A meta-analysis of prospective randomized controlled studies comparing percutaneous and surgical tracheostomy

Introduction: Tracheostomy is one of the most commonly performed procedures in the chronically ventilated patient. While percutaneous tracheostomy (PT) is becoming increasingly utilized as an alternative to conventional surgical tracheostomy (ST), most literature evaluating these two techniques is neither prospective nor controlled. We performed a meta-analysis of available prospective, randomized, controlled studies comparing PT and ST to more fully understand the relative benefits and risks of these two procedures. Methods: We performed a MEDLINE search of English language articles from 1966 to present to identify prospective randomized studies comparing PT and ST. After establishing homogeneity (Q-statistic), studies were analyzed by a Mantel-Haenszel fixed effect model. For each clinical endpoint examined, PT and ST were compared by calculating either absolute differences (±SD) or odds ratios (OR) with 95% confidence intervals (CI) for discrete or continuous variables, respectively. Results: We pooled data from 5 studies (236 patients) satisfying our search criteria to analyze 8 clinical endpoints. Operative time was shorter for PT than ST (9.84±2.01 minutes). Further, relative to ST, PT was associated with less perioperative bleeding [OR with 95% CI 0.147 (0.021 to 0.394)], post-operative bleeding [0.394 (0.1753 to 0.8854)], and stomal infection [0.0241 (0.0082 to 0.0707)]. However, there was no difference in days intubated prior to tracheostomy (0.16±1.06), overall procedure-related complications [0.732 (0.057 to 9.37)], or death [0.635 (0.1836 to 2.1968)] comparing these two techniques. Conclusions: The data prospectively evaluating PT and ST are limited, thus, meta-analysis represents a useful tool to evaluate these two procedures. Our results suggest potential advantages of PT relative to ST, including operative time, procedure related bleeding, and post operative infection. If confirmed by additional, adequately powered prospective trials, these findings support PT as the procedure of choice for the establishment of elective tracheostomy in the appropriately selected critically ill patient.