Videobronchoscopic guidance makes percutaneous dilational tracheostomy safer Percutaneous versus surgical tracheostomy: A randomized controlled study with long-term follow-up* Comparison of percutaneous and surgical tracheostomies. A prospective, randomized study comparing percutaneous with surgical tracheostomy in critically ill patients A comparison of percutaneous and operative tracheostomies in intensive care patients Bedside tracheostomy in the intensive care unit: a prospective randomized trial comparing open surgical tracheostomy with endoscopically guided percutaneous dilational tracheotomy. Percutaneous dilational tracheostomy or conventional surgical tracheostomy? Percutaneous tracheostomy in critically ill patients: A prospective, randomized comparison of two techniques Indications, timing, and techniques of tracheostomy in 152 French ICUs. Percutaneous translaryngeal versus surgical tracheostomy: A randomized trial with 1-yr double-blind follow-up* Percutaneous Tracheostomy with Single Dilatation Technique: A Prospective, Randomized Comparison of Ciaglia Blue Rhino Versus Griggs’ Guidewire Dilating Forceps Impact of neck length on the safety of percutaneous and surgical tracheotomy: a prospective, randomized study. Comparative clinical trial of standard operative tracheostomy with percutaneous tracheostomy Surgical Tracheostomy Versus Percutaneous Dilational Tracheostomy in Patients with Anterior Cervical Spine Fixation: Preliminary Report Percutaneous tracheostomy: a clinical comparison of dilatational (Ciaglia) and translaryngeal (Fantoni) techniques. Percutaneous versus surgical tracheostomy: a double-blind randomized trial. Surgical tracheostomy versus percutaneous dilatational tracheostomy. A prospective-randomized study with long-term follow-up. A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients* Percutaneous dilatational tracheostomy versus conventional surgical tracheostomy. A clinical randomised study. Guidelines for the inter- and intrahospital transport of critically ill patients* Preferred route of tracheostomy--percutaneous versus open at the bedside: a randomized, prospective study in the surgical intensive care unit. Percutaneous dilatational tracheostomy versus open tracheostomy--a prospective, randomized, controlled trial.
Background  Percutaneous dilational tracheostomy ( PDT )  can be performed under either conventional bronchoscopic or videobronchoscopic guidance . Only the latter procedure provides the surgeon with direct visual information . This study prospect ively assessed procedural parameters and complications of PDT guided by conventional bronchoscopy ( CB ) or videobronchoscopy ( VB ) . Methods Consecutive intensive care unit ( ICU ) patients who underwent PDT were enrolled in this study .  Videobronchoscopy was available in two ICUs , whereas CB was available in three ICUs . Demographic data , procedural variables , and complications were recorded . Results In this study , 36 patients underwent PDT guided by VB ( group V ) , and 38 patients underwent PDT guided by CB ( group C ) . The two groups were well matched in terms of gender , anatomic aspects , and positioning of the patient . Operating time , procedural difficulty , and extent of tracheal bleeding were not different between the two groups . Group V showed a tendency to younger age ( p = 0.055 ) . Surgeons significantly more often considered PTD to be “ completely safe ” in group V ( 92 % vs 61 % in group C ) . The skin incisions were smaller ( p = 0.003 ) , and the extent of stomal bleeding was less ( p = 0.001 ) . Complications were tendentiously less frequent in group V ( 5.5 % ) than in group C ( 23.7 % ; p = 0.062 ) . Conclusions The surgeon performing PDT guided by VB has a higher degree of safety , result ing in less bleeding than with PDT guided by CB Objective : To compare the safety , availability , and long-term sequelae of percutaneous vs. surgical tracheostomy . Design : Prospect i ve , r and omized , controlled study . Setting : Combined medical/surgical intensive care unit in a tertiary referral hospital . Patients : Two hundred critically ill mechanically ventilated patients who required tracheostomy .  Interventions : Tracheostomy by either percutaneous tracheostomy or surgical tracheostomy performed in the intensive care unit . Measurements and Main Results : The primary outcome measure was the aggregate incidence of predefined moderate or severe complications . The secondary outcome measures were the incidence of each of the components of the primary outcome . Long-term follow-up included clinical assessment , flow volume loops , and bronchoscopy .  Both groups were well matched for age , gender , admission Acute Physiology and Chronic Health Evaluation II score , period of endotracheal intubation , reason for intubation , and admission diagnosis . There was no statistical difference between groups for the primary outcome . Bleeding requiring surgical intervention occurred in three percutaneous tracheostomy patients and in no surgical tracheostomy patient ( p = .2 ) . Postoperative infection ( p = .044 ) and cosmetic sequelae ( p = .08 ) were more common in surgical tracheostomy patients . There was a shorter delay from r and omization to percutaneous tracheostomy vs. surgical tracheostomy ( p = .006 ) . Long-term follow-up revealed no complications in either group . Conclusions : Both percutaneous tracheostomies and surgical tracheostomies can be safely performed at the bedside by experienced , skilled practitioners OBJECTIVE To compare the safety and efficacy of percutaneous dilational tracheostomy ( PDT ) with surgical tracheostomy ( ST ) . DESIGN Prospect i ve r and omized trial . SETTING Public urban teaching hospital . PATIENTS Twenty-six patients were r and omized to undergo PDT and 27 patients to ST .  