Fiberoptic bronchoscopy–assisted percutaneous tracheostomy is safe in obese critically ill patients: A prospective and comparative study

doi:10.1016/j.jcrc.2008.06.001

Journal of Critical Care

Volume 24, Issue 4, December 2009, Pages 494-500

https://doi.org/10.1016/j.jcrc.2008.06.001 Get rights and content

Abstract

Background

Obesity has reached epidemic proportions worldwide. In Latin America, 10% to 35% of the population is obese. Obese critically ill patients are at greater risk for requiring intubation and prolonged mechanical ventilation; and in some cases, it is necessary to perform a tracheostomy.

Objective

The objective of the study was to compare the incidence of perioperative complications associated with percutaneous tracheostomy (PT) using the fiberoptic bronchoscopy–assisted Ciaglia Blue Rhino technique (Cook Critical Care, Bloomington, IN) in obese vs nonobese critically ill patients.

Patients and Method

A prospective evaluation was made of 120 patients who underwent PT because of prolonged mechanical ventilation. An analysis of the incidence of operative and early postoperative complications was performed comparing an obese patient group (n = 25) with a nonobese patient group (n = 80). Obesity was defined by a body mass index of at least 30 kg/m².

Results

The 2 groups had no significant differences in their demographic characteristics. The average body mass index for the obese patient group was 38 ± 9 kg/m² vs 22 ± 3 kg/m² for the nonobese patient group (P < .001). The obese patients required 18 ± 7 days of mechanical ventilation, on average, before PT vs 16 ± 7 days for the nonobese patients (P = .15). The incidence of operative complications for the obese patients vs nonobese patients was 8% and 7.5%, respectively (P = 1). The incidence of early postoperative complications was 8% for the obese patients vs 2.5% for the nonobese patients (P = .2).

Conclusion

Percutaneous tracheostomy using the fiberoptic bronchoscopy–assisted Ciaglia Blue Rhino technique is safe for obese critically ill patients when performed by an experienced intensivist.

Introduction

The prevalence of obesity, defined as a body mass index (BMI) of at least 30 kg/m², has increased significantly around the world in recent years. In the European Community, its prevalence is about 20% [1]; and in the United States, it is more than 30% [2]. An increase in the obese population has been seen in Latin America as well [3]. According to the latest report from the Chilean Ministry of Health, the prevalence of obesity in Chile is about 25% (www.minsal.cl). Obese critically ill patients are at greater risk for requiring intubation and prolonged mechanical ventilation [4]; and in some cases, it is necessary to perform a tracheostomy.

Tracheostomy is one of the most common surgical procedures performed on critically ill patients [5]. The prevalence reported in studies around the world varies between 10% and 20% [6], [7], [8]. The development of various percutaneous tracheostomy (PT) techniques has facilitated the performance of this procedure on critically ill patients by reducing the time it takes to do the procedure and improving the utilization of resources [5], [9], [10]. Currently, PT is considered the technique of choice in critically ill patients, despite the fact that, for many years, obesity has been listed as a relative contraindication to the procedure. Little information exists, however, about the true risks of PT in obese critically ill patients in comparison with nonobese patients [11].

The objective of this study was to compare the incidence of perioperative complications associated with PT using the fiberoptic bronchoscopy–assisted Ciaglia Blue Rhino technique (Cook Critical Care, Bloomington, IN) in obese vs nonobese critically ill patients.

Section snippets

Patients and method

Between October of 2004 and October of 2007, a prospective evaluation was conducted of all patients on mechanical ventilation (MV) for whom performance of a PT was required. Obesity was defined by a BMI of at least 30 kg/m². The indications for a tracheostomy were (1) prolonged MV (>2 weeks), (2) failure in weaning from MV with reintubation on 2 occasions, (3) quantitative compromise of level of consciousness with inability to protect the airway during the weaning process, and (4) neuromuscular

Statistical analysis

The categorical data are presented as frequencies and percentages, whereas average and standard deviation are given for the continuous data. Paired Student t test was used for comparison of the continuous data, and Fisher exact test was used for analysis of the categorical data. SPSS 14.0 (Chicago, IL) for Windows XP was used. A P value less than .05 was considered statistically significant.

