Tracheostomy is the most frequently performed surgical procedure in the intensive care unit (ICU) and has undergone a substantial change in the last few years. Percutaneous dilatational tracheostomy (PDT) has gained widespread acceptance in the ICU setting since its reintroduction in 1985,1 and several different PDT techniques have been developed over the last decade.2–5
Whether to use PDT or surgical tracheostomy (ST) is still a matter of debate. Recent literature suggests that PDT offers several potential advantages, and many specialists in intensive care view it as the method of choice for critically ill patients who require tracheostomy.6 However, the use of PDT in European ICUs is very heterogeneous. In a survey from France,7 ST techniques were largely preferred to PDT. Additionally, the ideal timing of tracheostomy and the appropriate technique in patients requiring prolonged mechanical ventilation (MV) are still a subject of debate. Surveys conducted in various European countries7–12 showed major differences in the frequency and the timing of tracheostomy and in the use of PDT techniques. The purpose of this nationwide survey was to collect information about the current practice of tracheostomy management in ICUs in Germany, in particular with regard to frequency, timing, and the choice of method.
We developed a questionnaire consisting of 15 items (Appendix). To ensure clarity, realism, and validity of the survey instrument, two physician experts with advanced training in survey methodology individually reviewed the questionnaire, which was then tested in the ICU of one of the investigators.
The questions were aimed at obtaining information regarding the hospital's and the ICU's demographics, the frequency and the timing of tracheostomy, the techniques applied, the use of endoscopic guidance, the operators and the location, the presence of guidelines, and the follow-up protocols. The physicians were further asked to give their opinion as to whether ST or PDT is the method of choice for patients requiring long-term ventilation, and which of these techniques is safer.
The survey was sent by mail to the head physicians of 513 ICUs in Germany in October 2006, excluding pediatric ICUs. The addresses of the hospitals were obtained from the German Hospital Register (Deutsches Krankenhaus Adressbuch. Freiburg: Rombach, 2006). The questionnaire was sent a second time to the ICUs that did not respond to the first mailing. Nonresponders to both mailings were then requested by phone to complete the survey by returning the filled-in questionnaire. Questionnaires were excluded from the analysis if more than three of the questions were not answered.
All the data were analyzed with Statistica (Version 6.0, StatSoft, Inc., Tulsa, OK). The data are presented as mean ± sd for the data that were normally distributed or as median (range) for data that were outside the normal distribution. For statistical comparisons between the groups, Fisher's exact test was used. A cut-off level of P < 0.05 was considered as statistically significant.
Response Rate and Type of the Participating ICUs
Four hundred fifty-five of 513 (88.7%) questionnaires were returned. Eight questionnaires were excluded from the analysis: six because the ICUs declared that they did not perform tracheostomies and two because of incomplete data. Not all questions were completely answered by all responders, so the number of replies varies by question.
Teaching hospitals (university- and community hospital-affiliated) accounted for 81% of the responding ICUs (362 of 447 ICUs). Of those, 194 ICUs (43.4%) were affiliated with university hospitals. Of the 447 ICUs, 99 had 1–8 beds, 162 had 9–12 beds, 90 had 13–16 beds, and 96 had more than 16 beds. Approximately one-half of the ICUs (45.2%) were managed by anesthesiologists, 25.3% were managed by medical departments, and 14.1% were multidisciplinary ICUs. The remainder (all <5%) were managed by departments of neurology, surgery, neurosurgery, cardiac surgery, or ear/nose/throat. The nonresponding units had a comparable pattern of ICU and hospital beds.
Frequency and Timing of Tracheostomy
The number of tracheostomies performed per year per unit varied widely, with 29.5% of the ICUs performing between 11 and 25 procedures per year and 15% (all teaching hospitals) performing more than 75 per year. Most tracheostomies were performed during the second week of MV (68.2%); an earlier tracheostomy (<7 d of MV) was performed by 21.7% of the respondents.
Techniques of Tracheostomy
Three hundred eighty-five (86.1%) ICUs routinely performed PDT, whereas 62 (13.9%) performed only ST. The use of PDT did not differ significantly among the community teaching hospitals, the university teaching hospitals, and the nonteaching hospitals (Fig. 1).
The distribution of the different percutaneous techniques is shown in Table 1. The modified Ciaglia technique was the most widely used percutaneous technique (69.4%), followed by the Griggs guidewire forceps technique (19.9%). Eighty-two (20.9%) units routinely used two different methods of PDT, and 17 (4.3%) units used three or more methods. Nearly all the ICUs (n = 389, 97.7%) routinely used bronchoscopic guidance during PDT. Of the remaining 9 ICUs, 4 (1%) would opt for bronchoscopy in the presence of a difficult airway.
Location and Operators
Of the participating ICUs, 71.5% performed STs in the operating room, whereas the majority (98.5%) of the percutaneous procedures were performed in the ICU. ST was performed by surgeons in 61.4%, by otorhinolaryngologists in 50.8%, and by intensivists in 3.5% (multiple answers possible). In contrast, PDT was mainly performed by intensivists (93.3%).
Follow-up and Guidelines
One hundred fifteen (25.9%) ICUs reported that the patients were followed up routinely, with a further 88 (19.8%) reporting that the patients were sometimes followed up. About half (54.3%) of the responding ICUs performed no long-term follow-up. University hospitals used follow-up examinations significantly more often than other hospitals (P < 0.01).
Guidelines regarding the indication, the timing and the technique of tracheostomy were available in 201 (45.3%) ICUs. University hospitals used guidelines more often than other hospitals. The difference was statistically significant (P < 0.01) (Fig. 1).
