Printer Friendly

The diagnostic yield and clinical impact of a chest X-ray after percutaneous dilatational tracheostomy: a prospective cohort study.

SUMMARY

A chest X-ray (CXR) is routinely performed after percutaneous dilatational tracheostomy (PDT). The purpose of this study was to evaluate the diagnostic yield of routine CXR following PDT and its impact on patient management and to identify predictors of post-PDT CXR changes. Two-hundred-and-thirty-nine patients who underwent PDT in a 21-bed intensive care unit were included prospectively in the study. The following data were collected: patient demographics, APACHE III scores, pre-PDT Fi[O.sub.2] and PEEP, PDT technique, perioperative complications and the use of bronchoscopic guidance. We compared post-PDT CXR with the last pre-PDT CAR. We documented any post-PDT new radiographic findings including atelectasis, pneumothorax, pneumomediastinum, surgical emphysema, pulmonary infiltrates or tracheostomy tube malposition. We also recorded management modifications based on post-PDT radiographic changes, including increased PEEP, chest physiotherapy, therapeutic bronchoscopy or chest tube insertion. Atelectasis was the only new finding detected on post-PDT CXRs of 24 (10%) patients. The new radiographic findings resulted in a total of 14 modifications of management in 10 (4%) patients including increased PEEP in six, chest physiotherapy in six and bronchoscopy in two patients. Trauma and pre-PDT PEEP >5 cm[H.sub.2]O were independent predictors of post-PDT CXR changes. Routine CXR following PDT has a low diagnostic yield, detecting mainly atelectasis and leading to a change in the management in only a minority ofpatients. Routine CXR after apparently uncomplicated PDT performed by an experienced operator may not be necessary and selective use may improve its diagnostic yield. Further studies are required to validate the safety of selective versus routine post-PDT CXR.

Key Words: chest radiograph, percutaneous dilatational tracheostomy, intensive care, complications

**********

Percutaneous dilatational tracheostomy (PDT) has become an integral part of airway management in the critical care setting and it is one of the most frequently performed procedures in critically ill patients. It has gained an increasing acceptance as an alternative to the classic operative tracheostomy and several prospective randomised trials (1-4) have reported a lower incidence of complications with PDT compared to surgical tracheostomy.

Chest X-ray (CXR) is routinely performed after PDT as a standard practice to confirm tracheostomy tube placement and to detect potentially serious complications. A few studies have been performed to determine the usefulness of routine CXR following either surgical tracheostomy (5) or PDT performed under bronchoscopic guidance (6, 7). However, PDT is also performed without bronchoscopic guidance. The yield of routine CXR after PDT performed without bronchoscopic guidance has not been examined before. Our hypothesis is that routine CXR after PDT performed without bronchoscopic guidance has a low diagnostic yield and leads to few changes in patient management. Therefore, we conducted this study to evaluate prospectively the yield of post-PDT CXR and to identify predictors of radiographic changes.

MATERIALS AND METHODS

Setting

This prospective cohort study was conducted in a 21-bed, tertiary care medical-surgical intensive care unit (ICU) in an 800-bed teaching hospital level-one trauma centre in Riyadh, Saudi Arabia. The ICU, which admits more than a thousand patients per year, is run as a closed unit 24 hours a day, seven days a week by in-house full-time Critical Care Board-certified Intensivists. The study was approved by the Institutional Board Review.

Patients

All consecutive patients older than 16 years who underwent PDT between May 2004 and December 2005 were included. An informed consent for PDT was obtained from all patients.

PDT techniques

PDTs were performed at the bedside by intensivists with a large cumulative experience of more than two-hundred PDTs, assisted by a critical care fellow or resident. The technique of PDT was either Ciaglia "single-step dilation" (8) using the Ultraperc Percutaneous Tracheostomy Kit (Smiths, Portex company; equivalent to the Ciaglia Blue Rhino) or Griggs9 (Guide Wire Dilator Forceps: GWDF) using the Percutaneous Tracheostomy Kit (SimsPortex). All patients were sedated, pharmacologically paralysed and mechanically ventilated with 100% oxygen during the procedure. Regularly, PDT was performed without bronchoscopic guidance. However, bronchoscopy was used in selected patients such as in patients with cervical spine injury or with a short fat neck.