Results

During the study period, 120 PTs were performed on 120 patients in the Critical Care Unit at the University of Chile Clinical Hospital. Within this group, 25 patients were obese, with an average BMI of 38 ± 9 (range, 31-60 kg/m²). Five patients met the definition of morbidly obese; and in this patient subgroup, the average BMI was 51 ± 8 kg/m² (range, 41-60 kg/m²). Concomitantly, 80 nonobese patients were identified who underwent PT; the average BMI for this last group was 22 ± 3 kg/m² (range,

Discussion

The results of our study show that, in experienced hands, PT using the fiberoptic bronchoscopy–assisted Ciaglia Blue Rhino technique is associated with a low incidence of perioperative complications in obese critically ill patients.

Obesity has reached epidemic proportions worldwide and is not confined to the industrialized nations; currently, there are more than 300 million people affected by this condition (www.who.int/en). The number of obese patients requiring treatment in an ICU for medical

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Cited by (36)

Performance, Long-term Management, and Coding for Percutaneous Dilational Tracheostomy
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For inexperienced operators, especially nonsurgeons, we recommend avoiding such cases. We do note that with increasing experience, PDT can be performed safely in select patients who are morbidly obese,15 have short, fat necks,16 with coagulopathy,17 have neck or cervical trauma,18 and even those with high oxygen requirements.19 These latter conditions require increased operator and team experience in PDT prior to performance; in some centers, these may be best accomplished via an open surgical approach.
Percutaneous dilatational tracheotomy (PDT) has become increasingly popular and has gained widespread acceptance. The modern PDT procedure has also evolved to whereby it can be safely performed by surgeons and nonsurgeons in the ICU. Moreover, bedside PDT has proven clinical outcomes and can save hospital resources. As such, PDT done in the ICU is now a widely performed procedure, often being the tracheostomy procedure of choice. Today, many pulmonologists and intensivists who can use bedside PDT do not perform this procedure; it is conceivable this practice may expand, especially among pulmonologists and intensivists. Although numerous indications exist for tracheostomy, the focus of this article is limited to bedside PDT for prolonged mechanical ventilation, which is the most common indication for this procedure. We describe the logistics and operations needed for programs to incorporate PDT into routine ICU care.
Evidence-based guidelines for the use of tracheostomy in critically ill patients
2017, Journal of Critical Care
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In contrast, other researchers have found no significant differences in complications in obese patients. Romero et al [98] conducted a prospective study evaluating the incidence of perioperative complications associated with PT using the Ciaglia Blue Rhino technique assisted by bronchoscopy and US in critical patients. The study included 105 patients who required PT because of prolonged MV (25 obese, defined as BMI ≥ 30 kg/m2 and 80 nonobese).
To provide evidence-based guidelines for tracheostomy in critically ill adult patients and identify areas needing further research.
A taskforce composed of representatives of 10 member countries of the Pan-American and Iberic Federation of Societies of Critical and Intensive Therapy Medicine and of the Latin American Critical Care Trial Investigators Network developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation system.
The group identified 23 relevant questions among 87 issues that were initially identified. In the initial search, 333 relevant publications were identified, of which 226 publications were chosen. The taskforce generated a total of 19 recommendations, 10 positive (1B, 3; 2C, 3; 2D, 4) and 9 negative (1B, 8; 2C, 1). A recommendation was not possible in 6 questions.
Percutaneous techniques are associated with a lower risk of infections compared with surgical tracheostomy. Early tracheostomy only seems to reduce the duration of ventilator use but not the incidence of pneumonia, the length of stay, or the long-term mortality rate. The evidence does not support the use of routine bronchoscopy guidance or laryngeal masks during the procedure. Finally, proper prior training is as important or even a more significant factor in reducing complications than the technique used.
Evidence-based guides in tracheostomy use in critical patients
2017, Medicina Intensiva
Proporcionar guías de traqueostomía para el paciente crítico, basadas en la evidencia científica disponible, y facilitar la identificación de áreas en las cuales se requieren mayores estudios.
Un grupo de trabajo formado con representantes de 10 países pertenecientes a la Federación Panamericana e Ibérica de Sociedades de Medicina Crítica y Terapia Intensiva y a la Latin American Critical Care Trial Investigators Network (LACCTIN) desarrollaron estas recomendaciones basadas en el sistema Grading of Recommendations Assessment, Development and Evaluation (GRADE).
