Percutaneous tracheostomy

The mortality risk associated with surgical tracheostomy has declined from 3–4% quoted in studies before 1985 to < 1%. The total complication rate has also declined over the same period from up to 90% to < 40%. The complication rate is doubled in ICU versus non-ICU patients and in tracheostomies performed in emergency situations. This is mainly due to an 8-fold increase in the intra-operative (as opposed to postoperative) complication rate, which itself is dependent on the surgical speciality performing the procedure. Most studies comparing percutaneous and surgical tracheostomies have shown that the operative time is halved with the percutaneous technique. The recent trend towards a single dilator technique may reduce the operative time further. Percutaneous tracheostomies are associated with less intraand early postoperative complications including fewer stoma infections and reduced bleeding problems due to the tamponade effect of the tightly fitting tracheostomy tube. Long-term complications of tracheostomies are more difficult to assess. Cosmetic results are improved in the percutaneous group and it appears that clinically significant long-term sequelae are no more frequent than with surgical tracheostomies. However, further studies are awaited. An important advantage of the percutaneous procedure is that it is usually performed in the ICU, eliminating the risk of transferring ventilated patients to and from the operating department. However, percutaneous tracheostomy does have some disadvantages compared with the open procedure. It was first described as a ‘blind’ technique with the risk of malpositioning the tracheostomy tube but bronchoscopic guidance has been shown to reduce this complication and is strongly advised. Although less likely to become dislodged than a surgical tracheostomy, the re-insertion of a dislodged percutaneously fashioned tube can be more difficult as the stoma may close immediately. Trainees should be encouraged to intubate these patients orally in the emergency situation. Percutaneous tracheostomy