eISSN 2635-5280

Original Article
J Neurointensive Care 2019;2(2):64-69
https://doi.org/10.32587/jnic.2019.00213

Safety and Feasibility of Percutaneous Dilatational

Tracheostomy Performed by a Neurointensivist Compared
with Conventional Surgical Tracheostomy in Neurosurgery
Intensive Care Unit
John Kwon1, Yong Oh Kim2, Jeong-Am Ryu1,2
1
Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
2
Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Received: August 28, 2019

Accepted: September 10, 2019 Objective
To evaluate safety and feasibility of percutaneous dilatational tracheostomy (PDT) performed by a
Corresponding Author: neurointensivist compared with conventional surgical tracheostomy (CST) in neurosurgery patients
Jeong-Am Ryu, M.D., Ph.D. and neurocritically ill patients.
Department of Critical Care Methods
Medicine and Department of This was a retrospective and observational study of adult patients who underwent tracheostomy in
Neurosurgery, Samsung Medical neurosurgical intensive care unit (ICU) from January 2015 to December 2017. The primary end-
Center, Sungkyunkwan University point was procedure-induced complications. Secondary endpoints were initial success of tracheosto-
School of Medicine, 81 Irwon-ro, my and procedure time.
Gangnam-gu, Seoul 06351, Korea
Results
Tel: +82-2-3410-6399
Fax: +82-2-2148-7088 A total of 118 patients underwent tracheostomy during the study period. Elective surgery of brain tu-
E-mail: lamyud.ryu@samsung.com mor (33.1%) and intracranial hemorrhage (20.3%) were the most common reasons for ICU admis-
sion. Prolonged intubation (42.4%) and airway protection or prevent risk of aspiration (25.4%) were
the most common reasons for tracheostomy. There was no significant difference in initial success rate
of tracheostomy between the two groups (p=0.110). However, procedural time was lengthier in CST
than that in PDT (39.0 [30.0–60.0] min vs. 15.0 [11.0–23.0] min, p<0.001). Procedure-induced
complications were more common in patients who underwent CST compared to those in patients
who underwent PDT (26.3% vs. 11.5%, p=0.039). Although moderate or major bleeding occurred in
five patients who underwent CST, only one patient had moderate bleeding in PDT. Especially, there
were two respiratory arrests during procedure in CST. In addition, two VAPs and seven wound infec-
tions occurred in CST.
Conclusions
PDT performed by a neurointensivist may be safe and feasible compared to CST in neurosurgery pa-
tients and neurocritically ill patients.

Keywords: Percutaneous dilatational tracheostomy; Neurointensivist; Neurosurgery intensive care unit

Copyright © 2019 The Korean Neurointensive Care Society

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/)
which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

64 www.e-jnic.org
PDT by a Neurointensivist John Kwon et al.