El grupo identificó 23 preguntas relevantes entre las 87 preguntas planteadas inicialmente. En la búsqueda inicial de la literatura se identificaron 333 estudios, de los cuales se escogieron un total de 226. El equipo de trabajo generó un total de 19 recomendaciones: 10 positivas (1B = 3, 2C = 3, 2D = 4) y 9 negativas (1B = 8, 2C = 1). En 6 ocasiones no se pudieron establecer recomendaciones.
La traqueostomía percutánea se asocia a menor riesgo de infecciones en comparación con la traqueostomía quirúrgica. La traqueostomía precoz solo parece reducir la duración de la ventilación mecánica pero no la incidencia de neumonía, la duración de la estancia hospitalaria o la mortalidad a largo plazo. La evidencia no apoya el uso de broncoscopia de forma rutinaria ni el uso de máscara laríngea durante el procedimiento. Finalmente, el entrenamiento adecuado previo es tanto o más importante que la técnica utilizada para disminuir las complicaciones.
Provide evidence based guidelines for tracheostomy in critically ill adult patients and identify areas needing further research.
A task force composed of representatives of 10 member countries of the Pan-American and Iberic Federation of Societies of Critical and Intensive Therapy Medicine and of the Latin American Critical Care Trial Investigators Network developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation system.
The group identified 23 relevant questions among 87 issues that were initially identified. In the initial search, 333 relevant publications were identified of which 226 publications were chosen. The task force generated a total of 19 recommendations: 10 positive (1B = 3, 2C = 3, 2D = 4) and 9 negative (1B = 8, 2C = 1). A recommendation was not possible in six questions.
Percutaneous techniques are associated with a lower risk of infections compared to surgical tracheostomy. Early tracheostomy only seems to reduce the duration of ventilator use but not the incidence of pneumonia, the length of stay, or the long-term mortality rate. The evidence does not support the use of routine bronchoscopy guidance or laryngeal masks during the procedure. Finally, proper prior training is as important or even a more significant factor in reducing complications than the technique used.
The Changing Role for Tracheostomy in Patients Requiring Mechanical Ventilation
2016, Clinics in Chest Medicine
Citation Excerpt :
Obesity is considered a risk factor for increased complications for many surgical procedures including tracheostomy.35 However, Romero and colleagues36 found that the complication rate was similar in obese versus nonobese patients (8% vs 7.5%; P = 1) in their prospective study of PT in 120 patients. Preoperative US and bronchoscopy were used for the procedures.
Real time ultrasound-guided percutaneous tracheostomy: Is it a better option than bronchoscopic guided percutaneous tracheostomy?
2015, Medical Journal Armed Forces India
Citation Excerpt :
Another difficulty was in identifying the balloon of the endotracheal tube with sonography; although we did not had a single case of tracheal cuff perforation. Two other studies reported a rate of tracheal tube cuff puncture of 13%–17% for bronchoscopy-guided PCT.7,8,16 Even though US cannot correctly identify the tracheal tube.
The purpose of this study was to evaluate the efficacy of ultrasound guided percutaneous tracheostomy (USPCT) and bronchoscopic guided percutaneous tracheostomy (BPCT) and the incidence of complications in critically ill, obese patients.
Seventy four consecutive patients were included in a prospective study and randomly divided into USPCT and BPCT. Incidence of complications, ease and efficacy were compared in obese USPCT (n = 38)and BPCT (n = 36). Results are expressed as the median (25th–75th percentile) or number (percentage).
The median times for tracheostomy were 12 min (9–14) in USPCT patients and 18 min (12–21.5) in BPCT (p = 0.05). The overall complication rate was higher in BPCT than USPCT patient group (75% vs. 321%, p < 0.05). Most complications were minor (hypotension, desaturation, tracheal cuff puncture and minor bleeding) and of higher number in the BPCT. Ultrasound-guided PCT was possible in all enrolled patients and there were no surgical conversions or deaths.
This study demonstrated that real US-guided PCT is a favourable alternative to BPCT with a low complication rate and ease, thus proving more efficacious. A US examination provides information on cervical anatomy, vasculature etc. and hence modifies and guides choice of the PCT puncture site.
Percutaneous Dilational Tracheostomy
2013, Clinics in Chest Medicine
Citation Excerpt :
A trial using multiple PDT techniques demonstrated a 2.7-fold increased risk for perioperative complications (43.8% vs 18.2%) and 4.9-fold increased risk for serious complications (9.6% vs 0.7%) in obese patients69; the complication rates in this study, however, were higher than in many comparable studies and interpretation of the results may be hindered by the use of multiple PDT methods. In contrast, several trials using a single dilator technique found no significant difference in complication rates between obese and nonobese populations.36,70,71 Although these studies categorized obesity based on body mass index, this index may not accurately reflect the impact of obesity on the soft tissue of the neck.

