Delaney Anthony, Bagshaw Sean M, Nalos Marek
Intensive Care Unit, Royal North Shore Hospital, Sydney, NSW, Australia.
Crit Care. 2006;10(2):R55. doi: 10.1186/cc4887.
Tracheostomy is one of the more commonly performed procedures in critically ill patients yet the optimal method of performing tracheostomies in this population remains to be established. The aim of this study was to systematically review and quantitatively synthesize all randomized clinical trials (RCTs), comparing elective percutaneous dilatational tracheostomy (PDT) and surgical tracheostomy (ST) in adult critically ill patients with regards to major short and long term outcomes.
MEDLINE, EMBASE, CINAHL and the Cochrane Controlled Clinical Trials Register databases were searched to identify relevant studies. Additionally, bibliographies and selected conference proceedings were reviewed, and experts in the field and manufacturers of two PDT kits were contacted. Randomized clinical trials comparing any method of elective PDT to ST that included critically ill adults and reported at least one clinically relevant outcome were included. Data extracted included trial characteristics, measures of study validity, and clinically relevant outcomes.
Seventeen RCTs involving 1,212 patients were included. Most PDTs used a multiple dilator technique and were performed in the intensive care unit (ICU). The pooled odds ratio (OR) for wound infection was 0.28 (95% confidence interval (CI), 0.16 to 0.49, p < 0.0005), indicating a significant reduction with PDT compared to ST. Overall, PDT was equivalent to ST for bleeding, major peri-procedural and long-term complications; however, subgroup analysis suggested PDT resulted in a lower incidence of bleeding (OR = 0.29 (95% CI 0.12 to 0.75, p = 0.01)) and death (OR = 0.71 (95% CI 0.50 to 1.0, p = 0.05)) when the STs were performed in the operating theatre.
PDT reduces the overall incidence of wound infection and may further reduce clinical relevant bleeding and mortality when compared with ST performed in the operating theatre. PDT, performed in the ICU, should be considered the procedure of choice for performing elective tracheostomies in critically ill adult patients.
气管切开术是危重症患者中较为常用的操作之一，但针对这一人群实施气管切开术的最佳方法仍有待确定。本研究的目的是系统回顾并定量综合所有随机临床试验（RCT），比较成年危重症患者行择期经皮扩张气管切开术（PDT）和外科气管切开术（ST）后的主要短期和长期结局。
检索MEDLINE、EMBASE、CINAHL和Cochrane对照临床试验注册数据库以识别相关研究。此外，还查阅了参考文献和选定的会议论文集，并联系了该领域的专家以及两种PDT套件的制造商。纳入比较任何择期PDT方法与ST的随机临床试验，试验对象包括成年危重症患者，并报告至少一项临床相关结局。提取的数据包括试验特征、研究效度指标和临床相关结局。
纳入了17项涉及1212例患者的RCT。大多数PDT采用多扩张器技术，且在重症监护病房（ICU）进行。伤口感染的合并比值比（OR）为0.28（95%置信区间（CI），0.16至0.49，p<0.0005），表明与ST相比，PDT可显著降低感染率。总体而言，PDT在出血、围手术期主要并发症和长期并发症方面与ST相当；然而，亚组分析表明，当在手术室进行ST时，PDT导致出血（OR = 0.29（95%CI 0.12至0.75，p = 0.01））和死亡（OR = 0.71（95%CI 0.50至1.0，p = 0.05））的发生率较低。
与在手术室进行的ST相比，PDT可降低伤口感染的总体发生率，并可能进一步降低临床相关出血和死亡率。在ICU进行的PDT应被视为成年危重症患者择期气管切开术的首选方法。
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