Percutaneous versus Open Tracheostomy: Comparison of Procedures and Surgical Site Infections

Abstract

Background:

Tracheostomy is one of the most common procedures performed in trauma patients in the intensive care unit (ICU). Few studies have evaluated the incidence of surgical site infections (SSIs) specifically in a trauma population. Our objective was to compare the incidence of SSI after open versus percutaneous tracheostomy and to discern whether there were any differences in outcome.

Methods:

A prospective single-institution study was conducted on 640 patients admitted to the ICU over eight years who underwent tracheostomy. Age, gender, race, admission Injury Severity Score (ISS) and Acute Physiology and Chronic Health Evaluation (APACHE) II score, and mechanism of injury were obtained. The majority of patients were male (56.1%) and white (62.5%) with a mean age of 43.2±20.2 years, ISS of 30.7±13.2 points, and APACHE score of 13.3±6.3 points. The majority of patients were admitted for blunt trauma (85.1%). The outcome was measured by hospital (HLOS) and ICU (ILOS) lengths of stay, duration of mechanical ventilation, infection rate, and mortality rate.

Results:

A total of 330 open and 310 percutaneous tracheostomies were performed. A total of 36 SSIs (5.3%) were found. Patients who underwent percutaneous tracheostomy had a statistically significantly lower rate of SSI (3.4%) than the open surgery group (7%) (p=0.04). There was no difference in HLOS, ILOS, ventilator days, or mortality rate.

Conclusion:

To our knowledge, this is the largest study of the benefit of percutaneous tracheostomy in a critically injured trauma population. The risk of SSI is significantly lower after percutaneous than open tracheostomy.

Tracheostomy is one of the most common procedures performed in trauma patients who are in the intensive care unit (ICU). Traditionally, open tracheostomy was used in all patients. Recently, percutaneous tracheostomy has been used more widely. The advantages of open tracheostomy include better visibility of the anatomy because of the larger incision and greater ability to control hemorrhage. Patients generally have an open tracheostomy performed in the operating room. The benefits of a percutaneous procedure are better views of the inside of the trachea with bronchoscopy, minimal surgical scarring, and the potential to perform the procedure at the bedside. However, percutaneous tracheostomy by its nature is a relatively blind procedure, and complications may be more common.

Surgical site infection (SSI) is a potential complication of either open or percutaneous tracheostomy. Many studies, including several meta-analyses, have been performed to evaluate the relative potential benefits of percutaneous tracheostomy, especially in terms of SSI [1 –6]. Randomized controlled trials have been done in a mixed medical-surgical ICU, which showed no differences in infection rates for the two techniques [7,8]. Other studies have shown a lower rate of SSI using percutaneous tracheostomy, but these studies lack power. Finally, few studies have examined this problem specifically in trauma patients. Our objective was to compare open and percutaneous tracheostomy to determine if there were differences in SSI with the two techniques.

Patients and Methods

Prospective data were collected on all 640 patients admitted to the ICU over an eight-year period (2001–2008) who underwent tracheostomy. Patients received either an open tracheostomy in the operating room (n=330) or a percutaneous tracheostomy either in the operating room or in the ICU (n=310) at the discretion of the surgical attending physician. All percutaneous tracheostomies were done under bronchoscopic guidance by either a trauma surgeon or a surgical critical care attending physician. Antibiotics were not administered routinely prior to the procedure. All procedures, both open and percutaneous, were performed under standard sterile technique using skin preparation (type not specified) and a sterile drape.

Age, gender, race, admission Injury Severity Score (ISS) and Acute Physiology and Chronic Health Evaluation (APACHE) II score, and mechanism of injury were obtained for each patient. The majority of patients were male (56.1%) and white (62.5%) with a mean age of 43.2±20.2 years. The mean ISS was 30.7±13.2 points, and the mean APACHE score was 13.3±6.3 points. The majority of patients were admitted after blunt trauma (85.1%).

An infectious disease specialist followed each patient daily. The diagnosis of SSI was established in a multidisciplinary fashion using clinical indicators, leukocytosis (white blood cell count >11,000/mm³), fever (>101.4^oF), positive site cultures, and the presence of erythema, cellulitis, abscess, or necrosis at the surgical site over a period of two weeks. Patients were required to meet all these criteria in order to establish the diagnosis of SSI.

Outcome was measured by hospital (HLOS) and intensive care unit (ILOS) lengths of stay, duration of mechanical ventilation, infection rate, and mortality rate. Pearson χ² and Fisher exact tests were used as appropriate to compare categorical variables in the two groups. Student t-tests were used to compare contiguous variables between groups. A p value <0.05 was considered significant.

Results

A total of 36 SSIs (5.3%) were found within two weeks of tracheostomy creation. Twenty-five infections were diagnosed in the open tracheostomy group (7.0%), whereas the percutaneous tracheostomy group had 11 infections (3.4%) (Table 1). This was a statistically significant difference with an odds ratio (OR) of 0.47 (p=0.041). We found no significant difference in HLOS, ILOS, ventilator days, or mortality rate in the open versus percutaneous tracheostomy groups (Table 2). Five patients (three with open tracheostomies, two with percutaneous tracheostomies) required a return to the operating room for incision and drainage of abscess, debridement of necrotic tissue, or revision of the tracheostomy.

Table 1.

