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Ann Thorac Surg 1999;68:492
© 1999 The Society of Thoracic Surgeons

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Invited Commentaries

^a Critical Care Services, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA 01199, USA

Invited commentary

Complications requiring prolonged mechanical ventilation (> 7 days) occur in about 2% of primary bypass and valve surgery patients and in up to 4% of reoperation patients. Tracheostomy is usually indicated when mechanical ventilation will be required for more than 2 weeks. Factors predisposing to prolonged ventilator support include emergency procedures, reoperations, congestive heart failure, chronic obstructive pulmonary disease, impaired renal function, advanced age, and debilitation. Given a tracheostomy rate of 0.7–1.5%, and approximately 400,000 cardiopulmonary bypass procedures, the annual number of tracheostomies performed in cardiac surgical patients in the United States can be estimated at between 2,800 and 6,000. Many of these patients are critically ill, on high level vasopressor and respiratory support, and frequently in renal failure. Transport from the intensive care unit is not only a logistical problem, but frequently associated with morbidity [1].

Interest in the time and cost savings of bedside tracheostomy has been tempered by concerns about complications, especially airway trauma and infection, when procedures are performed in the intensive care unit rather than the operating room. This prospective trial should lay to rest some of these concerns. Westphal and colleagues conclude that bedside percutaneous techniques are equally safe, and result in lower costs and reduced incidence of bacterial wound contamination when compared with traditional open tracheostomy.

Bedside procedures are not without problems. Patient positioning and lighting of the surgical field are frequently inferior, and working space at the bedside is limited compared to the operating room. Percutaneous techniques have a learning curve, not only for the surgeon, but also for the anesthesiologist or intensivist called upon to manage the bronchoscopy and sedation. Open tracheostomy may still be preferable when anatomic considerations limit the ability to safely access the airway and control possible bleeding. As the authors note, bedside tracheostomy should only be performed by physicians capable of dealing with any eventual surgical and airway complications. Finally, physicians responsible for intensive care must be aware that translaryngeal reintubation is the preferred approach, should a percutaneous tracheostomy become accidentally dislodged, since the smaller stoma makes emergency reinsertion of the tracheostomy tube difficult.

References

1. Smith I, Fleming S, Cernaianu A. Mishaps during transport from the intensive care unit. Crit Care Med 1990;18:278–81.

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Thomas L. Higgins Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Higgins, T. L. Search for Related Content PubMed Articles by Higgins, T. L. Related Collections Related Article