Department of Anesthesiology, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil.
Internal Medicine, Hospital São Rafael, Salvador, Brazil.
J Intensive Care Med. 2020 May;35(5):445-452. doi: 10.1177/0885066618755334. Epub 2018 Feb 7.
Percutaneous dilational tracheostomy (PDT) is a common and increasingly used procedure in the intensive care unit (ICU). It is usually performed with bronchoscopy guidance. Ultrasound has emerged as a useful tool in order to assist PDT, potentially improving its success rate and reducing procedural-related complications.
To investigate whether the ultrasound-guided PDT is equivalent or superior to the bronchoscopy-guided or anatomical landmarks-guided PDT with regard to procedural-related and clinical complications.
A systematic review of randomized clinical trials was conducted comparing an ultrasound-guided PDT to the control groups (either a bronchoscopy-guided PDT or an anatomical landmark-guided PDT) in patients undergoing a PDT in the ICU. The primary outcome was the incidence of major procedural-related and clinical complication rates. The secondary outcome was the incidence of minor complication rates. Random-effect meta-analyzes were used to pool the results.
Four studies fulfilled the inclusion criteria and they were analyzed. The studies included 588 participants. There were no differences in the major complication rates between the patients who were assigned to the ultrasound-guided PDT when compared to the control groups (pooled risk ratio [RR]: 0.48; 95% confidence interval [CI]: 0.13-1.71, = 0%). The minor complication rates were not different between the groups, but they had a high heterogeneity (pooled RR: 0.49; 95% CI 0.16-1.50; = 85%). The sensitivity analyzes that only included the randomized controlled trials that used a landmark-guided PDT as the control group showed lower rates of minor complications in the ultrasound-guided PDT group (pooled RR: 0.55; 95% CI: 0.31-0.98, = 0%).
The ultrasound-guided PDT seems to be safe and it is comparable to the bronchoscopy-guided PDT regarding the major and minor procedural-related or clinical complications. It also seems to reduce the minor complications when compared to the anatomical landmark-guided PDT.
经皮扩张气管切开术（PDT）是重症监护病房（ICU）中常用且日益普及的操作。该操作通常在支气管镜引导下进行。超声已成为一种有用的工具，可以辅助 PDT，有可能提高其成功率并减少与操作相关的并发症。
研究超声引导的 PDT 在操作相关和临床并发症方面与支气管镜引导或解剖学标志引导的 PDT 相比是否等效或更优。
对比较 ICU 中接受 PDT 的患者接受超声引导 PDT 与对照组（支气管镜引导 PDT 或解剖学标志引导 PDT）的随机临床试验进行系统评价。主要结局是主要操作相关和临床并发症发生率。次要结局是小并发症发生率。采用随机效应荟萃分析汇总结果。
四项研究符合纳入标准并进行了分析。这些研究共纳入 588 名患者。与对照组相比，接受超声引导 PDT 的患者主要并发症发生率无差异（汇总风险比 [RR]：0.48；95%置信区间 [CI]：0.13-1.71， = 0%）。两组间小并发症发生率无差异，但存在高度异质性（汇总 RR：0.49；95% CI 0.16-1.50； = 85%）。仅纳入以标志引导 PDT 为对照组的随机对照试验的敏感性分析显示，超声引导 PDT 组小并发症发生率较低（汇总 RR：0.55；95% CI：0.31-0.98， = 0%）。
超声引导 PDT 似乎是安全的，与支气管镜引导 PDT 相比，在主要和次要操作相关或临床并发症方面是等效的。与解剖学标志引导 PDT 相比，它似乎还可以减少小并发症。