Pre-and post-PDT CXR

A CXR is performed, as daily routine, in the morning before PDT and another CXR is performed, as post-procedure, within the first 30 minutes following the PDT.

Data collection

The following data were collected: patient demographics including age, gender, height and weight; admission categories (surgical, medical, trauma or burns); Acute Physiology and Chronic Health Evaluation III (APACHE III) scores (10); pre-PDT fraction of inspired oxygen (Fi[O.sub.2]) and positive end-expiratory pressure (PEEP); the use of bronchoscopic guidance and technique of PDT (Griggs "GWDF" or Ciaglia "single-step dilation"). We compared the post-procedure CXR with the last pre-procedure CXR and recorded any new changes including atelectasis, pneumothorax, pneumomediastinum, subcutaneous emphysema, pulmonary infiltrates, tracheostomy tube malposition, or para-tracheal tube placement. We documented modifications in management based on the post-procedure radiographic new findings including increase of PEEP, chest physiotherapy, therapeutic bronchoscopy, chest tube insertion, or tracheostomy tube repositioning.

Statistical analysis

We used Minitab for Windows (Minitab Inc., Release 12.1, State College, PA, U.S.A.) for statistical analysis. We used descriptive statistics to describe patients' baseline characteristics, post-PDT CXR changes and their impact on patient management. Continuous variables were described as mean and standard deviation (SD) and categorical variables were expressed as absolute and relative frequencies. We used univariate analysis to identify predictors of post-PDT CXR changes. Significant predictors were entered into stepwise regression to identify independent predictors of CXR changes.

RESULTS

Baseline characteristics

Two-hundred-and-thirty-nine patients underwent PDT during the study period. The mean ([+ or -] SD) age of patients was 54 [+ or -] 22 years. Male patients totalled 185 (77.4%). The admission categories were as follows: medical 145 (61%), trauma 67 (28%), surgical 25 (10%) and burn 2 (1%). The mean ([+ or -] SD) of APACHE III score was 79 [+ or -] 29 (Table 1).

PDT data

The pre-PDT Fi[O.sub.2] ([+ or -] SD), PEEP [+ or -] SD (cm[H.sub.2]O), PEEP > 5 (cm[H.sub.2]O) and Fi[O.sub.2] >0.4 were 0.33 [+ or -] 0.07, 5.8 [+ or -] 3.8, 58 (24%), and 20 (8.3%), respectively. In all, 228 patients (95.4%) underwent PDT without bronchoscopic guidance and 11 patients (4.6%) under bronchoscopic visualisation. "Single-step dilation" Ciaglia technique was used in 209 (87.5%) patients and Griggs (GWFD) technique in 30 (12.5%) patients (Table 2).

Post-PDT CXR changes and impact on management

Atelectasis was the only new change detected on the post-procedure CXR and was found in 24 (10%) patients. In the remaining 215 (90%) patients, there were no significant abnormalities detected on the post-procedure CXR. Fourteen modifications in management, based on post-procedure CXR findings, were noted in 10 (4%) patients. These modifications in management included increase of PEEP (by 3 to 5 cm[H.sub.2]O) in six (2.5%) patients, chest physiotherapy in six (2.5%) patients and therapeutic bronchoscopy in two (1%) patients.

Predictors of post procedure CXR changes

Table 3 shows the results of univariate analysis of predictors of post-procedure CXR changes. Trauma and pre-PDT PEEP >5 cm[H.sub.2]O were predictors of post-tracheostomy CXR changes (OR=4.28, 95% CI=1.80-10.20, P=0.001 and OR=3.01, 95% CI=1.27-7.15, P=0.013, respectively). However, age and medical admissions were associated with lower incidence of post-procedure CXR changes (OR=0.97 for each year of age, 95% CI=0.950.99, P=0.002; and OR=0.35, 95% CI=0.15-0.83, P=0.018, respectively). The following variables were not significantly associated with an increase or a decrease in the incidence of post-procedure CXR changes: gender, surgical reason for ICU admission, APACHE III score, pre-PDT Fi[O.sub.2] >0.4, technique of PDT, bronchoscopy use, or the occurrence of perioperative complications. Using stepwise regression of predictors of post-procedure CXR changes, only trauma and pre-PDT PEEP >5 cm[H.sub.2]O remained as significant independent predictors of CXR changes (Table 4). The incidence of post-procedure CXR changes was 3% in non-trauma patients receiving PEEP [less than or equal to] 5 cm[H.sub.2]O, 14% in non-trauma patients receiving PEEP >5 cm[H.sub.2]O, 18% in trauma patients receiving PEEP > 5 cm[H.sub.2]O, and 29% in trauma patients receiving PEEP >5 cm[H.sub.2]O (P<0.001).

