Optimal approach to the tracheostomy technique in critically ill patients with a short fat neck

Background and goal of study

To examine and to compare our experience with surgical tracheostomy (ST) and percutaneous tracheostomy (PCT) in the critically ill patients with a short fat neck. Nowadays PCT is widely used for prolonged mechanical ventilation in critically ill patients with normal neck anatomy instead of ST. Indications for PCT in adverse anatomical conditions like a short fat neck are still under discussion due to minimal positive experience.

Materials and methods

From January 1998 to August 2003, a group of 42 critically ill patients with obesity or overweight underwent tracheostomy for prolonged mechanical ventilation. During the first 3 years only ST was used in 18 patients, but from 2000 to 2003 PCT by Griggs technique was performed in 24 patients. ST was done by standard technique under general anesthesia (GA) in the operating room. PCT was performed as a bedside procedure under GA by one trained team including a general surgeon and anesthesiologist. Hospital records were reviewed retrospectively for patients' demography, weight, height, and anatomical characteristics of the neck, duration of the procedure, and complications.

Results

There was no difference in the sizes of the neck between the ST patients (mean = 47.1 cm, median = 47 cm, range = 45–51 cm) and the PCT patients (mean = 47.3 cm, median = 47 cm, range = 45–53 cm) (P = 0.9). The distance between the cricoid and sternal notch was small (ST group: mean = 1.35 cm, median = 1.35 cm, range = 0.5–1.9 cm, and PCT group: mean = 1.37 cm, median = 1.5 cm, range = 0.5–1.9 cm) without significant differences between the groups (P = 0.83). In both groups of patients tracheostomy was done without bleeding, paratracheal insertion of the tracheostomy tube or loss of airway control. Duration of the procedure for the ST group was mean = 41 min, median = 41 min, range = 40–45 min, and for the PCT group duration was mean = 10.7 min, median = 11 min, range = 10–12 min, with P < 0.0001. In the early postoperative period we met three hemorrhagic complications after ST, and four after PCT, which were treated conservatively (difference not significant P > 0.05). However, inflammation occurred after ST in six patients and after PCT in one patient (P < 0.03, odds ratio = 11.5). There was no operative mortality in both groups.

Conclusions

Both techniques provided good results in experienced hands. However, our study demonstrated that PCT was less traumatic, had a shorter procedure time and better healing of tissues around the tracheostomy tube in comparison with ST.