RESULTS The time from r and omization into the study until tracheostomy was performed was 28.5 + /- 27.9 h in the PDT group and 100.4 + /- 95.0 h in the ST group ( p < 0.001 ) . PDT was performed in 8.2 + /- 4.9 min vs 33.9 + /- 14.0 min for ST ( p < 0.0001 ) . There was no significant difference in intraprocedural complications between the groups . Postprocedural complication rates were 12 % for PDT and 41 % for ST ( p = 0.008 ) . CONCLUSION PDT is superior to ST logistically . PDT can be performed at the bedside eliminating the risk of patient transport . Because operating room scheduling is not necessary , PDT can be performed earlier once the decision to do a tracheostomy is made , which will improve ICU utilization . PDT is a faster procedure to perform and has fewer postprocedural complications Objective To determine the relative cost-effectiveness of percutaneous dilational tracheostomy ( PDT ) and surgical tracheostomy ( ST ) in critically ill patients . Design Prospect i ve r and omized study . Setting Medical , surgical , and coronary intensive care units at Barnes-Jewish Hospital , a tertiary care medical center . Patients Eighty critically ill mechanically ventilated patients requiring elective tracheostomy . Interventions R and omization to either PDT performed in the intensive care unit or ST performed in the operating room . Measurements and Main Results Treatment groups were well matched with respect to age ( PDT , 65.44 ± 2.82 [ mean ± se ] years ; ST , 61.4 ± 2.89 years , p = Ns ) , gender ( PDT , 45 % males ; ST , 47.5 % males , p = NS ) , severity of illness ( Acute Physiology and Chronic Health Evaluation II score : PDT , 16.87 ± 0.84 ; ST , 17.88 ± 0.92 , p = NS ) , and principle diagnosis . PDT was performed more quickly ( PDT , 20.1 ± 2.0 mins ; ST , 41.7 ± 3.9 mins , p < .0001 ) and was associated with lower patient charges than ST ( total patient charges : PDT , $ 1,569 ± $ 157 vs. ST , $ 3,172 ± $ 114 ; equipment/supply charges : PDT , $ 688 ± $ 103 vs. ST , $ 1,526 ± $ 87 ; professional charges : PDT , $ 880 ± $ 54 vs. ST , $ 1,647 ± $ 50;p < .0001 for all ) . There were no differences in days intubated before tracheostomy ( PDT , 12.7 ± 1.1 days ; ST , 15.6 ± 1.9 , p = .20 ) , intensive care unit length of stay ( PDT , 24.5 ± 2.5 days ; ST , 28.5 ± 3.1 days , p = .33 ) , or hospital length of stay ( PDT 49.7 ± 4.2 days ; ST , 43.7 ± 3.5 days , p = .28 ) when we compared these two techniques . Conclusions PDT is a cost-effective alternative to ST . The reduction in patient charges  associated with PDT in this study result ed from the procedure being performed in the intensive care unit , thus eliminating the need for operating room facilities and personnel . PDT may become the procedure of choice for electively establishing tracheostomy in the appropriately selected patient who requires long-term mechanical ventilation The aim of our study was to compare the complication rate of convenional surgical and percutaneous dilational tracheostomies performed under general anaesthesia in critically ill patients . Fifty-three consecutive patients whose lungs were mechanically ventilated and who required tracheostomy were r and omised to undergo either conventional surgical tracheostomy ( n = 28 ) in the operating room or percutaneous dilational tracheostomy ( n = 25 ) in the intensive care unit under general anaesthesia . All of the procedures were successfully completed . No deaths were related to the performance of either tracheostomy technique . Three patients in each group required a dressing change for minor bleeding at the tracheostomy site . There was no major bleeding requiring blood transfusion . One patient in each group developed atelectasis detected on chest x-ray postoperatively . In the surgical tracheostomy group , there were two patients with cuff leaks , one with a stomal infection and one with a pneumothorax . None of these complications occurred after percutaneous , dilational tracheostomy . We conclude that the low incidence of complications in both groups indicates that percutaneous dilational tracheostomy can be performed as safely in the intensive care unit with general anaesthesia as surgical tracheostomy can be performed in the operating room . RésuméNous comparons l’incidence des complications causées par la trachéotomie chirurgicale traditionnelle avec celles de la trachéotomie percutanée par dilatation réalisées sous anesthésie générate chez des gr and s malades . Cinquante-trois patients consécutifs sous ventilation mécanique do nt l’état nécessitait une trachéotomie sous anesthésie générate sont répartis pour subir soit une trachéotomie chirurgicale traditionnelle ( n = 28 ) en salle d’opération , soit une trachéotomie percutanée par dilatation ( n = 25 ) a l’unité des soins intensifs . Toutes les interventions ont été complétées avec succès . Aucun décès en rapport avec une ou l’autre des méihodes n’est survenu . Dans les deux groupes , on a du changer le pansement de trois patients pour un saignement mineur du site de la trachéotomie . Il n’y a pas eu de saignement majeur nécessitant de transfusions . Dans chaque groupe , on a détecté de l’atélectasie à la radiographie postopératoire . Dans le groupe de la trachéotomie chirurgicale , deux patients ont présenté des fuites au niveau du ballonnet de la canule , un patient a présenté une infection du stoma et un autre a présenté un pneumothorax . Ces complications ne sont pas survenue avec la méthode percutanée . L’incidence faible de complications dans les deux groupes montre que la trachéotomie percutanée peut être réalisée aussi bien à l’unité des soins intensifs sous anesthésie générate que la trachéotomie chirurgicale en salle d’opération OBJECTIVES Objectives of the study were 1 ) to analyze the complication incidence and re source utilization of two methods of bedside tracheostomy and 2 ) to define selection criteria for bedside tracheostomy . STUDY DESIGN Prospect i ve r and omized trial in the setting of a tertiary care center at a university hospital . METHODS One hundred sixty-four consecutive intubated patients selected for elective tracheostomy were enrolled . One hundred patients met selection criteria for bedside tracheostomy  and were r and omly assigned to either open surgical tracheostomy ( 50 ) or endoscopically guided percutaneous dilational tracheotomy(50 ) . The remaining 64 patients received open surgical tracheostomies in the operating room . Main outcome measures were 1 ) perioperative and postoperative complication incidence and 2 ) re source utilization . RESULTS Patients meeting our selection criteria for bedside tracheostomy had a significantly reduced perioperative complication rate compared with those who failed to meet these criteria , and subsequently underwent tracheostomy placement in the operating room ( 5 % vs. 20 % , P less than or equal to.01 ) . No statistically significant difference was found in the perioperative complication incidence between the two methods of bedside tracheostomy . However , percutaneous tracheostomy placement at the bedside result ed in a significant increase in postoperative complication incidence ( 16 % vs. 2 % , P < .05 ) and incurred an additional patient charge of $ 436 per bedside procedure . CONCLUSIONS This investigation prospect ively confirms the safety of bedside tracheostomy placement in properly selected patients .  Complication incidence and re source utilization are defined for two methods of bedside tracheostomy . The results of this study confirm that open surgical tracheostomy represents the st and ard of care in bedside tracheostomy placement by providing a more secure airway at a markedly reduced patient charge . These findings will aid in the development of protocol s and pathways for surgical airway management in critically ill patients to maximize cost-effective , high- quality care Objective : Percutaneous dilational tracheostomy ( PDT ) is increasingly used in intensive care units ( ICU ) , and it has a low incidence of complications . The aim of this study was to compare the costs , complications , and time consumption of PDT with that of conventional surgical tracheostomy ( ST ) when both procedures were performed in the ICU . Design : The study was a prospect i ve , r and omized trial . Setting : The procedures were performed routinely in the ICU of Satakunta Central Hospital . Patients : During a 23‐month period from December 1995 to November 1997 , 30 patients underwent PDT and 26 patients had ST .  In one patient , PDT was converted to ST .  All patients were receiving ventilation in the ICU , and all tracheostomies were performed at the patient 's bedside in the ICU . The Portex percutaneous tracheostomy kit was used for all PDTs . Results : The mean time to perform PDT was 11 mins ( SD , 6 ; range , 2‐40 ) , and the mean time to perform ST was 14 mins ( SD , 6 ; range , 3‐39 ) . In the PDT group , five patients had moderate bleeding during the procedure . In three patients , the bleeding was resolved with compression ; in one patient , it was resolved with ligation of the vessel ; and in one patient , it was resolved with electrocoagulation . Bleeding did not cause any complications afterward . In the PDT group , one patient had minimal oozing from the wound edge on the first postoperative day and it was resolved spontaneously . In the ST group , there were no intraprocedural complications . One patient had bleeding from the wound on first postoperative day . The sutures were removed , and the bleeding vessel was ligated . The mean cost ( in U. S. dollars ) of PDT was $ 161 ( SD , 10.4 ; range , $ 159‐$219 ) , and the mean cost of ST was $ 357 ( SD , $ 74 ; range , $ 239‐$599 ) . The cost of PDT was significantly lower than the cost of ST ( p < .001 ) . Conclusion : We found that PDT  is a cost‐effective procedure in critically ill ICU patients . Although we performed ST at the bedside in the ICU to avoid the risks associated with moving critically ill patients to the operating room , we found PDT to be a simple and safe procedure Objective To prospect ively compare two commonly used methods for percutaneous dilational tracheostomy ( PDT ) in critically ill patients . Design Prospect i ve , r and omized , clinical trial . Setting Trauma and general intensive care units of a university tertiary teaching hospital , which is also a level 1 trauma center . Patients One hundred critically ill patients with an indication for PDT .  