DISCUSSION

The main findings of this prospective study are that a) the diagnostic yield of routine CXR following PDT performed without bronchoscopic guidance is low; b) atelectasis is the main change detected on the post-PDT CXR; c) trauma and pre-PDT PEEP >5 cm[H.sub.2]O are independent predictors of post-tracheostomy CXR changes; and d) the post-PDT CXR leads to modification of management in a small number of patients.

The incidence of perioperative complications with PDT has ranged in different studies from 3 to 18% (11-16). Several tools have been suggested to minimise the incidence and severity of complications and to improve the safety of PDT such as bronchoscopic guidance and post-procedure CXR. Studies have demonstrated that bronchoscopic monitoring during PDT facilitates the procedure and reduces potential complications, hence providing a higher degree of safety (16-22). However, bronchoscopic guidance is not always necessary and a growing body of literature supports the safety of performing PDT without bronchoscopic guidance (11, 23-6). Studies reported no significant differences in the incidence of complications of PDT performed with or without bronchoscopy (11).

The complications that would be detected on the post-procedure CXR following PDT include atelectasis, pneumothorax, pneumomediastinum, pulmonary infiltrates, tracheostomy tube mal-positioning and paratracheal tube placement. However, recently, the value of routine post-tracheostomy CXR has been challenged as well as its impact on patient management.

Few studies have examined the value of routine post-procedure CXR following PDT performed under bronchoscopic guidance. Datta et al (6), in a retrospective study, examined the usefulness of routine CXR following PDT performed under bronchoscopic visualisation. In two (3.3%) of the 60 patients, postoperative complications were detected on the post-procedure CXR, one with a pneumomediastinum that was treated conservatively and the other with a tension pneumothorax that was treated with a chest tube insertion. In both cases, the PDT procedure was noted to be difficult, with a high physician anticipation of complications. However, it is unclear whether the investigators examined procedure difficulty systematically for all patients or only for those who had CXR changes. The authors concluded that CXR is not necessary after PDT if performed under bronchoscopic guidance unless there is procedural difficulty. The retrospective nature and the small number of patients make the conclusion difficult to generalise. In contrast to the findings of Datta, our study did not show that bronchoscopic guidance during PDT reduces the incidence of CXR changes, or that there is an association between perioperative complications and occurrence of post-PDT CXR changes. Based on the above, the decision to perform CXR after PDT cannot be made on whether bronchoscopy was used or not, nor on whether the PDT procedure was difficult or not.

Recently, Hoehne et all', in a retrospective study of 73 patients, evaluated the utility of CXR after PDT performed with bronchoscopic guidance. The study detected no complication on the post-PDT CXR in the 73 patients. Again, the retrospective nature and the small number of patients might have underestimated the incidence of post-PDT CXR changes.

Nevertheless, it is important to note that serious and life-threatening complications of PDT such as paratracheal tube placement are usually self-evident and should be recognised clinically and managed instantly prior to a CXR being performed. Consequently, CXR is not the standard tool for the diagnosis of such life-threatening complications. Conversely, other complications such as atelectasis are of less clinical significance and delayed diagnosis until the next-day CXR might not have a major consequence.