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^☆: The authors declare that they have no competing interest. This study was not supported by a medical company.

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Respiration/Ventilation and TracheostomyFiberoptic bronchoscopy–assisted percutaneous tracheostomy is safe in obese critically ill patients: A prospective and comparative study☆

Abstract

Background

Objective

Patients and Method

Results

Conclusion

Introduction

Section snippets

Patients and method

Statistical analysis

Results

Discussion

Clin Chest Med

Chest

Ann Thorac Surg

Injury

Chest

Chest

Surgery

J Am Coll Surg

Chest

Trends in coronary risk factors in the WHO Monica Project

Int J Epidemiol

Prevalence of overweight and obesity in the United States, 1999-2004

JAMA

Obesity prevalence and trends in Latin American countries

Obes Rev

Effect of obesity on intensive care morbidity and mortality: a meta-analysis

Crit Care Med

Recent developments in percutaneous tracheostomy: improving techniques and expanding roles

Curr Opin Crit Care

Outcome of mechanically ventilated patients who require a tracheostomy

Crit Care Med

The effect of tracheostomy on outcome in intensive care unit patients

Acta Anaesthesiol Scand

Evolution of mechanical ventilation in response to clinical research

Am J Respir Crit Care Med

Clinical review: percutaneous dilational tracheostomy

Crit Care

The impact of percutaneous tracheostomy on intensive care unit practice and training

Anaesthesia

Peri-operative complications during percutaneous tracheostomy in obese patients

Anaesthesia

Obesity-related excess mortality rate in an adult intensive care unit: a risk-adjusted matched cohort study

Crit Care Med

A prospective, randomized study comparing early percutaneous dilation tracheostomy to prolonged translaryngeal intubation (delayed tracheostomy) in critically ill medical patients

Crit Care Med

Tracheostomy timing and the duration of weaning in patients with acute respiratory failure

Crit Care Med

Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation

BMJ

A comparative study of the complications of surgical tracheostomy in morbidly obese critically ill patients

Crit Care

Appraisal of percutaneous tracheostomy

Br J Surg

Respiration/Ventilation and Tracheostomy
Fiberoptic bronchoscopy–assisted percutaneous tracheostomy is safe in obese critically ill patients: A prospective and comparative study☆