INTRODUCTION cheostomy and procedure time were investigated. Procedure time

was defined as time from sterilization to connection of the trache-
Percutaneous dilatational tracheostomy (PDT) has been increas- ostomy tube with the mechanical ventilator after successful trache-
ingly used because of its easy placement with lower rates of clinically ostomy11,12). Primary endpoint was procedure-induced complica-
significant bleeding and wound infection in critically ill patients17). tion. We investigated complications at insertion or during mainte-
Tracheostomy may be performed in neurosurgery or neurocritially nance such as insertional injury, bleeding or hematoma, fracture of
ill patients due to various reasons such as prolonged intubation, air- tracheal ring, cuff perforation, accidental decannulation, surgical
way protection, or to prevent risk of aspiration caused by brain inju- conversion, hypoxemia, stomal ulcer, and ventilator-associated
ries12,17). In patients with brain injuries, tracheostomy has to be more pneumonia (VAP). Regarding associated post-procedural bleeding
vigilantly performed17). Neurointensivists are specialists focusing on complications, major bleeding was defined as bleeding that re-
management of brain injured patients16). Therefore, PDT per- quired cauterization, surgical treatment, or additional blood trans-
formed by a neurointensivist may have many theoretical advantages fusion11,12). Minor bleeding was defined as bleeding from the inci-
due to easy placement at bedside, low risk of complications, and sion site that required dressing more than three times a day or epi-
specialized management for brain injured patients17). nephrine for local hemostasis. VAP was defined if patients received
However, there are limited reports of PDT in neurocritially ill clinical diagnosis more than 48 hours after tracheotomy and re-
patients12,17). In addition, there has been no report about complica- ceived antimicrobial therapy with a new radiographical infiltrate
tions associated with fiberoptic bronchoscopy during PDT. In pa- and two of three clinical criteria: purulent secretions, fever, and
tients with head injuries, fiberoptic bronchoscopy can lead to intra- leukocytosis or leukopenia13,17). Secondary endpoints were initial
cranial hypertension10). Therefore, the purpose of this study was to success of tracheostomy and procedure time.
investigate the safety and feasibility of PDT performed by a neuro-
intensivist compared with conventional surgical tracheostomy Procedure
(CST) in neurosurgery patients and neurocritically ill patients. In this study, a neurointensivist or a neurosurgeon determined
tracheostomy. Tracheostomy was considered if a patient was ex-
METHODS pected to be on prolonged mechanical ventilation, need air way
protection, or show decreased sedation due to neurocritically ill
Study population and design and/or general critically conditions6). We considered optimal
This was a retrospective, single-center, observational study of candidates to be patients without (1) uncontrolled increased in-
adult patients admitted to the neurosurgical intensive care unit tracranial hypertension, or impending brainstem herniation; (2)
(ICU) at Samsung Medical Center from January 2015 to De- acute phase of stroke or delayed cerebral ischemia in subarach-
cember 2017. This study was approved by the Institutional Re- noid hemorrhage; (3) refractory status epilepticus; (4) fraction
view Board of Samsung Medical Center (approval number: SMC of inspired oxygen (FiO2) greater than 0.6, positive end-expirato-
2018-09-011). The requirement for informed consent was ry pressure greater than 10 cm H2O or plateau pressure greater
waived due to its retrospective nature. We included adult patients than 40 cm H2O; (5) requiring high-dose inotropes or vasopres-
admitted to the neurosurgical ICU who underwent tracheosto- sors; (6) uncontrolled dysrrhythmia; (7) severe acidosis; (8) ac-
my during the study period. Those who were hospitalized for tive bleeding; (9) active infection at the tracheostomy site or
more than 14 days after tracheostomy were selected. Of these pa- gross neck deformity6). In PDT performed by a neurointensivist,
tients, we excluded patients under age 18, those who did not patients received sedation and pain control with propofol or mid-
have brain injury, those who were discharged before 14 days after azolam, intravenous analgesics with fentanyl and/or remifentanil,
tracheostomy, and those who had insufficient medical records. and topical analgesic with 1.5% lidocaine and 1:200,000 epi-
Additionally, patients were excluded if they were admitted to de- nephrine17). Especially, at least 30 minutes before the procedure,
partments other than neurosurgery. a continuously high dose infusion of propofol and bolus admin-
istration of osmotic agent were performed for patients with intra-
Definitions and outcomes cranial hypertension. Mechanical ventilation was controlled and
We retrospectively reviewed all neurosurgery patients and neu- FiO2 was increased to 1.0. Before administration of neuromuscu-
rocritcally ill patients admitted to the neurosurgery ICU who un- lar blockade, the goal of sedation was to achieve Richmond Agi-
derwent tracheostomy during the study period. Regarding data tation Sedation Scale goal of negative 4 to 56,18). Anatomic land-
associated with the tracheostomy procedure, initial success of tra- marks were identified by palpation. We also used ultrasonography

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PDT by a Neurointensivist John Kwon et al.

to identify and avoid large blood vessels near the tracheostomy Statistical analyses
site6). PDT was performed using Ciaglia Blue Rhino® (Cook Medi- All data are presented as medians and interquartile ranges
cal Inc., Bloomington, IN, USA) by a neurointensivist at bedside. (IQRs) for continuous variables and numbers (percentages) for
Patients were kept in supine position with hyperextension of the categorical variables. Data were compared using Mann-Whitney U
neck during procedure. About 10 mm vertical incision was made test for continuous variables and Chi-squared test or Fisher’s exact
at the inferior edge of the cricoid cartilage5,11). Pretracheal soft tis- test for categorical variables. All tests were two-sided and p-values
sues were bluntly dissected with a mosquito clamp if needed. Un- < 0.05 were considered statistically significant. Data were analyzed
derlying trachea was then identified using a needle and introducer using IBM SPSS statistics version 20 (IBM, Armonk, NY, USA).
sheath under bronchoscopic visualization. After a J-tipped Selding-
er wire was inserted through the introducer sheath into the trachea, RESULTS
the introducer sheath was then removed and dilation of the trachea
and soft tissue was performed initially with a short dilator followed Baseline characteristics and procedural
by a curved conical dilator5,11). Finally, the tracheostomy tube was characteristics
loaded onto an introducer dilator and gently inserted into the tra- A total of 118 patients were analyzed in this study. Among these
chea over the guidewire through the dilated stoma and secured in patients, 61 underwent PDT by a neurointensivist and 57 patients
place under bronchoscopic visualization9). underwent CST (36 by neurosurgeons, 21 by otolaryngologists)
CST was performed by a neurosurgeon or an otolaryngologist at during the study. CST was performed in 4 (1 by neurosurgeons, 3
bedside or surgical room. In tracheostomy performed by a neuro- by otolaryngologists) patients in the operating room. Median age of
intensivist or neurosurgeon, T-cannula was changed by neurosur- patients was 61 (IQR 49–70) years. Of 118 patients, 51 (43.2%)
gery residents at the first seven day. However, in CST performed were males. Elective surgery of brain tumor (33.1%) and intracrani-
by an otolaryngologist, T-cannula was changed by an otolaryngol- al hemorrhage (20.3%) were the most common reasons for ICU
ogist at the first three day after CST. admission. There was no significant difference in age, gender, body
mass index, comorbidities, Glasgow Coma Scale, or APACHE II