Our study advances the clinical management of the post-PDT patients in important ways, as well as complementing current literature. Along with other studies, it demonstrated that routine CXR following tracheostomy, whether surgical (5) or PDT performed with (6, 27) or without bronchoscopic guidance, is probably unnecessary and selective use may be more appropriate. The question is what are the criteria to perform a CXR after tracheostomy? Our study provided some clues to such a decision. In trauma patients, trauma was the most significant predictor of CXR changes after PDT This finding may be explained by the fact that trauma patients who require tracheostomy are at high risk of developing respiratory complications for several reasons including loss of ability to clear the bronchial tree (intense analgesia and sedation) leading to retention of secretions and formation of mucous plugs with resultant atelectasis. Moreover, trauma has been identified as an independent risk factor for the development of nosocomial pneumonia (28, 29). We also found that PEEP >5 cm[H.sub.2]O was also a significant predictor of CXR changes after PDT This is probably related to alveolar collapse and derecruitment due to the loss of PEEP after tracheal opening and dilatation.

This study has a number of strengths including the prospective nature, the inclusion of all consecutive patients and the large number of patients. As a potential limitation, the study was observational and was conducted in a single centre.

CONCLUSIONS

Post-procedure CXR following PDT performed without bronchoscopic guidance has a low diagnostic yield, detecting mainly atelectasis and leading to a change in the management in a minority of patients. Routine CXR after apparently uncomplicated PDT performed by an experienced operator may not be necessary and selective use may improve its diagnostic and clinical yield and reduce the risk of tube dislodgement. Our study identified trauma and pre-PDT PEEP >5 cm[H.sub.2]O as independent predictors of post-procedure CXR changes. Further studies are required to validate the safety of selective versus routine use of post-procedure CXR following PDT performed without bronchoscopic guidance.

Accepted for publication on December 6, 2006.

REFERENCES

(1.) Stoeckli SJ, Bretbach T, Schmid S. A clinical and historical comparison of percutaneous dilatational vs. conventional surgical tracheostomy. Laryngoscope 1997; 107:1643-1646.

(2.) Petros S. Percutaneous tracheostomy. Crit Care 1999; 3:R5-R10.

(3.) Moe KS, Stoeckli SJ, Schmidt S, Weymuller EA Jr. Percutaneous tracheostomy: a comprehensive evaluation. Ann Otol Rhinol Laryngol 1999; 108:384-391.

(4.) DeBoisblanc BP. Percutenous dilatational tracheostomy techniques. Clin Chest Med 2003; 24:399-407.

(5.) Tarnoff M, Moncure M, Jones F, Ross S, Goodman M. The value of routine, post-tracheostomy chest radiography. Chest 1998; 113:1647-1649.

(6.) Datta D, Onyirimba F, McNamee MJ. The utility of chest radiographs following percutaneous dilatational tracheostomy. Chest 2003; 123:1603-1606.

(7.) Gonzalez I, Bonner S. Routine chest radiographs after endoscopically guided percutaneous dilatational tracheostomy. Chest 2004; 125:1173-1175.

(8.) Byhahn C, Wilke HJ, Halbig S, Lische V, Westphal K. Percutaneous tracheostomy: Ciaglia blue rhino versus the basic Ciaglia technique of percutaneous dilatational tracheostomy. Anesth Analg 2000; 91:882-886.

(9.) Griggs WM, Worthley LIG, Gilligan JE, Thomas PD, Myburgh JA. A simple percutaneous tracheostomy technique. Surg Gynec Obstet 1990; 170:543-545.

(10.) Knaus WA, Wagner DP, Draper EA, Zimmerman JE, Bergner M, Bastos PG et al. The APACHE III prognostic system: risk prediction of hospital mortality for critically ill hospitalized adults. Chest 1991; 100:1619-1636.

(11.) Berrouschot J, Oeken J, Steiniger L, Schneider D. Perioperative complications of percutaneous dilatational tracheostomy. Laryngoscope 1997; 107:1538-1544.

(12.) Bodenham A, Diament R, Cohen A, Webster N. Percutaneous dilatational tracheostomy: a bedside procedure on the intensive care unit. Anaesthesia 1991; 46:570-572.

(13.) Moore FA, Haenel JB, Moore EE, Read RA. Percutaneous tracheostomy/ gastrostomy in brain injured patients: a minimally invasive alternative. J Trauma 1992; 33:435-439.

(14.) Marelli D, Paul A, Manolidis S, Walsh G, Odim JN, Burdon TA et al. Endoscopic guided percutaneous tracheostomy: early results of a consecutive trial. J Trauma 1990; 30:433-435.

