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Use of Bronchoscopy in Percutaneous Dilational Tracheostomy

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Use of Bronchoscopy in Percutaneous Dilational Tracheostomy Research Original Investigation Use of Bronchoscopy in Percutaneous Dilational Tracheostomy Shekhar K. Gadkaree, BS; Diane Schwartz, MD; Kevin Gerold, DO, JD; Young Kim, MD, PhD IMPORTANCE A modified percutaneous dilational tracheostomy (PDT) is a relatively new alternative method of performing PDTs in which tissues overlying the trachea are dissected, but needle entry is still performed blindly. Many centers use bronchoscopy-assisted PDT, but the necessity of bronchoscope assistance for modified PDTs has not been examined. Discontinuing bronchoscopy for this procedure could potentially decrease cost and increase efficiency with similar outcomes compared with bronchoscopy-assisted PDT. OBJECTIVE To evaluate the necessity of bronchoscopy in placement of PDT. DESIGN, SETTING, AND PARTICIPANTS A single-center, retrospective cohort study of 149 patients who underwent PDT, with or without bronchoscope assistance, was conducted between May 1, 2007, and February 1, 2015, in a tertiary care facility. Data analysis was performed from April 15, 2015, to May 1, 2015. INTERVENTIONS Modified PDT with or without bronchoscopy. MAIN OUTCOMES AND MEASURES The primary outcomes of interest were postprocedural complications and length of stay during the hospitalization at which the tracheostomy was placed. RESULTS Of the 149 patients who underwent modified PDT during the study period and met the inclusion criteria, 107 were in the no-bronchoscope cohort (66 [61.7%] were men; mean [SD] age, 56.0 [18.7] years) and 42 were in the bronchoscope-assisted cohort (26 [61.9%] were men; mean [SD] age, 58.0 [15.7] years). Complications with PDT were significantly associated with use of a bronchoscope (odds ratio, 6.7; 95% CI, 1.3-43.4; P = .04). The rate of complications was 1.9% in the no-bronchoscope cohort and 11.9% in the bronchoscope- assisted cohort (P = .05). The mean (SD) length of hospital stay was not significantly different between the 2 groups (51.4 [49.4] days in the no-bronchoscope cohort vs 46.9 [28.6] days in the bronchoscope-assisted cohort; P = .58). CONCLUSIONS AND RELEVANCE Percutaneous dilational tracheostomy can be performed with similarly low complication rates with or without the use of bronchoscopy. Discontinuing the use of bronchoscopy in these procedures appears to be a safe, cost-effective alternative with Author Affiliations: Department of reassuring outcomes and low complication rates. Otolaryngology–Head & Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland (Gadkaree, Kim); Department of General Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland (Schwartz); Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland (Gerold). Corresponding Author: Young Kim, MD, PhD, Department of Otolaryngology–Head & Neck Surgery, School of Medicine, Johns Hopkins University, 1650 Orleans St, CRB1 (Cancer Research Bldg), Room JAMA Otolaryngol Head Neck Surg. 2016;142(2):143-149. doi:10.1001/jamaoto.2015.3123 4M61, Baltimore, MD 21287 (ykim76 Published online December 30, 2015. @jhmi.edu). (Reprinted) 143 Copyright 2016 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 Research Original Investigation Bronchoscopy in Percutaneous Dilational Tracheostomy ercutaneous dilational tracheostomy (PDT) is a com- morbidities were classified by the Charlson Comorbidity In- mon, minimally invasive procedure to facilitate trache- dex, which scores the presence or absence of 22 medical co- P ostomy placement at the bedside or in the operative the- morbidities to create an overall score reflective of 10-year ater. This technique represents an alternative to traditional predicted mortality.13 The reason for tracheostomy place- open tracheostomy and functions through a controlled, se- ment was categorized by evaluating both the initial admis- rial dilation mechanism. The PDT method differs from tradi- sion notes and the hospital course immediately before trache- tional surgical tracheostomy by using serial dilation to create ostomy placement. Operative notes were used to evaluate an opening in the neck and trachea.1 The modified method of incision size, endotracheal tube (ETT) depth at procedure ini- PDT combines aspects of both of these techniques and in- tiation, procedure location, and complications related to the volves dissecting from the skin to the pretracheal fascia, vi- procedure. sualization of the trachea, and needle entry into the trachea The primary outcomes of interest were postprocedural that is visualized using bronchoscopy.2,3 The PDT method has complications and length of stay during the hospitalization in been recognized as a fast, safe, and effective