Table 1. Baseline characteristics

PDT (n=61) CST (n=57) p-value
Age (yr) — median (IQR) 59.0 (47.0–70.0) 64.0 (55.0–70.0) 0.297
Gender, male — no. of patients (%) 28 (45.9) 23 (40.4) 0.673
BMI (kg/m2) — median (IQR) 23.9 (20.9–25.7) 23.5 (20.2–25.5) 0.368
Obese (BMI >30 kg/m2) — no. of patients (%) 4 (6.6) 4 (7.0) 0.999
Comorbidities — no. of patients (%)
 Hypertension 33 (54.1) 35 (61.4) 0.538
  Diabetes mellitus 20 (32.8) 13 (22.8) 0.316
 Dyslipidemia 11 (18.0) 18 (31.6) 0.135
 Malignancy 17 (27.9) 8 (14.0) 0.107
  Coronary artery disease 4 (6.6) 5 (8.8) 0.737
  Chronic kidney disease 3 (4.9) 4 (7.0) 0.710
  Chronic liver disease 3 (4.9) 3 (5.3) 0.999
Reason for ICU admission — No. of patients (%)
  Brain tumor 29 (47.5) 10 (17.5) 0.014
  Intracranial hemorrhage 10 (16.4) 14 (24.6)
  Traumatic brain injury 10 (16.4) 13 (22.8)
  Subarachnoid hemorrhage 7 (11.5) 17 (29.8)
  Cerebral infarction 2 (3.3) 3 (5.3)
 Other 3(4.9) 0 (0)
GCS on ICU admission — median (IQR) 7.0 (4.0–12.0) 7.0 (4.0–8.0) 0.412
APACHE II score on ICU admission — median (IQR) 26.0 (24.0–30.0) 28.0 (25.0–30.0) 0.117
PDT: Percutaneous dilatational tracheostomy; CST: conventional surgical tracheostomy; IQR: interquartile range; BMI: body mass index; ICU: intensive care
unit; CNS: central nerve system; GCS: Glasgow Coma Scale; APACHE: Acute Physiology and Chronic Health Evaluation.

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Table 2. Procedural characteristics at the time of tracheostomy

PDT (n=61) CST (n=57) p-value
Reason for tracheostomy—No. of patients (%) 0.51
  Difficult ventilator weaning or prolonged intubation 29 (47.5) 21 (36.8)
  Airway protection or prevent risk of aspiration 14 (23.0) 16 (28.1)
  Reduction of sedative 10 (16.4) 14 (24.6)
  Airway toilet 5 (8.2) 2 (3.5)
  Difficult airway 3 (4.9) 4 (7.0)
Use of antiplatelet agent—No. of patients (%) 3 (4.9) 1 (1.8) 0.619
Use of hyperosmolar agent during tracheotomy—No. of patients (%) 0 (0) 2 (0) 0.231
GCS on procedure—median (IQR) 7.0 (6.0–12.0) 7.0 (6.0–10.0) 0.967
Invasive ICP monitoring—No. of patients (%) 33 (54.1) 32 (56.1) 0.97
Duration of mechanical ventilation before tracheostomy (days)— 9.0 (4.0–14.0) 8.0 (5.0–11.0) 0.49
median (IQR)
Inserted site—No. of patients (%) 0.177
 1st tracheal membrane 13 (21.3) 21 (36.8)
 2nd tracheal membrane 36 (59.0) 27 (47.4)
 3rd tracheal membrane 12 (19.7) 9 (15.8)
Lab results on the day of tracheostomy—median (IQR)
  Platelet count (×103/μl) 228 (164–288) 220 (165–265) 0.579
 PT(INR) 1.1 (1.1–1.2) 1.1 (1.1–1.2) 0.333
  aPTT (sec) 36.4 (34.0–40.9) 36.1 (33.1–41.4) 0.605
Ventilator setting—median (IQR)
 FiO2 (%) 35.0 (30.0–40.0) 35.0 (30.0–40.0) 0.638
  PEEP (cmH2O) 5.0 (5.0–5.0) 5.0 (5.0–5.0) 0.638
Vasopressor requirement—No. of patients (%) 9 (14.8) 9 (15.8) 0.876
PDT: Percutaneous dilatational tracheostomy; CST: conventional surgical tracheostomy; GCS: Glasgow Coma Scale; IQR: interquartile
range; ICP: intracranial pressure; INR: international normalized ratio; aPTT: activated partial thromboplastin time; FiO2: Fraction of
inspired oxygen; PEEP: positive end-expiratory pressure.

