Percutaneous dilatational tracheotomy in high-risk ICU patients

Abstract

Background: Percutaneous dilatational tracheotomy (PDT) has become an established procedure in intensive care units (ICU). However, the safety of this method has been under debate given the growing number of critically ill patients with high bleeding risk receiving anticoagulation, dual antiplatelet therapy (DAPT) or even a combination of both, i.e. triple therapy. Therefore, the purpose of this study, including such a high proportion of patients on antithrombotic therapy, was to investigate whether PDT in high-risk ICU patients is associated with elevated procedural complications and to analyse the risk factors for bleeding occurring during and after PDT.

Methods: PDT interventions conducted in ICUs at 12 European sites between January 2016 and October 2019 were retrospectively analysed for procedural complications. For subgroup analyses, patient stratification into clinically relevant risk groups based on anticoagulation and antiplatelet treatment regimens was performed and the predictors of bleeding occurrence were analysed.

Results: In total, 671 patients receiving PDT were included and stratified into four clinically relevant antithrombotic treatment groups: (1) intravenous unfractionated heparin (iUFH, prophylactic dosage) (n = 101); (2) iUFH (therapeutic dosage) (n = 131); (3) antiplatelet therapy (aspirin and/or P2Y₁₂ receptor inhibitor) with iUFH (prophylactic or therapeutic dosage) except for triple therapy (n = 290) and (4) triple therapy (DAPT with iUFH in therapeutic dosage) (n = 149). Within the whole cohort, 74 (11%) bleedings were reported to be procedure-related. Bleeding occurrence during and after PDT was independently associated with low platelet count (OR 0.73, 95% CI [0.56, 0.92], p = 0.009), chronic kidney disease (OR 1.75, 95% CI [1.01, 3.03], p = 0.047) and previous stroke (OR 2.13, 95% CI [1.1, 3.97], p = 0.02).

Conclusion: In this international, multicenter study bronchoscopy-guided PDT was a safe and low-complication airway management option, even in a cohort of high risk for bleeding on cardiovascular ICUs. Low platelet count, chronic kidney disease and previous stroke were identified as independent risk factors of bleeding during and after PDT but not triple therapy.

Keywords: Airway management; Anticoagulation; Bleeding; Dual antiplatelet therapy; Percutaneous dilatational tracheotomy.

Fig. 1

Study flowchart. Flow diagram depicting patient selection

Fig. 2

Percutaneous dilatational tracheotomy according to Ciaglia’s technique. Percutaneous dilatational tracheotomy according to Ciaglia’s technique with accompanying bronchoscopy: first, a colour Doppler ultrasound examination may be performed to ensure that no blood vessels run below the intended puncture site. After administration of local anaesthesia (A), median puncture of the trachea below the second or third tracheal clasp under bronchoscopic visualization and insertion of a Seldinger wire (B) is performed. The Seldinger guidewire is used for bougienage with different dilators (Ciaglia Blue Rhino® Set, Cook Medical) (C) under bronchoscopic visualization (D). Subsequently, the tracheal cannula is inserted along an introducer and—after bronchoscopy-guided confirmation of correct localization of the cannula within the trachea and subsequent cuff inflation—connected to the respiratory system (E). Final bronchoscopic position control of the tracheal cannula (F)