared to studies of bronchoscopically guided PDT, which have not shown these complications.4 Our audit confirmed the low rate of complications and, similarly to the study by Datta et al,1 questioned the value of the routine postprocedure chest radiograph. In 221 procedures, the postprocedure chest radiograph served only to review the angulation of one tracheostomy. However, given the low rate of complications, together with the potentially life-threatening nature of potential complications, we are currently continuing this study prospectively and have gathered data on a further 80 patients to date. We agree with Datta et al1 that more data are required before we can agree that after the performance of uncomplicated, endoscopically guided PDTs in adult patients there is no need to perform a routine postprocedure chest radiograph.

References

  1. Datta, D, Onyirimba, F, McNamee, MJ (2003) The utility of chest radiographs following percutaneous dilational tracheostomy. Chest 123,1603-1606[Abstract/Free Full Text]
  2. Gonzalez, I, Davis, A, Schrinner, S, et al The value of routine chest x-ray post endoscopically guided percutaneous dilatational tracheostomy. Intensive Care Med 2002;28,S29
  3. Ciaglia, P, Graniero, KD Percutaneous dilatational tracheostomy: results and long term follow up. Chest 1992;101,464-467[Abstract/Free Full Text]
  4. Leinhart, DJ, Mughal, M, Bowles, B, et al Appraisal of percutaneous tracheostomy. Br J Surg 1992;79,255-258[ISI][Medline]




This Article
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