score on ICU admission between the two groups except for reason tious complication in patients who underwent PDT, two VAPs and
for admission among baseline characteristics (Table 1). Difficult seven wound infections occurred in patients who underwent CST.
ventilator weaning or prolonged intubation (42.4%) and airway However, there was no significant difference in mortality or length
protection or prevent risk of aspiration (25.4%) were the most com- of stay in the ICU or hospital between the two groups. There was
mon reasons for tracheostomy. There were no significant differenc- no procedure-induced intracranial hypertension (intracranial pres-
es in laboratory results of platelet count or coagulation on the day of sure [ICP] > 20 mmHg) during tracheostomy in either group.
tracheostomy between the two groups (Table 2). Clinical outcomes were shown in Table 3

Clinical outcomes DISCUSSION

There was no significant difference in initial success rate of tra-
cheostomy between the two groups (p = 0.110). However, pro- In this study, we investigated the safety and feasibility of PDT
cedural time was lengthier in CST than that in PDT (39.0 [30.0– performed by a neurointensivist at bedside compared with CST
60.0] min vs. 15.0 [11.0–23.0] min, p < 0.001). Procedure-in- in neurocritically ill patients. This study had the following major
duced complications were more common in patients who under- findings: 1) Procedure-induced complications were more com-
went CST compared to those in patients who underwent PDT mon in the CST group than those in the PDT group; 2) There was
(26.3% vs. 11.5%, p=0.039). Although moderate or major bleed- no significant difference in initial success rate of tracheostomy be-
ing occurred in five patients who underwent CST, only one patient tween the two groups; 3) Procedural time was lengthier in CST
had moderate bleeding in PDT. Especially, there were two respira- than that in PDT; 4) However, there were no significant differenc-
tory arrests during procedure in CST. Although there was no infec- es in mortalities or length of stay in the ICU or hospital between

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PDT by a Neurointensivist John Kwon et al.

Table 3. Clinical outcomes

PDT (n=61) CST (n=57) p-value
Procedural data
  Initial success of tracheostomy — No. of patients (%) 61 (100) 54 (94.7) 0.110
  Procedure time (min) — median (IQR) 15.0 (11.0–23.0) 39.0 (30.0–60.0) <0.001
Complication — No. of patients (%) 7 (11.5) 15 (26.3) 0.039
 Bleeding 4 (6.6) 9 (15.8) 0.109
   Moderate or major bleeding 1 (1.6) 5 (8.8) 0.105
  Minor bleeding 3 (4.9) 4 (7.0) 0.710
 Infection 0 (0) 3 (5.3) 0.110
  Ventilator-associated pneumonia 0 (0) 2 (3.5) 0.231
   Wound infection within 7days 0 (0) 1 (1.8) 0.483
  Fracture of tracheal ring 3 (4.9) 0 (0) 0.244
  Lost airway & respiratory arrest 0 (0) 2 (3.5) 0.231
  Subcutaneous emphysema 0 (0) 1 (1.8) 0.483
Outcomes
  ICU mortality — No. of patients (%) 2 (3.3) 0 (0) 0.496
  Hospital mortality — No. of patients (%) 6 (9.8) 3 (5.3) 0.493
  Length of stay in ICU (days) — median (IQR) 16.0 (10.0–22.0) 13.0 (10.0–17.0) 0.279
  Length of stay in hospital (days) — median (IQR) 49.0 (26.0–73.0) 49.0 (36.0–73.0) 0.550
PDT: Percutaneous dilatational tracheostomy; CST: conventional surgical tracheostomy; IQR: interquartile range; ICU: intensive care unit.

the two groups. emic encephalopathy, and neuromuscular respiratory failure16).