Admission Demographics ^a

	Percutaneous (n=310)	Open (n=330)
Age (years)^b	43.5±21.1	42.8±19.5
Male/female (%)	39.2/50.9	60.8/49.1
White/black (%)	43.5/42.3	56.5/57.7
Injury Severity Score^b	31.5±13.6	30.2±13.0
Acute Physiology and Chronic Health Evaluation-II score^b	14.0±6.0	13.0±6.5
Blunt/penetrating trauma (%)	45.6/54.5	54.5/64.7

None of the differences is statistically significant.

Mean±standard deviation.

Table 2.

Statistical Analysis of Outcomes of Percutaneous versus Open Tracheostomy ^a

	Percutaneous (N=310)	Open (N=330)	OR (95% CI)	p value
HLOS (days)	28.1±17.8	27.2±16.0		NS
ILOS (days)	23.4±28.9	20.2±12.6		NS
Ventilator days	21.8±14.5	20.7±13.8		NS
Infection	11 (3.4%)	25 (7.0%)	0.47 (0.23–0.97)	0.041
Mortality rate	23 (8.2%)	27 (7.6%)	1.08 (0.60–1.92)	0.795

Data presented as mean±SD.

CI=confidence interval; HLOS=hospital length of stay; ILOS=intensive care unit length of stay; NS=not significant; OR=odds ratio.

Discussion

The presence of SSI is an extremely important outcome measure. Many studies, including several large meta-analyses, have been done to evaluate the benefits of the percutaneous procedure in terms of infection rates. Friedman et al. conducted a randomized study of 53 patients in a mixed medical-surgical ICU who received either open or percutaneous tracheostomy with similar rates of infection in the two groups [1]. The randomized study of 164 patients by Massick et al. and the randomized study of 70 patients by Gysin et al. comparing percutaneous and open tracheostomy in a mixed medical-surgical ICU showed no incidents of SSI in either group [7,8].

Other studies have shown a lower rate of SSI with percutaneous tracheostomy, but these studies lack power [2 –6]. Al-Ansari and Hijazi's review comparing 260 open and 272 percutaneous tracheostomies showed infections of 19 in the open group, whereas the percutaneous group had only 10 infections (OR, 0.02) [9]. Most studies, like those of Silvester et al. and Freeman et al., included a small number of trauma patients in a mixed medical-surgical ICU population [3,5]. Few studies to our knowledge have evaluated the incidence of SSIs specifically in a trauma population. One of these few was that of Ivatury et al., which examined 61 critically ill patients, the majority (89%) trauma patients, who received percutaneous tracheostomies and demonstrated a low rate of complications [10].

There often is a perception of better efficacy with minimal-access interventions, as with the percutaneous tracheostomy [7]. The benefits of the percutaneous procedure include bronchoscopic viewing, decreased surgical site exposure, a smaller incision, and shorter procedural times [7,11,12]. Al-Ansari and Hijazi's review of percutaneous tracheostomies demonstrated that complications are, including bleeding, infection, and hypoxia. In addition, infrequent because it is a bedside procedure, percutaneous tracheostomy avoids the inconvenience of operating room scheduling and waiting lists [9]. Kearney et al. had a mortality rate of 0.6% with a peri-operative complication rate of 6% in a study of 827 percutaneous tracheostomies, with most complications involving premature extubation [13]. However, in the studies by Friedman et al., Nun et al., and Liao et al., patients who had extenuating variables, such as clinical instability, high peak airway pressures (>15 cm H₂O), or anatomic distortion of the tracheal region, whether caused by trauma or by body habitus, were excluded [1,14,15]. These factors may have played a role in determining which of our patients received an open versus a percutaneous tracheostomy; however, these issues will have to be examined in more detail in future studies. We did note that there was a propensity for a higher rate of infection in obese patients, but this difference was not statistically significant and will have to be studied further.

On the other hand, open tracheostomy allows greater procedural variation in creation of the incision, tracheostomy site construction, and management of the skin incision [1]. However, the surgical technique may give rise to more skin irritation and exudation of secretions at the stoma site during the early post-operative period, predisposing to infection, whereas the stoma site created with the percutaneous procedure tends to be drier and less irritated [5].

We saw no differences in HLOS, ILOS, ventilator days, or mortality rate when open tracheostomy was compared with percutaneous tracheostomy. The percutaneous procedure did have a significantly lower infection rate. Assessment of variables such as ventilator days, use of vasoactive medications at the time of procedure, and degree of ventilator support should be evaluated in greater detail. Because the selection of an open versus percutaneous procedure was at the discretion of the surgeon, there is an element of selection bias in the population; however, the populations were well matched statistically. The observational design of our study is a limitation; ideally, we should attempt a randomized controlled study to examine the correlation between the type of tracheostomy and the infection rate.

To our knowledge, this is the largest study to evaluate the benefit of percutaneous versus open tracheostomy in a critically injured trauma population. In addition, there is the benefit of a significant decrease in total cost, equipment charges, transportation cost, and operating room charges with the percutaneous procedure. In the analysis by Freeman et al., percutaneous tracheostomy typically cost around $1,569±157 versus $3,172±114 for surgical tracheostomy [16]. In view of the benefits of lower cost and decreased SSI, percutaneous tracheostomy should be considered the standard of care in critically ill trauma patients.

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