The current practice of tracheostomy in the United Kingdom: a postal survey
Summary
A postal questionnaire was sent to 228 intensive care units throughout the United Kingdom to determine aspects of current tracheostomy practice. From the number of units responding (n = 178, 78%), the majority (n = 173, 97%) practised percutaneous tracheostomy as opposed to open surgical tracheostomy. The Blue Rhino single dilator was the most popular technique (n = 114, 64%). Percutaneous tracheostomy is increasingly carried out under bronchoscopic guidance (n = 148, 83%); however, there remains considerable variation in the timing of tracheostomy and only 61 units (34%) have set follow-up procedures.
Tracheostomy is electively performed in critically ill patients requiring prolonged respiratory support, weaning and frequent broncho-pulmonary toilet. Since the introduction of percutaneous tracheostomy in 1985 by Ciaglia et al. [1], it has found widespread acceptance and now supersedes surgical tracheotomy for all but the most difficult or complicated cases. Several meta-analyses conclude that percutaneous tracheostomy is a simpler, quicker and a safer procedure with a lower complication rate than the surgical approach [2–4]. Regardless of the technique employed, tracheostomy is better tolerated than oral or nasal tracheal intubation and is thought to reduce sedation requirements and duration of mechanical ventilation. Evidence also suggests that the incidence of nosocomial pneumonia may be lower following tracheostomy [5].
Over the last decade many methods of percutaneous tracheostomy have been introduced into clinical practice and have undergone modification, leading to a number of commercially available kits. These include Blue Rhino (Cook Critical Care, Bjaeverskov, Denmark), Ultraperc (Portex, Smiths Industries Medical Systems, Hythe, Kent, UK), translaryngeal technique (Mallinckrodt Medical, Mirandola, Italy) and Percutwist (Willy Rusch GmbH, Kernen, Germany). With the increasing popularity of percutaneous tracheostomy we wished to ascertain current practice of tracheostomy in critically ill patients and compare this with previous reports.
Methods
We compiled a simple questionnaire asking about various aspects of tracheostomy practice in the intensive care unit (ICU). Names and addresses of eligible general ICUs were obtained from ‘The Directory of Critical Care 2003’ (CMA Medical Data, Loughborough, UK). Questionnaires were sent to the lead clinicians of 228 UK general ICUs with a covering letter explaining our aims and a stamped addressed envelope for return postage. Specialist units such as paediatric, neurosurgical and cardiac ICUs were excluded. The completed data were entered and analysed using the Statistical Package for Social Sciences (SPSS 11 for Windows, SPSS Inc., Chicago, IL).
Results
From the 228 units, 178 (78%) questionnaires were returned. Half of these units carried out 11–50 tracheostomies per annum, a quarter performed 51–100 per annum and the final quarter more than 100 per annum. The latter were all teaching hospitals. One hundred and seventy-three (97%) units primarily performed percutaneous tracheostomy and, rarely, open surgical tracheostomy. Five (3%) units performed only surgical tracheostomies. Tracheostomy was mainly carried out in the ICU by the intensivists (n = 160, 90%) with the remainder being performed by the Ear, Nose & Throat (ENT) surgeons either on the ICU or in the operating theatre.
Trial extubation
One hundred and eight units (61%) did not routinely allow any trial extubation. Only 53 units (29%) allowed one trial extubation before deciding to perform a tracheostomy and another 17 units (10%) allowed at least two trial extubations.
Timing of tracheostomy
Half of the units reported performing tracheostomy within the first week of ICU admission with the remainder waiting until the second week or later. Early tracheostomy, defined as tracheostomy within a week, was preferred by 103 units (58%) for neuromuscular problems, by 69 units (39%) for head injury patients, by 45 units (25%) for trauma patients and by 40 units (23%) for patients with adult respiratory distress syndrome. Only 26 units (14%) considered early tracheostomy for burns patients.
Tracheostomy technique
The Blue Rhino single dilation technique is currently used in 114 (64%) units. The classical Ciaglia method remains the method of choice in only 25 (14%) units. Other techniques including the guide wire dilating forceps method, the Ultraperc and the Percutwist are performed in 14 (8%), 16 (9%) and 9 (5%) units, respectively (Fig. 1). Fantoni translaryngeal tracheostomy is no longer practised in any of the units.
The percentages of the responding units performing various techniques of percutaneous tracheostomy.
Conventional surgical tracheostomy was opted for by 76% of clinicians in ICU patients who had a failed percutaneous tracheostomy procedure. Two-thirds of the clinicians indicated this as the preferred option for morbidly obese patients and half favoured its use in difficult airway situations. During percutaneous tracheostomy, 169 (95%) units maintain the patient's airway by withdrawing the existing tracheal tube; the remainder (n = 9, 5%) change to a standard laryngeal mask airway.