(15.) Ciaglia P, Graniero K. Percutaneous dilatational tracheostomy. Chest 1992; 101:464-467.

(16.) Winkler WB, Karnik R, Seelmann O, Havlicek J, Slany J. Bedside percutaneous dilatational tracheostomy with endoscopic guidance: experience with 71 ICU patients. Intensive Care Med 1994; 20:476-479.

(17.) Barba CA, Angood PB, Kauder DR, Latenser B, Martin K, McGonigal MD et al. Bronchoscopic guidance makes percutaneous tracheostomy a safe, cost-effective and easy-to-teach procedure. Surgery 1995; 118:879-883.

(18.) Oberwalder M, Weis H, Nehoda H, Kafka-Ritsch R, Bonatti H, Prommegger R et al. Videobronchoscopic guidance makes percutaneous dilational tracheostomy safer. Surg Endosc 2004; 18:839-842.

(19.) Ciaglia P Video-assisted endoscopy, not just endoscopy, for percutaneous dilatational tracheostomy. Chest 1999; 115:915-916.

(20.) Hinerman R, Alvarez F, Keller CA. Outcome of bedside percutaneous tracheostomy with bronchoscopic guidance. Intensive Care Med 2000; 26:1850-1856.

(21.) Jefferson P, Ball DR. Endoscopy is useful during percutaneous tracheostomy. BMJ 2002; 324:977-978.

(22.) Bardell T, Drover J. Recent developments in percutaneous tracheostomy: improving techniques and expanding roles. Curr Opin Crit Care 2005; 11:326-332.

(23.) Reilly PM, Sing RF, Giberson FA, Anderson HL 3rd, Rotondo MF, Tinkoff GH et al. Hypercarbia during tracheostomy: a comparison of percutaneous endoscopic, percutaneous Doppler, and standard surgical tracheostomy. Intensive Care Med 1997; 23:859-864.

(24.) Paran H, Butnaru G, Hass I, Afanasyv A, Gutman M. Evaluation of a modified percutaneous tracheostomy technique without bronchoscopic guidance. Chest 2004; 126:868-871.

(25.) Mallick A, Venkatanath D, Elliot SC, Hollins T, Nanda Kumar CG. A prospective randomised trial of capnography vs. bronchoscopy for blue rhino percutaneous tracheostomy. Anaesthesia 2003; 58:864-868.

(26.) Maddali M, Paratap M, Fahr J, Zarroug AW Percutaneous tracheostomy by guide wire dilating forceps technique: is bronchoscopic guidance mandatory? Middle East J Anesthesiol 2002; 16:509-519.

(27.) Hoehne F, Ozaeta M, Chung R. Routine chest X-ray after percutaneous tracheostomy is unnecessary. Am Surg 2005; 71:51-53.

(28.) Rello J, Ollendorf DA, Oster G, Vera-Llonch M, Bellm L, Redman R et al. Epidemiology and outcomes of ventilatorassociated pneumonia in a large US database. Chest 2002; 122:2115-2121.

(29.) Tejada Artigas A, Bello Dronda S, Chacon Valles E, Mroz Marco J, Villuendas Uson Macrolides, Figueras P et al. Risk factors for nosocomial pneumonia in critically ill trauma patients. Crit Care Med 2001; 29:304-309.

S. H. HADDAD *, A. S. ALDAWOOD ([dagger]), Y. M. ARABI ([double dagger])

Intensive Care Department, King Fahad National Guard Hospital, King Abdulaziz Medical City, Riyadh, Saudi Arabia

* M.D., C.E.S., Consultant, Intensive Care Department, King Fahad National Guard Hospital and Fellow, Surgical Intensive Care Unit, Anesthesia Department, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States.

([dagger]) M.D., F.R.C.P.C., F.C.C.P, Consultant, Intensive Care Department, King Fahad National Guard Hospital and Assistant Professor, King Saud Bin Abdulaziz University for Health Sciences.

([double dagger]) M.D., F.C.C.P, Consultant and Chairman, Intensive Care Department, King Fahad National Guard Hospital and Assistant Professor, King Saud Bin Abdulaziz University for Health Sciences.