Interventions PDT with the Ciaglia technique using the Ciaglia PDT introducer set and the Griggs technique using a Griggs PDT kit and guidewire dilating forceps . Measurements and Main Results Surgical time , difficulties , and surgical and anesthesia complications were measured at 0–2 hrs , 24 hrs , and 7 days postprocedure . Groups were well matched , and there were no differences between the two methods in surgical time or in anesthesia complications . Major bleeding complications were 4.4 times more frequent with the Griggs PDT kit . With the Ciaglia PDT kit , both intraoperative and at 2 and 24 hrs , surgical complications were less common ( p = .023 ) and the procedure was more often completed without expert assistance ( p = .013 ) . Tracheostomy bleeding was not associated with either anticoagulant therapy or an abnormal clotting profile . Multivariate analysis identified the predictors of PDT complications as the Griggs PDT kit ( p = .027 ) and the Acute Physiology and Chronic Health Evaluation ( APACHE ) II score ( p = .041 ) . The significant predictors of time required to complete PDT were the APACHE II score ( p = .041 ) , a less experienced operator ( p = .0001 ) , and a female patient ( p = .013 ) . Conclusions Patients experiencing PDT  with the Ciaglia PDT kit had a lower surgical complication rate ( 2 % vs. 25 % ) , less operative and postoperative bleeding , and less overall technical difficulties than did patients undergoing PDT with the Griggs PDT kit . Ciaglia PDT is , therefore , the preferred technique for percutaneous tracheostomy in critically ill patients STUDY OBJECTIVES To investigate the current practice of tracheostomy in French ICUs , focusing on the frequency , timing , indications , and techniques . DESIGN A retrospective study . SETTING A question naire was sent to all ICUs included in the national registry of the Societe de Reanimation de Langue Francaise . PATIENTS All ICU patients receiving mechanical ventilation ( MV ) during the year preceding the survey ( excluding noninvasive ventilation ) were covered by the question naire . INTERVENTION None . MEASUREMENTS AND RESULTS Of the 708 ICUs invited to participate , 152 ( 21.5 % ) answered the question naire . Overall , 35,322 patients ( median , 212 patients per unit ; interquartile range [ IQR ] , 148 to 329 patients ) had received MV , including one fourth of patients for > 7 days . A median of 7.2 % of patients ( IQR , 2.9 to 11.1 % ) had undergone a tracheostomy . The most frequently reported indications for tracheostomy were prolonged MV ( 95 % , after a median of 20 days ) and failure of extubation ( 48 % ) . An indication for " early " tracheostomy  ( ie , < 3 weeks ) was considered in 68 % of the ICUs , after a median time of 7 days . Physicians thought that performing tracheostomy would facilitate weaning from MV and early oral nutrition , and would improve overall patient comfort . The main disadvantages listed were tracheal complications , the aggressiveness of the procedure , and the risk of infection . Surgical techniques largely remained preferred compared to percutaneous techniques . CONCLUSIONS There is much heterogeneity in the reported practice s of tracheostomy in French ICUs . Three fourths of physicians considered that a r and omized study comparing prolonged translaryngeal intubation and early tracheostomy in patients expected to receive prolonged MV would be necessary to clarify those issues Objective : To compare the outcomes and the short- and long-term complications of percutaneous translaryngeal tracheostomy ( TLT )  and surgical tracheostomy ( ST ) . Design : Prospect i ve , r and omized clinical trial with 1-yr double-blind follow-up . Setting : A general intensive care unit of a university hospital . Patients : A total of 139 consecutive critically ill patients who required a tracheostomy between February 2001 and June 2002 were r and omly assigned to receive either ST or TLT . Results : TLTs were performed more rapidly than STs ( 17 ± 10 mins vs. 22 ± 6 mins , p = .003 ) . Early complications were rare in both groups . Major postoperative bleeding was less frequent with TLT ( 0 [ 0 % ] vs. 6 [ 8 % ] , p = .03 ) . Only one case of bleeding ( in the ST group ) required blood transfusion . Immediately after tracheostomy , six TLT patients ( 9 % ) and six patients ( 8 % ) in the ST group ( p = .56 ) developed culture-confirmed bacteremia with microbes previously isolated from the pharynx or trachea . Group rates for stomal infections and pneumonia after tracheostomy were similar . At 1-yr follow-up , the overall survival rate was 27 % , and 14 patients ( 45 % of survivors ) still had open tracheostomies . Both groups rated their quality of life as moderately to severely compromised , and the deterioration was strictly related to the presence of tracheostomy . One TLT and two ST survivors ( p = .53 ) had