Bronchoscopy
More than three-quarters (n = 148, 83%) of units routinely use bronchoscopy throughout the procedure to ensure correct tracheal placement of needle, guide wire, dilator and the final insertion of the tracheostomy tube. The remaining units use air aspiration through a saline-filled syringe alone for confirmation. Of the 30 (17%) units not routinely using bronchoscopy, half would opt for bronchoscopy in the presence of a difficult airway and the other half would never use bronchoscopy at all.
Tracheostomy tubes
Half the units use a size 9-mm internal diameter tracheostomy tube for male patients and the remainder an 8-mm tube. An 8-mm internal diameter tracheostomy tube is used by 70% of units for female patients; the remaining units used a size 7-mm instead. Half of the units use the Portex tracheostomy tube (Portex, Smiths Industries Medical Ltd.). Twenty percent of units use Portex blue line tubes, 11% Shiley tubes (Mallinckrodt Inc., St. Louis, MO) (Table 1). Only 34 (19%) of the responding units would consider an adjustable flange tube.
| Manufacturer | Tracheostomy tube | No. of ICUs (n = 178) |
|---|---|---|
| Portex | DIC tracheostomy tube | 91 (51%) |
| Portex | Blueline | 36 (20%) |
| Shiley | Low pressure cuffed tracheostomy tube | 20 (11%) |
| Tracoe | Tracoe twist tracheostomy tube | 12 (7%) |
| Rusch | Crystal Clear tracheostomy tube | 7 (4%) |
| Mallinckrodt | Single cannula cuffed tracheostomy tube | 7 (4%) |
| Others | 5 (3%) |
Complications
Seventy percent of clinicians (n = 124) reported bleeding as the most common complication. Other complications were surgical emphysema (20%), false passage (8%) and pneumothorax (2%) (Table 2). Units were divided almost equally as to whether or not they routinely changed the tracheostomy tube. Thirty-one percent of units changed the tracheostomy tube routinely after 7 days and 20% of units only after it had been in for more than 14 days. Forty-nine percent of responding units did not routinely change the tracheostomy tube unless there was evidence of blockage.
| Complications | ICUs (n = 178) |
|---|---|
| Bleeding; n (%) | 125 (70) |
| Surgical emphysema; n (%) | 35 (20) |
| False passage; n (%) | 14 (8) |
| Pneumothorax; n (%) | 4 (2) |
Clinical benefits
Clinicians believed that tracheostomy reduced sedation requirements. Two-thirds of them felt that tracheostomy reduced the duration of mechanical ventilation. Three-quarters of the ICU clinicians also believed that tracheostomy reduced the ICU length of stay. Only a quarter of them accepted that tracheostomy might reduce the incidence of nosocomial infection.
Decannulation and follow-up
Decannulation of tracheostomy was undertaken by the ICU clinicians and the outreach nurses in three-quarters of the units; in the remainder, decannulation was done by other physicians and physiotherapists. Only a third of the units have a written protocol for routine follow-up of tracheostomy patients once discharged from the ICU.
Training
Three-quarters of the ICU clinicians recommend a trainee should be supervised for a minimum of six percutaneous tracheostomies before performing the procedure independently.
Discussion
This survey shows that percutaneous tracheostomy is well established, as 97% of the responding units in the UK perform the procedure. This is a substantial increase from the 78.4% of the units reported in a previous tracheostomy survey in 1998 [6]. Conventional surgical tracheostomy remained the method of choice in only 3% of units. Clinicians will, however, opt for the surgical approach when the airway is difficult, in failed percutaneous tracheostomies and in the morbidly obese. Conventional surgical tracheostomy will still be carried out for emergency access to the airway, although percutaneous tracheostomy in ‘experienced hands’ can also be used for this purpose [7].
This survey demonstrated that opinion remains divided on timing of tracheostomy for patients requiring prolonged mechanical ventilation. Half of the units perform tracheostomy within the first week and the other half within the second week or later. The benefits of early over late tracheostomy have not been shown in a large randomised controlled trial, although three small studies have shown some benefits of early tracheostomy in selected ICU populations [5, 8, 9]. A recently published study has shown a significant reduction in mortality and a reduced length of ICU stay following early tracheostomy in medical intensive care patients [5]. The definition of ‘early tracheostomy’ remains ambiguous, with the literature reporting a range between 1 and 7 days. The TracMan (Tracheostomy Management in Critical Care) study presently being conducted by the Intensive Care Society aims to recruit 1206 patients to compare early (within 4 days of ICU admission) vs. late (after more than 10 days of ICU admission) tracheostomy [10]. This may help clarify best practice as to timing.