Address for reprints: Dr S. H. Haddad, Surgical Intensive Care Unit, Anesthesia Department, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, IA 52242, U.S.A.
TABLE 1
Patients' characteristics

Variable Result (%)

Number 239
Age [+ or -] SD 54 [+ or -] 22
Male gender 185 (77.4%)
Admission category
 Medical 145 (61%)
 Surgical 25 (10%)
 Trauma 67 (28%)
 Burn 2 (1%)
APACHE III [+ or -] SD 79 [+ or -] 29

SD: standard deviation; APACHE: Acute Physiology and Chronic
Health Evaluation.

TABLE 2
Percutaneous dilatational tracheostomy (PDT) data

Variable Result (%)

Pre-PDT Fi[O.sub.2] ( [+ or -] SD) 0.33 [+ or -] 0.07
Pre-PDT PEEP [+ or -] SD (cm[H.sub.2]O) 5.8 [+ or -] 3.8
Pre-PDT Fi[O.sub.2] >0.4 20 (8.3%)
Pre-PDT PEEP >5 (cm[H.sub.2]O) 58 (24%)
PDT without bronchoscopy 228 (95.4%)
PDT with bronchoscopy 11 (4.6%)
Technique of PDT
 Griggs (GWFD) 30 (12.5%)
 Ciaglia (single-step dilation) 209 (87.5%)

PDT: percutaneous dilatational tracheostomy; Fi[O.sub.2]: fraction of
inspired oxygen; SD: standard deviation; PEEP: positive end-
expiratory pressure; GWFD: guide wire forceps dilator.

TABLE 3
Univariate predictors of post procedure chest X-ray changes

 P OR 95% CI

Age 0.002 0.97 0.95-0.99

Male gender 0.467 1.52 0.49-4.64

Medical 0.018 0.35 0.15-0.83

Surgical 0.309 0.35 0.04-2.68

Trauma 0.001 4.28 1.80-10.20

APACHE III 0.32 0.99 0.98-1.01

Pre-PDT Fi[O.sub.2] >0.4 0.45 1.66 0.45-6.12

Pre-PDT PEEP >5 (cm[H.sub.2]O) 0.013 3.01 1.27-7.15

Technique of PDT (Ciaglia vs. 0.52 0.69 0.22-2.17
Griggs)

Bronchoscopy used 0.368 2.08 0.42-10.24

Perioperative complications 0.445 1.66 0.45-6.15

P: P value; OR: odds ratio; CI: confidence interval; APACHE:
Acute Physiology and Chronic Health Evaluation; Fi[O.sub.2]: fraction
of inspired oxygen; PEEP: positive end-expiratory pressure; PDT:
percutaneous dilatational tracheostomy.

TABLE 4
Stepwise regression of predictors of chest X-ray changes

Predictor Coefficient SD t-test P value

Constant 0.03087 0.02463 1.25 0.211
PEEP >5 0.11515 0.04395 2.62 0.009
Trauma 0.14887 0.04195 3.55 0.000

The regression equation is: any CXR change=0.0309 + 0.115 PEEP
>5 + 0.149 trauma.
COPYRIGHT 2007 Australian Society of Anaesthetists
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2007 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Author:Haddad, S.H.; Aldawood, A.S.; Arabi, Y.M.
Publication:Anaesthesia and Intensive Care
Article Type:Clinical report
Geographic Code:1USA
Date:Jun 1, 2007
Words:3512
Previous Article:Phaeochromocytoma causing acute pulmonary oedema during emergency caesarean section.
Next Article:Presentation of hemiplegic migraine--hemiplegia and hemi-sensory loss following general anaesthesia.
Topics:


Related Articles
Preventing posterior tracheal wall perforation in percutaneous dilational tracheotomy.
Prospective randomized comparison of progressive dilational vs forceps dilational percutaneous tracheostomy.
Forceps dilatational percutaneous tracheostomy: safe and short.
Locally developed guidelines reduce immediate complications from percutaneous dilatational tracheostomy using the Ciaglia Blue Rhino technique: a...
Safety of percutaneous tracheostomy in obese critically ill patients: a prospective cohort study.
Tracheal tube position during percutaneous tracheostomy.

Terms of use | Privacy policy | Copyright © 2019 Farlex, Inc. | Feedback | For webmasters