A Meta-analysis of Prospective Trials Comparing Percutaneous and Surgical Tracheostomy in Critically Ill Patients

摘要

Study objectives: Tracheostomy is one of the most commonly performed procedures in thenpatient receiving long-term mechanical ventilation. While percutaneous dilational tracheostomyn(PDT) is becoming increasingly utilized as an alternative to conventional surgical tracheostomy,nmost literature evaluating these two techniques is neither prospective nor controlled. Wenperformed a meta-analysis of available prospective controlled studies comparing PDT andnsurgical tracheostomy in critically ill patients to more fully understand the relative benefits andnrisks of these two procedures in this population.nDesign: Meta-analysis using Mantel-Haenszel fixed effect model.nInterventions: We performed searches of MEDLINE, Current Contents, Best Evidence, Cochrane,nand HealthSTAR databases from 1985 to present to identify prospective controllednstudies comparing PDT and surgical tracheostomy in critically ill patients. After establishingnclinical and statistical homogeneity (Q statistic), studies were analyzed by a Mantel-Haenszel fixedneffect model. For each clinical end point examined, PDT and surgical tracheostomy werencompared by calculating either absolute differences or odds ratios (ORs) with 95% confidencenintervals (CIs) for continuous or discrete variables, respectively.nMeasurements and results: We pooled data from five studies (236 patients) satisfying our searchncriteria to analyze eight clinical end points. Operative time was shorter for PDT than surgicalntracheostomy: absolute difference with 95% CI, 9.84 min (7.83 to 10.85 min). There was nondifference comparing PDT and surgical tracheostomy with respect to overall operative complicationnrates: OR with 95% CI, 0.732 (0.05 to 9.37). However, relative to surgical tracheostomy,nPDT was associated with less perioperative bleeding (OR with 95% CI, 0.14 [0.02 to 0.39]), anlower overall postoperative complication rate (OR with 95% CI, 0.14 [0.07 to 0.29]), as well as anlower postoperative incidence of bleeding (OR with 95% CI, 0.39 [0.17 to 0.88]), and stomalninfection (OR with 95% CI, 0.02 [0.01 to 0.07]). No difference was identified in days intubatednprior to tracheostomy (absolute difference with 95% CI, 0.16 days [2 0.9 to 1.22 days]), overallnprocedure-related complications (OR with 95% CI, 0.73 [0.06 to 9.37]), or death (OR with 95% CI,n0.63 [0.18 to 2.20]) comparing these two techniques.nConclusions: Despite its popularity, there are currently only a limited number of small studiesnprospectively evaluating PDT and surgical tracheostomy. Our meta-analysis of these studies suggestsnpotential advantages of PDT relative to surgical tracheostomy, including ease of performance, andnlower incidence of peristomal bleeding and postoperative infection. If confirmed by additional,nadequately powered prospective trials, these findings support PDT as the procedure of choice for thenestablishment of elective tracheostomy in the appropriately selected critically ill patient.