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Eur J Cardiothorac Surg 2007;32:412-421. doi:10.1016/j.ejcts.2007.05.018
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
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a Department of Thoracic Surgery, University Hospital Leuven, Belgium
b Department of Pneumology, Middelheim Hospital, Belgium
c Department of Pneumology, University Hospital Leuven, Belgium
d Department of Intensive Care, University Hospital Ghent, Belgium
e Department of Thoracic and Vascular Surgery, ZOL Hospital Genk, Belgium
f Department of Thoracic Surgery, Erasme University Hospital Brussels, Belgium
g Department of Pneumology, CHU A. Vesale, Montigny-le-Tilleul, Belgium
h Department of Thoracic and Vascular Surgery, University Hospital Antwerp, Belgium
Received 12 March 2007; received in revised form 1 May 2007; accepted 24 May 2007.
* Corresponding author. Address: Department of Thoracic Surgery, University Hospital Leuven, Herestraat 49, 3000 Leuven, Belgium. Tel.: +32 16346822; fax: +32 16346821. (Email: Paul.deleyn{at}uz.kuleuven.ac.be).
Tracheotomy is a commonly performed procedure. The Belgian Society of Pneumology (BVP-SBP) and the Belgian Association for Cardiothoracic Surgery (BACTS) developed guidelines on tracheotomy for mechanical ventilation in adults. The levels of evidence as developed by the American College of Chest Physicians (ACCP) were used. The members of the guideline committee reviewed peer-reviewed publications on this subject. After discussion, a proposal of guidelines was placed on the website for remarks and suggestions of the members. Remarks and suggestions were discussed and used to adapt the guidelines when judged necessary. The different techniques of tracheotomy are described. The potential advantages and disadvantages of surgical and percutaneous tracheotomy versus endotracheal intubation are discussed. An overview of early and late complications is given. Low-pressure, high-volume cuffs should be used. The cuff pressure should be monitored with calibrated devices and recorded at least once every nursing shift and after manipulation of the tracheotomy tubes. Inspired gas should be humidified and heated. Regarding the timing of tracheotomy there are not enough well-designed studies to establish clear guidelines. Therefore, the timing of tracheotomy should be individualised. In critically ill adult patients requiring prolonged mechanical ventilation, tracheotomy performed at an early stage (within the first week) may shorten the duration of artificial ventilation and length of stay in intensive care. Percutaneous dilatational tracheotomy (PDT) appears to be at least as safe as surgical tracheotomy (ST) as measured in terms of peri-procedural complications. With PDT, less wound infection is observed. When PDT is compared to ST performed in the operating room, PDT is less expensive, reduces the time between the decision and the performance of tracheotomy and has a lower mortality rate. Different techniques of PDT are discussed. We recommend performing PDT under bronchoscopic guidance. Because of its technical simplicity and short procedure time, the modified Ciaglia Blue Rhino technique is advocated as technique of choice. PDT should be considered the procedure of choice in elective non-urgent tracheotomy. There are some relative contraindications for PDT, but with growing experience, they become less frequent.
Key Words: Mechanical ventilation • Artificial airway • Weaning • Tracheal stenosis • Surgical tracheostomy • Percutaneous dilatational tracheostomy
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