procedure to ob- which the tracheostomy was placed. Complications were tain an airway for individuals who require chronic ventilator determined from reviewing the clinical course of each pa- support, with the option to rapidly convert to open tracheos- tient, including postdischarge medical record information. tomy should the need arise.2-6 Bleeding was defined as excessive blood loss requiring in- Initial PDT placement instituted the use of a broncho- tervention, prolonged bleeding, or unexpected bleeding as de- scope for direct visualization of the trachea during the dila- termined by the surgeon performing the procedure.14 Dyspha- tion. Bronchoscopy enables visualization and confirmation of gia and stenosis were documented in follow-up visits after the needle entry into the trachea, obviates blind insertion, and has initial hospitalization by a health care professional. Length of traditionally been considered safer than nonbronchoscope- stay was recorded at the time of discharge, and any previous assisted PDT.7 Although it has been suggested that broncho- hospitalizations or future stays in rehabilitation facilities were scopic visualization decreases the long-term complications not included. of tracheostomy, these studies are limited, and it is unclear Patients were classified as being part of the no bronchoscope whether visualization of the interior of the airway is a neces- or bronchoscope-assisted cohort. The no-bronchoscope cohort sary component of the procedure, particularly when the did not have a bronchoscope involved in the procedure before trachea is directly punctured.8-10 Low complication rates dem- needle entry. The bronchoscope-assisted cohort had direct onstrated in other studies, with and without use of a broncho- visualization of needle entry into the trachea through the scope, suggest that visualization is not required for tracheos- bronchoscope. Surgeon preference was the sole determinant tomy placement.11,12 The purpose of this study was to examine of whether the bronchoscope was used. The general surgery modified PDTs performed with and without bronchoscopy and group had a directed change in practice during the study to compare complication profiles for determination of bron- period. All PDTs before January 1, 2014, were performed choscopic necessity. Discontinuing bronchoscopy use during definitively with the use of the bronchoscope, and all PDTs tracheostomy placement may provide a viable method by from 2014 onward were performed without the use of the which to achieve similar patient outcomes, decrease proce- bronchoscope. dural costs, and increase overall efficiency. Procedure General surgeons, otolaryngologists, and critical care anes- Methods thesiologists performed all PDTs during the study period. The PDTs were performed using the same type of dilator (Cook Blue Patient Selection Rhino single dilator kit; Cook Medical), with either a size 6 or Institutional review board approval for the study and waiver 8 cuffed tracheostomy cannula (Shiley). The choice of the size of informed consent were obtained from Johns Hopkins School of the original tracheostomy used was based on the patient’s of Medicine prior to beginning this study. Clinical, operative, ventilator weaning history, current ETT depth, and surgeon and hospital course records from May 1, 2007, to February 1, preference. A modified method of PDT was used for obtain- 2015, were retrospectively reviewed, and patients who under- ing access to the airway in cases in which the trachea was di- went PDT with selected surgeons at a single tertiary care rectly punctured.2,3 Patients were placed supine, with neck ex- institution during the study period were included in this study. tension only if cervical spine injury was not apparent. A Patients were excluded if their medical records were missing transverse or vertical incision was carried down through the data fields for any of the outcomes of interest. Surgeons per- midline to the level of the pretracheal fascia. The thyroid isth- forming the procedure were credentialed in the departments mus was either retracted from the field if possible or divided of surgery, otolaryngology, and anesthesia. using electrocautery. The tracheal tube was withdrawn using direct palpation on the trachea or with bronchoscopic visual- Recorded Variables ization, depending on the method selected by the surgeon, to Information was collected on patient demographics, comor- the level above the operative site, and a needle was inserted bidities, reason for tracheostomy placement, duration of in- into the trachea between the second and third tracheal rings. tubation, time to last follow-up, and whether the procedure After needle insertion, a guidewire was introduced into the tra- was performed at the bedside or in
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