clinical signs of tracheal stenosis , and bronchoscopy revealed narrowing of > 50 % . Conclusions : Compared with ST , the main advantages of TLT are that it is more rapid and associated with less postoperative bleeding . Infectious complications , particularly postoperative bacteremia , and long-term effects ( physical and emotional ) are similar with the two procedures Percutaneous tracheostomy with single-step dilation technique using Griggs ’ guidewire dilating forceps ( GWDF ) is a well-recognized procedure . Recently , Ciaglia has introduced a one-step dilation technique using a curved , gradually tapered dilator , the Ciaglia Blue Rhino ( CBR ) . In a prospect i ve , r and omized study , we performed percutaneous tracheostomy in 60 consecutive patients , using either the CBR or the GWDF technique . Postoperatively , all patients had bronchoscopy by a blinded consultant , and stoma characteristics and injuries to the trachea were studied . Mean tracheostomy time ( skin incision to insertion of tracheostomy tube ) in the two procedures ( CBR 7.5 min versus GWDF 6.5 min ) was not different ( P > 0.05 ) . The GWDF technique was associated with under-dilation and over-dilation of the tracheal stoma , each in almost one-third of patients . In the CBR group , the procedure was associated with a significant increase in peak airway pressure ( P < 0.05 ) in all patients . There were nine cases of tracheal cartilage rupture , three cases of longitudinal tracheal abrasion , and one pneumothorax . Three patients had tracheal in-drawing at the scar site with huskiness of voice at 8 wk after decannulation ; however , none had any breathing difficulty . We conclude that the techniques are equally effective in the formation of percutaneous tracheostomy . However , tracheal stoma over-dilation with GWDF and increase in peak airway pressure and rupture of tracheal rings with CBR remain major concerns OBJECTIVE To investigate a correlation between neck length and the incidence of complications after both  percutaneous and surgical tracheotomy ( ST )  and to compare the relative safety of the two procedures at our institution . STUDY DESIGN Prospect i ve , r and omized study of patients undergoing tracheotomy at a tertiary care center . METHODS Forty-three patients evaluated for tracheotomy at our institution between the years 2003 and 2004 were enrolled in the study and were r and omly assigned to receive either an  ST or a percutaneous dilatational tracheotomy ( PDT ) .  All patients underwent st and ardized measurement of the  cricosternal distance ( CSD ) in the neutral and extended positions before the procedure . Demographic and procedural variables were recorded , and the occurrence of postoperative complications was followed for 1 week . RESULTS PDT was performed in 29 patients and ST in 14 patients . The mean CSD of 2.7 cm increased to 3.7 cm after extension with a shoulder roll . PDT required less time ( mean 8 vs. 23 minutes ) and result ed in less blood loss compared with ST . A trend toward a higher incidence of complications with PDT ( 40 % ) compared with ST ( 7 % ) and in the first half of our series ( learning curve ) was noted . This , however , did not reach statistical significance . There was no correlation between the incidence of complications and neck length as determined by the CSD in either group of patients . CONCLUSIONS We failed to demonstrate a correlation between CSD and tracheotomy related complications .  Patients with short necks may be at no higher risk during either a PDT or ST . Experience , awareness of complications , and a dedicated team approach are necessary for the safe performance of PDT Objective To compare percutaneous tracheostomy with conventional operative tracheostomy . Design R and omized clinical trial . Setting The medical and surgical critical care units of a large , tertiary-care , private hospital . Patients Twenty-five male and 21 female translaryngeally intubated patients with respiratory failure , in whom tracheostomy was indicated on clinical grounds , were r and omly assigned to one of two groups . Interventions The 24 patients in group 1 underwent conventional operative tracheostomy , and the 22 patients in group 2 underwent percutaneous tracheostomy . One patient in group 2 required tracheostomy on three separate occasions during a prolonged hospital stay . Measurements and Main Results Patients were examined daily throughout their hospital stays for adverse events related to the tracheostomy . In all patients who survived until decannulation , plain tomography of the trachea was performed within 3 days of decannulation . Repeat physical and tomographic examinations were performed 6 and 12 wks later . Fifty-eight percent ( 14/24 ) of the operative tracheostomies were associated with at least one complication , compared with 25 % ( 6/24 ) of the percutaneous tracheostomies ( p < .05 , 95 % confidence interval 7 % to 59 % ) . Predecannulation problems were more frequent in group 1 patients than in group 2 ( 46 % vs. 13 % , respectively ; p < .01 , 95 % confidence interval 9 % to 57 % ) , as were later sequelae ( 88 % vs. 27 % ; p < .05 , confidence interval 26 % to 96 % ) in survivors . Group 1 patients were more likely to have multiple complications , and their complications