Opinions of the Responding Head Physicians
In 328 (73.4%) ICUs, PDT was considered the first choice for tracheostomy performance in long-term ventilated patients (Table 2). Of 62 ICUs using only ST, 56.5% considered this to be the method of choice (12.9% considered both methods to be the method of choice, 14.5% had no opinion). In contrast, almost all (98%) of the 200 ICUs using only PDT considered this to be the method of choice.
One hundred nineteen (26.6%) respondents considered PDT safer than ST; however, one-half of the respondents (n = 223, 49.9%) considered the methods to be equally safe.
Our survey showed that in more than four of five German ICUs, PDT is a well-established technique. Furthermore, 73% of the physicians returning our survey believed that the percutaneous technique is the method of choice for critically ill patients who require tracheostomy.
Several studies have shown a clear trend towards the increasing use of PDT in European ICUs.11,12 In the current study, 86% of the responding units in Germany reported performing the procedure routinely. This is a substantial increase from the 44% reported in a tracheostomy survey in 199913 and 51% in a survey in 2001.14 In contrast, a more recent survey from France in 20057 reported that 82% of physicians rarely or never used PDT. However, as the authors pointed out, the 21.5% survey response rate raises concerns about whether the results are generalizable. Unfortunately, the French ICU physicians were not queried about the reasons for their reluctance to use percutaneous techniques. The authors assumed that organizational aspects and lack of adequate training in the use of these techniques could, in part, explain this finding. In an even more recent French multicenter study, surgical techniques also predominated.15
As in other European countries,11 the modified Ciaglia technique has become the most popular technique for percutaneous tracheostomy in Germany (Table 3), outpacing the use of the classic Ciaglia technique, which has decreased from nearly 60% in 1999 and 200113,14 to just 13% (Table 1). There are no studies addressing this question for North America. The modified Ciaglia technique is a modification of the classic Ciaglia technique in which the series of dilators has been replaced with a single, sharply tapered dilator, permitting complete dilation in one step. This technique appears to be popular because it is technically simple, easy to teach and learn, and takes less operative time than the classic Ciaglia technique.16 However, the current evidence shows no clear advantage among different percutaneous techniques with regard to complications.
Fantoni's translaryngeal method is favored by some centers, especially in patients considered to be at risk of bleeding. However, in our survey, only 13% of units used this method. The most likely reason, in our opinion, is the complexity of the procedure; furthermore, there is evidence that other methods can be safe to use in thrombocytopenic patients, too.17
The optimal timing of tracheostomy is still a subject of debate. However, since the introduction and widespread acceptance of percutaneous techniques in the ICU setting, the timing of tracheostomy has changed over the last few years, with the procedure being undertaken significantly earlier during the intensive care stay. Ninety percent of the responding German physicians in our survey perform tracheostomies within the first 14 d of MV; this is earlier than in the 1999 survey.14
Nearly all the German ICUs (98%) in our study used the bronchoscope continuously during the PDT. This number is comparable to a survey from the United Kingdom (83%), but much higher than reported in surveys from the Netherlands (36%) and Spain (16%).9,11,12 Many authors advocate the use of bronchoscopy to visualize correct placement of the needle, guidewire, dilator and tracheostomy cannula. Furthermore, it can prevent iatrogenic damage to the posterior tracheal wall. Disadvantages of bronchoscopy include compromised ventilation, carbon dioxide retention, increased cost, and time.
The majority of percutaneous procedures were, unlike ST, performed in the ICU. This is one of the advantages of the PDT technique, as the transport of critically ill patients is often logistically difficult and increases the likelihood of adverse events and risk to safety.
In our survey, only 26% of respondents reported that the tracheostomized patients were followed up routinely. Similarly, surveys published in the last 5 yr also report relatively low rates of follow-up, ranging from 7% in the Netherlands12 to 34% in the United Kingdom.11 Overall, intensivists working in university-affiliated hospitals are more likely to follow up tracheostomized patients (Fig. 1).
It has been shown that local guidelines can reduce the rate of complications from PDT.18 Although nearly half of the units queried had guidelines for tracheostomy, nonteaching hospitals were less likely to have guidelines.
One limitation of this survey is that, like others, it relies on self-reporting by physicians. However, in Germany, inpatient hospital procedure coding is done using the operation and procedure system, a very refined classification of diagnostic and therapeutic procedures comprising about 24,000 codes. Data on the frequency and timing of tracheostomy (questions 5 and 9) were provided by the head physicians of each ICU. We assume that all head physicians had access to the individual database of their hospital administration, and that therefore the numbers are likely to be accurate. Other tracheostomy surveys have used similar designs, methods and questions, which allows direct comparisons between them.
Despite this possible limitation, we think that we successfully achieved a wide cross-sectional sampling of intensivists, thus enhancing the validity of the survey results. This is supported by the high response rate of our survey (89%). We used several methods to maximize questionnaire response rates, including a stamped return envelope, follow-up with a second mailing of the survey, and a subsequent phone call.
In conclusion, the technique of PDT is well established in German ICUs and is the first choice for tracheostomy performed in long-term ventilated patients. Among the various techniques of PDT, the modified Ciaglia technique is the preferred approach, and nearly all physicians routinely use bronchoscopic guidance to do it. Currently, most tracheostomies are performed during the first 2 wk of ventilation, and follow-up of tracheostomized patients is not usually performed.
The authors thank all the physicians who took time to complete the questionnaire.
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