Percutaneous and surgical tracheostomy in critically ill adult patients: a meta-analysis

Putensen et al. Critical Care (2014) 18:544 DOI 10.1186/s13054-014-0544-7 RESEARCH Open Access Percutaneous and surgical tracheostomy in critically ill adult patients: a meta-analysis Christian Putensen1*, Nils Theuerkauf1, Ulf Guenther1, Maria Vargas2 and Paolo Pelosi2 Abstract Introduction: The aim of this study was to conduct a meta-analysis to determine whether percutaneous tracheostomy (PT) techniques are advantageous over surgical tracheostomy (ST), and if one PT technique is superior to the others. Methods: Computerized databases (1966 to 2013) were searched for randomized controlled trials (RCTs) reporting complications as predefined endpoints and comparing PT and ST and among the different PT techniques in mechanically ventilated adult critically ill patients. Odds ratios (OR) and mean differences (MD) with 95% confidence interval (CI), and I2 values were estimated. Results: Fourteen RCTs tested PT techniques versus ST in 973 patients. PT techniques were performed faster (MD, −13.06 minutes (95% CI, −19.37 to −6.76 (P <0.0001)); I2 = 97% (P <0.00001)) and reduced odds for stoma inflammation (OR, 0.38 (95% CI, 0.19 to 0.76 (P = 0.006)); I2 = 2% (P = 0.36)), and infection (OR, 0.22 (95% CI, 0.11 to 0.41 (P <0.00001)); I2 = 0% (P = 0.54)), but increased odds for procedural technical difficulties (OR, 4.58 (95% CI, 2.21 to 9.47 (P <0.0001)); I2 = 0% (P = 0.63)). PT techniques reduced odds for postprocedural major bleeding (OR, 0.39 (95% CI, 0.15 to 0.97 (P = 0.04)); I2 = 0% (P = 0.69)), but not when a single RCT using translaryngeal tracheostomy was excluded (OR, 0.58 (95% CI, 0.21 to 1.63 (P = 0.30)); I2 = 0% (P = 0.89)). Eight RCTs compared different PT techniques in 700 patients. Multiple (MDT) and single step (SSDT) dilatator techniques are associated with the lowest odds for difficult dilatation or cannula insertion (OR, 0.30 (95% CI, 0.12 to 0.80 (P = 0.02)); I2 = 56% (P = 0.03)) and major intraprocedural bleeding (OR, 0.29 (95% CI, 0.10 to 0.85 (P = 0.02)); I2 = 0% (P = 0.72)), compared to the guide wire dilatation forceps technique. Conclusion: In critically ill adult patients, PT techniques can be performed faster and reduce stoma inflammation and infection but are associated with increased technical difficulties when compared to ST. Among PT techniques, MDT and SSDT were associated with the lowest intraprocedural risks and seem to be preferable. Introduction Tracheostomy is among the most commonly conducted procedures in critically ill patients. Despite percutaneous tracheostomy (PT) techniques gaining acceptance, the debate continues about their precise indications, their possible advantages over conventional surgical tracheostomy (ST), and whether one PT technique is superior to the others [1-3]. Observational studies indicate that ST is still performed in 33 to 50% of critically ill patients [4,5], especially in the presence of neurological disorders. Conflicting results have been reported in three previous meta-analyses comparing complication rates between PT techniques and ST [6-8]. All of these meta-analyses * Correspondence: 1 Department of Anesthesiology and Intensive Care Medicine, University of Bonn, Sigmund-Freud-Straße 25, 53105 Bonn, Germany Full list of author information is available at the end of the article included only multiple dilator tracheostomy (MDT) [9], guide wire dilating forceps (GWDF) [10], and translaryngeal tracheostomy (TLT) [11] in the PT group. Since newer PT techniques such as single-step dilation tracheostomy (SSDT) [12], rotational dilation tracheostomy (RDT) [13], or balloon dilation tracheostomy (BDT) [14] are increasingly used due to easy application and shorter procedure times [15], previous meta-analyses may not reflect current clinical practice. Recently, a meta-analysis including randomized, controlled trials (RCTs) comparing different PT techniques concluded that SSDT appears to be superior in terms of safety and success rate [15]. Our objective was to determine whether a specific PT technique is superior to ST or to other PT techniques in adult critically ill patients with an indication for tracheostomy with respect to complications during the procedure (major and minor bleeding, technical difficulties, false © 2014 Putensen et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Putensen et al. Critical Care (2014) 18:544 route, subcutaneous emphysema, pneumothorax, and oxygen desaturation) or after the procedure (major and minor bleeding, stoma inflammation or infection, tracheomalacia, and tracheal stenosis), the length of the procedure and hospital survival. Materials and methods Data sources and searches We aimed to identify all RCTs assessing the complications and outcomes between PT and ST and among the different PT techniques in adult critically ill patients. The electronic search strategy applied standard filters for identification of RCTs. Databases searched were the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library Issue 3, 2012), MEDLINE (from inception to July 2013), and EMBASE (from inception to July 2013). We did not apply language restrictions. Our search included the following key words: tracheotomy, tracheostomy, percutaneous, dilatation, surgical, Griggs, forceps, Percutwist, Ciaglia, Blue Rhino, Fantoni, translaryngeal, Blue Dolphin, multiple dilator technique, guide wire dilating forceps, translaryngeal technique, single-step dilation technique, rotational dilation technique balloon dilation technique, critical care, intensive care, critically ill, and random. In addition to the electronic search, we checked cross-references from original articles and reviews. We retrieved additional studies by hand searching the abstracts of the meetings of the American Thoracic Society, the Society of Critical Care Medicine, and the European Society of Intensive Care Medicine held from 2010 to 2013. Completed but unpublished studies were identified by searching the websites for the Public Registers of Clinical Trials [16,17]. Neither ethical approval nor patient consent was needed in this meta-analysis. Selection of studies We restricted the analysis to RCTs to guarantee control of selection bias. Study designs containing cointerventions unequally applied to the treatment and control group as well as nonrandomized or crossover trials were not included. RCTs reporting complications as predefined endpoints and comparing PT with ST and comparing the different PT techniques in mechanically ventilated adult critically ill patients were cons (...truncated)