tended to be more serious . Conclusion In this study , percutaneous tracheostomy appeared to be superior to the conventional operation Study Design . A prospect i ve , r and omized study . Objectives . To compare the incidence of perioperative and early postoperative complications of surgical tracheostomy ( ST ) vs. ultrasound-guided percutaneous dilational tracheostomy ( PDT ) in patients with anterior cervical spine fixation ( ACSF ) . Summary of Background Data . The patients with ACSF after acute spinal cord injury often require tracheostomy . Surgical tracheostomy is burdened with relatively high incidence of peristomal infections , and , recently , ultrasound-guided PDT is proposed in patients with ACSF . Methods . Sixteen adult patients who underwent tracheostomy after acute spinal cord injury and ACSF were analyzed . The patients were r and omly assigned to two groups : eight patients ( six males ; age range , 24–59 years ) who underwent ST and eight patients ( seven males ; age range , 19–47 years ) who underwent ultrasound-guided PDT with dilatational forceps technique . The incidence of peri- and early postoperative complications was followed up , as well as the stoma infections and the duration of the procedure . Results . Not one patient from either group had any major perioperative complication of tracheostomy . In each group , there was one case of prolonged bleeding , which stopped spontaneously inside 24 hours . In two patients ( 25 % ) from the ST group , purulent infection of the stoma was verified during subsequent treatment at an intensive care unit . The average time of ST was 21 ± 7 minutes ; the average time of ultrasound-guided PDT was 8 ± 6 minutes ( P < 0.05 ) . Conclusions . Our preliminary data demonstrate that ultrasound-guided PDT as regards to complications is at least equally safe as ST ; at the same time , it is much quicker method , probably with less late infections of the stoma , which could be an important advantage in patients with ACSF UNLABELLED A number of percutaneous procedures for tracheostomy have been established within the last few years , among them a new technique by Fantoni using a translaryngeal approach for cannula placement . To compare the new translaryngeal tracheostomy ( TLT ) to the common percutaneous dilatational technique ( PDT ) , we prospect ively studied 90 patients who required elective tracheostomy . Tracheostomy was performed according to either the Ciaglia or the Fantoni technique in 45 patients at bedside . The overall complication rate was 11.1 % ( n = 5 ) in PDT , including aspiration of blood ( n = 4 ) and severe bleeding requiring surgical intervention ( n = 1 ) . During TLT , there were technical difficulties involving guidewire placement in 31.1 % ( n = 14 ) , and one patient required conversion to PDT . No other complications were noted in TLT . Regardless of the technique used , the postoperative PaO2/FIO2 ratio was slightly lower than preoperatively ( P was not significant ) . When PDT and TLT were compared , the postoperative PaO2/FIO2 ratio was significantly lower in PDT than in TLT ( P < 0.05 ) , whereas the preoperative levels did not vary significantly between PDT and TLT . During TLT , the PaCO2 increased significantly , whereas it remained stable throughout PDT . No infection of the tracheostoma was noted in either the PDT or the TLT . We therefore consider both the PDT and the TLT equally safe and attractive techniques for establishing long-term airway access in critically ill patients . IMPLICATION S Elective tracheostomy is a widely accepted procedure for gaining long-term airway access . Two techniques for percutaneous tracheostomy-the established Ciaglia method and the new translaryngeal Fantoni technique-were prospect ively studied for perioperative complications and practicability in 90 critically ill- patients OBJECTIVE To compare surgical ( SgT ) and percutaneous ( PcT ) tracheostomies .  BACKGROUND  Percutaneous tracheostomy  has been said to provide numerous advantages over classical SgT. METHODS A prospect i ve r and omized trial with a double-blind evaluation was used to compare SgT and PcT. SgT and PcT were performed according to established techniques ( n = 70 ) . The procedure was performed at the bedside in the intensive care unit in 21 cases ( 30 % ) . The outcome measures were divided into procedure-related variables , perioperative complications , and postoperative complications . The procedure-related variables ( location , duration , and difficulty ) were evaluated by the surgeon . The perioperative and postoperative complications were divided into serious , intermediate , and minor . Perioperative and early postoperative ( 14 days ) complications were evaluated daily by an intensive care unit nurse blinded to the technique used . Long-term postoperative complications were evaluated 3 months after decannulation by a surgeon blinded to the surgical technique . RESULTS There were no major complications in either group . Most variables studied were not statistically different between the PcT and SgT groups . The only variables to reach statistical significance were the size of the incision ( smaller with PcT , p < 0.0001 ) , minor perioperative complications ( greater with PcT , p = 0.02 ) , and difficult cannula