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University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL 33136, USA
* Corresponding author. Address: P.O. Box 016960 (r-114) 1611 N.W. 12th Avenue, ET 3072, Jackson Memorial Hospital, Miami, FL 33136, USA. Tel.: +1 305 5855271; fax: +1 305 5472185. (Email: tsalerno{at}med.miami.edu).
In the current manuscript, Ngaage et al. [1], retrospectively reviewed a series of 7002 patients undergoing heart surgery through median sternotomy, and identified 100 patients (1.4%) who received percutaneous dilatational tracheostomy (PDT) due to continued ventilator-dependency. A variety of procedures were performed, such as aortic valve surgery, mitral valve surgery, coronary artery surgery, and others. The median time interval between cardiac surgery and tracheostomy was only 7 days (IQR 6–9 days). Also, in 43% of the patients, PDT was performed after re-intubation for respiratory failure. The authors found that the risk factors for tracheostomy were NYHA class III/IV, chronic obstructive pulmonary disease (COPD), renal failure, low cardiac index, prior stroke, poor ejection fraction (EF), and cardiopulmonary bypass time. The incidence of superficial and deep sternal wound infection was significantly higher in the PDT patients than in non-tracheostomy patients [1]. Multivariate analysis showed that percutaneous tracheostomy was a predictor for deep sternal wound infection (OR 3.22, 95% CI 1.14–9.31, p < 0.0001).
PDT has been introduced as a minimally invasive approach, replacing in many units the conventional surgical technique of performing tracheostomy in ventilator-dependent patients [2]. This new terminology, PDT, may give the impression that this is a simpler method of dealing with patients who require prolonged ventilation post surgery, possibly less invasive and with diminished risks. However, while cost-effectiveness of this strategy has been suggested in some reports [3], it has also been shown that the risk of major complications may, in fact, be higher following PDT than surgical tracheostomy [3]. In this regard, the findings by the authors confirm that, regardless of the approach, tracheostomy remains a procedure associated with certain complications. With current methods of intubation with low-pressure cuff endotracheal tubes, patients may be safely kept orally intubated much longer than recommended by the authors (7 days on average). Tracheostomy, whether performed surgically or percutaneously, remains an invasive procedure that has potentially serious complications [3], especially in a debilitated post-cardiac surgery patient. It is unknown whether delaying the PDT could have decreased the incidence of sternal infections. Although it could be argued that, in principle, delaying the tracheostomy could interfere less with the early phase of sternal and incisional healing. Also, we are uncertain as to why the authors decided to perform PDT so soon after the cardiac surgical procedure, since conventional endotracheal intubation can be continued safely for over 3 weeks, if necessary. In our experience, inability to come off the respirator 7 days after cardiac surgery does not always translate to the need for permanent ventilatory support. Many of these patients simply need more time to be weaned and do not necessarily need to be committed to a tracheostomy.
One aspect unclear in this manuscript relates to what team is performing the PDT (surgeons vs anesthesia vs critical care vs ENT, etc.). Is the team qualified to deal with the consequences of a failed percutaneous tracheostomy or its complications, or do they rely on surgeons as back up should an adverse event occur? Furthermore, these authors give an impression that none of their PDT was associated with any complication. This should be further clarified.
The association between PDT and superficial and deep wound infection should also be further investigated. While the cause for such association remains unclear, it is possible that local contamination from entering the trachea in respirator-dependent, colonized patients could involve the mediastinal structures by continuity. In the manuscript it is not clear what type of antimicrobial coverage was used, if any, at the time of PDT.
On a final note, the surgeon must ask the question as to whether it is worth-the price for an early PDT post heart surgery, or whether it is better to be more conservative and utilize the oral intubation route for longer periods of time. This is particularly useful considering the low-pressure cuff tubes that we currently use. This is not answered in this study, which will require a prospective evaluation of these patients into a clinical trial. Only then will we have the definitive answer as to whether the risk of PDT in early post-cardiac surgery is justified. As the authors point out, one of the limitations of this study is the absence of a control group constituted by patients receiving an open surgical tracheostomy. Therefore, their outcomes following PDT were compared to other series of surgical tracheostomy from the literature, thus introducing a potentially significant bias.
In summary, in our opinion the present study highlights the potential dangers of PDT in post-cardiac surgery patients, and raises concerns on the strategy of early PDT in this subset of patients. The authors have shown that early PDT should be discouraged or delayed after cardiac surgery.
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  O. Friberg and R. Svedjeholm Post-sternotomy percutaneous tracheostomy and risky multivariable analyses Eur. J. Cardiothorac. Surg., October 1, 2008; 34(4): 930 - 930. [Full Text] [PDF]
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