PDT is a relatively safe procedure that can be easily learned by Tracheostomy is generally performed in patients with these neuro-
physicians with less experience in surgery than CST21). A recent critically ill problems1,2,7,8,15,20). Neurointensivists may be more vigi-
study has shown that there are no significant differences in clinical lant in recognizing and managing subtle dangers such as hypoven-
outcomes or complications between trainee-led PDT and experi- tilation, head-down positioning, hypoxia, hypotension, and elevat-
enced intensivist-led PDT11). Therefore, PDT performed by sub- ed ICP that might occur in brain injured patients during the proce-
specialty trainees of critical care medicine is a safe and feasible pro- dure14,19,20). Therefore, a neurointensivist may have advantages of
cedure11). In addition, PDT can be performed by an intensivist at performing the procedure for managing neurocritically ill patients.
bedside in critically ill patients due to risk of transport3,4,11,12,17,21). In This study has several limitations. First, it was a retrospective re-
fact, PDT has been recognized as a reliable alternative to CST21). view of medical records. Second, tracheostomy was determined by
Recently, PDT has been increasingly used because of its lower a neurointensivist or a neurosurgeon. It was not protocol-based. In
complications such as bleeding and wound infections17). In this addition, the non-randomized nature of registry data might have
study, procedure-induced complications were much lower in pa- resulted in selection bias. Third, there was no procedure-induced
tients who underwent PDT than those in patients who underwent intracranial hypertension during tracheostomy. However, the mea-
CST. Especially, there was no fatal complication in patients who surement of ICP during procedure might not be accurate. Finally,
underwent PDT. There has been no report about complications our study had limited statistical power due to its small sample size.
associated with fiberoptic bronchoscopy during PDT. In patients Although it provides valuable insight, prospective large-scale stud-
with head injuries, fiberoptic bronchoscopy can lead to intracranial ies are needed to evaluate the usefulness of PDT performed by a
hypertension10). Sustained increased ICP may lead to poor out- neurointensivist for patients with severe brain injuries to obtain ev-
come in neurocritically ill patients9,10). However, there was no pro- idence-based conclusions.
cedure-induced intracranial hypertension during tracheostomy in
either group of the present study. CONCLUSION
Why is it important for a neurointensivist to perform a PDT in
brain injured patients? Neurointensivists are specialists focusing on In this study, procedure-induced complications were fewer in
management of patients with acute neurologic conditions, includ- patients who underwent PDT compared to those in patients who
ing traumatic brain injury, stroke, status epilepticus, hypoxic-isch- underwent CST. In addition, procedural time was shorter in

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PDT by a Neurointensivist John Kwon et al.

PDT compared to CST. Therefore, PDT performed by a neuro- with spontaneous supratentorial hemorrhage. Cerebrovasc Dis
intensivist may be safe and feasible compared to CST in neuro- 2006;21:159–165.
surgery patients and neurocritically ill patients. 9. Jeon SB, Koh Y, Choi HA, Lee K. Critical care for patients with
massive ischemic stroke. J Stroke 2014;16:146–160.
NOTES 10. Kerwin AJ, Croce MA, Timmons SD, Maxwell RA, Malhotra
AK, Fabian TC. Effects of fiberoptic bronchoscopy on intracra-
Conflict of interest nial pressure in patients with brain injury: a prospective clinical
The authors declare that they have no competing interests. study. J Trauma 2000;48:878–882; discussion 882-873.
11. Lee D, Chung CR, Park SB, Ryu J-A, Cho J, Yang JH, et al. Safe-
Informed consent ty and Feasibility of Percutaneous Dilatational Tracheostomy
Informed consent was obtained from each participant includ- Performed by Intensive Care Trainee. Korean J Crit Care Med
ed in this study. 2014;29:64–69.
12. Lee DH, Jeong J-H. Safety and Feasibility of Percutaneous Dila-
ACKNOWLEDGEMENTS tational Tracheostomy in the Neurocritical Care Unit. J Neuro-
crit Care 2018;11:32–38.
We would like to thank Hye Jung Kim, the nursing director of 13. Michael SN, Donald EC. Guidelines for the management of
the neurosurgical intensive care unit, for providing excellent ad- adults with hospital-acquired, ventilator-associated, and health-
vice and engaging in fruitful discussions. We would also like to care-associated pneumonia. Am J Respir Crit Care Med
thank all nurses of the neurosurgery intensive care unit at Sam- 2005;171:388–416.
sung Medical Center. 14. Milanchi S, Magner D, Wilson MT, Mirocha J, Margulies DR.
Percutaneous tracheostomy in neurosurgical patients with in-
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