changes ( greater with PcT ; p < 0.05 ) . Among nonsignificant differences , difficult procedures and false passages were more frequent with PcT , whereas long-term unesthetic scars were more frequent with SgT. CONCLUSIONS Both techniques are associated with a low rate of serious or intermediate complications when performed by experienced surgeons . There were more minor perioperative complications with PcT and more minor long term complications with BACKGROUND To compare surgical tracheostomy ( ST ) versus percutaneous dilatational tracheostomy ( PDT ) in terms of complication rates . In particular we specifically studied the late tracheal complications of both methods by means of endoscopic controls of patients up to 6 months after the procedures . METHODS DESIGN prospect ive-r and omized clinical study . SETTING University-affiliated tertiary care referral hospital . PATIENTS 50 consecutive translaryngeally intubated patients with respiratory failure were r and omized to undergo either ST ( 25 patients ) or endoscopic guided PDT ( 25 patients ) . RESULTS ST was performed in 41+/-14 min versus 14+/-6 min for PDT ( p<0.0001 ) . There was no procedure-related death . In the ST group there were no intraoperative complications . In the PDT group 2 intraoperative complications ( minor hemorrhages ) were observed . In the ST group 9 early postoperative complications occurred : one minor bleeding , 7 stomal infections and one accidental decannulation . In the PDT group only one early postoperative complication ( minor bleeding ) occurred . Early postoperative complication rates were 36 % for ST and 4 % for PDT . In the ST group there were no late tracheal complications . In the PDT group 2 late tracheal complications ( one segmental malacia and one stenosis at the level of the stoma ) were observed . CONCLUSIONS This study confirms that PDT is a simpler and quicker procedure than ST and that it has a lower rate of early postoperative complications . Late tracheal complications were more frequent , although the difference was not statistically-significant , in the PDT group . Further investigations of long-term outcome following PDT are therefore necessary Objective : The timing of tracheotomy in patients requiring mechanical ventilation is unknown . The effects of early percutaneous dilational tracheotomy compared with delayed tracheotomy in critically ill medical patients needing prolonged mechanical ventilation were assessed . Design : Prospect i ve , r and omized study . Setting : Medical intensive care units . Patients : One hundred and twenty patients projected to need ventilation > 14 days . Interventions : None . Measurements and Main Results : Patients were prospect ively r and omized to either early percutaneous tracheotomy within 48 hrs or delayed tracheotomy at days 14–16 . Time in the intensive care unit and on mechanical ventilation and the cumulative frequency of pneumonia , mortality , and accidental extubation were documented . The airway was assessed for oral , labial , laryngeal , and tracheal damage . Early group showed significantly less mortality ( 31.7 % vs. 61.7 % ) , pneumonia ( 5 % vs. 25 % ) , and accidental extubations compared with the prolonged translaryngeal group ( 0 vs. 6 ) . The early tracheotomy group spent less time in the intensive care unit ( 4.8 ± 1.4 vs. 16.2 ± 3.8 days ) and on mechanical ventilation ( 7.6 ± 2.0 vs. 17.4 ± 5.3 days ) . There was also significantly more damage to mouth and larynx in the prolonged translaryngeal intubation group . Conclusions : This study demonstrates that the benefits of early tracheotomy outweigh the risks of prolonged translaryngeal intubation . It gives credence to the practice of subjecting this group of critically ill medical patients to early tracheotomy rather than delayed tracheotomy BACKGROUND As no clinical r and omised studies have previously been performed comparing complications with the Ciaglia Percutaneous Dilatational Tracheostomy Introducer Set ( PDT ) and conventional surgical tracheostomy ( TR ) , we design ed a study with the aim of comparing the efficacy and safety of the two techniques . METHODS Sixty patients selected for elective tracheostomy were r and omised for either PDT ( 30 patients ) or TR ( 30 patients ) . All patients had general anaesthesia and were ventilated with 100 % oxygen . Furthermore , lidocaine with epinephrine 1 % ( 3 - 5 ml ) was used for local analgesia and to minimise bleeding during the procedure . RESULTS The median time for insertion of the tracheostomy tube was 11.5 min ( range 7 - 24 min ) in the PDT group and 15 min ( range 5 - 47 min ) in the TR group ( P<0.01 ) . Complications during the procedure were cuff puncture of the endotracheal tube in 5 cases in the PDT group . Minor bleeding was encountered in 6 cases in the PDT group as opposed to 24 cases in the TR group ( P<0.01 ) , major bleeding in none versus 2 cases , respectively . In 8 cases in the PDT group , increased resistance to insertion of the tracheostomy tube was met by further dilatation . During the post-tracheostomy period , complications occurred with minor bleeding in 2 cases in the PDT group as opposed to 9 cases in the TR group ( P<0.05 ) , and major bleeding was encountered in 1 case in each group . Minor infections were encountered