Tracheostomy involves two stages. Initially, a tracheal stoma is created below the first or the second tracheal ring. The second stage involves placement of a tracheostomy tube. The stoma can be created either surgically or percutaneously. There are a number of percutaneous kits commercially available. All involve midline insertion of a needle into the trachea and the subsequent placement of a guide wire. In order to create a stoma, dilation is carried out using a Seldinger technique by inserting the dilators from either the inside or the outside of the trachea. Dilation techniques from outside the trachea include classical serial dilators, single dilator, guide wire forceps dilator and a threaded dilator. Each dilator claims to have its own advantages but Blue Rhino single dilation technique is increasingly popular (as shown in this survey), being adopted currently by 64% of the responding units. Stoma dilation from inside the trachea (Fantoni translaryngeal method) appears to be no longer practised, probably due to the complexity and length of the procedure and associated risks of hypoxia during the tracheal tube change.
Each percutaneous tracheostomy technique has its own learning curve. A great deal of experience was initially gained using the classical Ciaglia serial dilation technique. Subsequent reports of damage to the posterior tracheal wall as a result of multiple dilator insertion led to the introduction of the single dilation technique [11]. This is supported by our survey where the use of the Ciaglia technique has fallen from 42% in 1998 to 14% in 2004. Single dilation techniques, particularly the Blue Rhino and Ultraperc, are increasing in popularity.
The use of bronchoscopic guidance during percutaneous tracheostomy has dramatically increased over the last 6 years. Our survey showed that 83% of units use the bronchoscope continuously throughout tracheostomy, with 9% of units only electing to use it in difficult situations. This is an improvement compared to 31% of the units using bronchoscopy in the 1998 survey [6]. Bronchoscopy enables the operator to visualise correct placement of needle, guide wire, dilator and the tracheostomy cannula. The reported disadvantages of bronchoscopy include a rise in airway pressure, ventilatory compromise, carbon dioxide retention, time and expense implications. However, randomised studies have reported that percutaneous tracheostomy using bronchoscopy is associated with a lower complication rate [12]. Direct vision during the procedure can prevent iatrogenic damage to the posterior tracheal wall.
Air aspiration does not guarantee that the needle is in the trachea. A cadaver study [13] in patients whose tracheostomies were performed without bronchoscopic guidance showed that only 45% of guide wire insertions entered the trachea at the right level, with 33% of guide wires piercing the thyroid thymus.
Numerous studies have focused on immediate peri-operative complications and the safety of the tracheostomy technique. The results of these studies show that there has been a decreasing trend in the incidence of peri-operative complications [14]. The commonest complication seen in our survey was bleeding. It is not known whether prior ultrasound examination of the neck would have reduced the incidence of procedural bleeding complications.
Responding units used a number of tracheostomy tubes, with the Portex tracheostomy tube being the most popular. Tracheostomy tubes with an internal diameter greater than 8 mm tend not to be used for ICU patients. Half of the units do not change tracheostomy tubes unless there is a blockage. It has been suggested that by using an inner disposable tube and changing this every day, the incidence of blockage and nosocomial pneumonia can be reduced [5]. This may also avoid frequent tracheostomy tube changes, especially they are done outside the ICU where risks may be increased.
A number of studies [15] have suggested the clinical benefits following tracheostomy include reduced sedation requirements, improved patient comfort, reduced ICU stay, less damage to the airway, easier mobilisation of patients and increased tolerance to enteral feeding. These advantages might prompt early tracheostomy. From this survey all clinicians believed that tracheostomy reduced the need for sedation, although they were less sure whether tracheostomy reduces the duration of mechanical ventilation and length of stay.
The immediate and long-term follow-up of patients with a tracheostomy is a matter of concern; only 32% of the units report having a written follow-up protocol. However, most decannulations are carried out by the ICU staff. With the advent of ‘outreach’, follow-up of tracheostomy patients once discharged from ICU should be an achievable goal in most units.
Operator training in tracheostomy appears poor. The number of surgical tracheostomies has decreased, with our survey showing only 3% of units performing them. This must impact on the ENT trainees' ability to perform the procedure, especially as this is likely to be required in an emergency situation. Time spent in ICU by anaesthetic trainees in the UK is also shorter due to implementation of the European Working Time Directive. Therefore anaesthetic trainees may also receive little training in the procedure. The consensus view among clinicians in our survey was that trainees should perform a minimum of six supervised tracheostomies before being deemed competent.
Percutaneous tracheostomy is an established technique for long-term airway management in critically ill patients. Single dilation is the technique of choice. Bronchoscopic guidance has become routine during percutaneous tracheostomy insertion. Bleeding is the most common peri-operative complication. The timing of tracheostomy remains debatable. Most clinicians agree that a trainee should be supervised for at least six procedures. Long-term tracheostomy follow-up needs further resources and development.
