Is prophylactic minitracheostomy beneficial in high-risk patients undergoing thoracotomy and lung resection?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether prophylactic minitracheostomy (PM) is beneficial in high-risk patients undergoing thoracotomy and lung resection. Altogether, 115 papers were found using the reported search, of which four represented the best evidence to answer the question. Three randomised controlled trials (RCT) compared a total of 161 patients who underwent thoracotomy and received either PM or standard postoperative treatment alone. Another non-RCT of 144 patients observed the reduction of toilet bronchoscopy with the increased use of PM. These are summarised in the Table. The studies assessed the benefit of PM inserted immediately after lung resection surgery in patients perceived as at high-risk of developing pulmonary complications. High-risk defined patients as those who smoked, have poor lung function, ischaemic heart disease, chronic obstructive pulmonary disease, absence/failure of regional analgesia, and/or cerebrovascular accident. In the largest randomised study (102 patients), Bonde et al. [Bonde P, Papachristos I, McCraith A, Kelly B, Wilson C, McGuigan JA, McManus K. Sputum retention after lung operation: prospective randomized trial shows superiority of prophylactic minitracheostomy in high-risk patients. Ann Thorac Surg 2002;74:196-202] concluded that the PM group had a significant reduction in sputum retention and postoperative atelectasis. The authors also reported a reduction in the incidence of pneumonia and toilet bronchoscopy but this did not achieve statistical significance. Issa et al. [Issa MM, Healy DM, Maghur HA, Luke DA. Prophylactic minitracheotomy in lung resection. A randomized controlled study. J Thorac Cardiovasc Surg 1991;101:895-900] were able to demonstrate a significant reduction in the rate of pneumonia in the PM group and Randell et al. [Randell TT, Tierala E, Lepäntalo MJ, Lindgren L. Prophylactic minitracheostomy: a prospective, random control, clinical trial. Eur J Surg 1991;157:501-504] showed a significant reduction in postoperative atelectasis and toilet bronchoscopy in their PM group. Au et al. [Au J, Walker WS, Inglis D, Cameron EW. Percutaneous cricothyroidostomy (minitracheostomy) for bronchial toilet: results of therapeutic and prophylactic use. Ann Thorac Surg 1989;48:850-852] observed a reduction in toilet bronchoscopy from 9% to 4% in a four-year period; however, the authors could not directly relate this to the use of PM but believed it was likely. None of the studies demonstrated a statistical difference in mortality or intensive care unit or hospital length of 38 stay. All the studies reported some complications associated with minitracheostomy (MT) insertion, the incidence of which ranged from 5.6% to 57%. One percent of 227 patients who received MT in the studies experienced a life-threatening complication, the rest were minor and easily controlled. None of the complications resulted in death.