in 3 cases in the PDT group as opposed to 11 cases in the TR group ( P<0.01 ) . Major infection was encountered in none versus 8 cases , respectively ( P<0.01 ) . CONCLUSION Our results indicate that the percutaneous dilatational tracheostomy technique performed with the Ciaglia Introducer Set is effective , safe and superior to conventional surgical tracheostomy as immediate complications as well as complications with the tracheostomy tube in situ are fewer and of less severity Objective The development of practice guidelines for the conduct of intra- and interhospital transport of the critically ill patient . Data Source Expert opinion and a search of Index Medicus from January 1986 through October 2001 provided the basis for these guidelines . A task force of experts in the field of patient transport provided personal experience and expert opinion . Study Selection and Data Extraction Several prospect i ve and clinical outcome studies were found . However , much of the published data comes from retrospective review s and anecdotal reports . Experience and consensus opinion form the basis of much of these guidelines . Results of Data Synthesis Each hospital should have a formalized plan for intra- and interhospital transport that addresses a ) pretransport coordination and communication ; b ) transport personnel ; c ) transport equipment ; d ) monitoring during transport ; and e ) documentation . The transport plan should be developed by a multidisciplinary team and should be evaluated and refined regularly using a st and ard quality improvement process . Conclusion The transport of critically ill patients carries inherent risks . These guidelines promote measures to ensure safe patient transport . Although both intra- and interhospital transport must comply with regulations , we believe that patient safety is enhanced during transport by establishing an organized , efficient process supported by appropriate equipment and personnel Percutaneous tracheostomy has been touted as the preferred route of tracheostomy . However , to date , no prospect i ve r and omized study comparing bedside percutaneous ( BP ) to bedside open ( BO ) tracheostomy has been performed . Surgical intensive care unit ( sICU ) patients were r and omized to receive either a BP or a BO tracheostomy .  Patients were monitored for complications . Procedure time was documented . A group of medical ICU patients had open tracheostomies in the operating room ( OR ) and served as contemporaneous controls . Over 11 months , there were 24 surgical ICU patients r and omized to receive either BP tracheostomy or BO tracheostomy , 12 in each group . Forty-six medical ICU patients received st and ard open tracheostomy in the OR . The number of ventilator days before placing the tracheostomy was similar between the BP and BO groups , 9.8 and 12.4 , respectively . The clinical indications for tracheostomy were similar between the two groups . The procedure time for the BP group was 14.5 minutes , whereas 25.2 minutes for the BO group . There were no postprocedure complications in the BP and BO groups . There was a trend toward more complications in the BP group , including the loss of the airway , leading to death . The procedure time and complications were similar between the BO and OR groups . These data do not support that BP tracheostomy is the preferred route of tracheostomy when compared with BO tracheostomy . These data support that experienced surgical intensivists can perform BO tracheostomies with lower risk and cost , when compared with BP tracheostomy BACKGROUND Percutaneous dilatational tracheostomy has gained popularity , but its superiority to open tracheostomy is unclear . The object of this study was to compare procedure time , complication , safety and cost-effect between the percutaneous dilatational tracheostomy ( PDT ) and the conventional open tracheotomy ( OT ) . METHODS A prospect i ve r and omized clinic trial was conducted in a general Intensive Care Unit of an University-based hospital . Eighty-three consecutive patients who needed elective tracheostomies were selected for this study . PDT was performed using the Ciaglia method with OT as control group . Age , gender , operative data , complications and mortality were recorded for analysis . RESULTS The procedure time was 22.0 + /- 12.1 minutes in PDT group , and 41.5 + /- 5.9 minutes in OT group , with significant statistical difference ( p < 0.001 ) . The incidences of complications were not different between both groups . Ages , gender or days of pre-tracheostomy intubation showed no difference between two groups . CONCLUSIONS The PDT appears to be a simple , safe and time-saving bedside procedure . It can be recommended when an elective tracheostomy is needed in a critical patient
Introduction Tracheostomy is one of the more commonly performed procedures in critically ill patients yet the optimal method of performing tracheostomies in this population remains to be established .
The aim of this study was to systematic ally review and quantitatively synthesize all r and omized clinical trials ( RCTs ) , comparing elective percutaneous dilatational tracheostomy ( PDT ) and surgical tracheostomy ( ST ) in adult critically ill patients with regards to major short and long term outcomes .