Impact of real-time ultrasound guidance on complications of percutaneous dilatational tracheostomy: a propensity score analysis

Venkatakrishna Rajajee, Craig A Williamson, Brady T West

Recent studies have demonstrated the feasibility of real-time ultrasound guidance (RUSG) during Percutaneous Dilatational Tracheostomy (PDT), including in patients with risk factors such as coagulopathy, cervical spine immobilization (CSI) and morbid obesity. Use of RUSG has been shown to improve the technical accuracy of PDT, however, it is unclear if there is an associated reduction in complications. Our objective was to determine whether the peri-procedural use of RUSG is associated with a reduction in complications of PDT using a propensity score analysis. This study reviewed all PDTs performed in a eight-year period in a neurocritical care unit. PDTs were typically performed by trainees under guidance of the attending intensivist. Bronchoscopic guidance was used for all procedures with addition of RUSG at the discretion of the attending physician. RUSG was used to guide endotracheal-tube withdrawal, guide tracheal puncture, identify guidewire entry level and confirm bilateral lung sliding. The primary outcome was a composite of previously defined complications including (among others) bleeding, infection, loss of airway, inability to complete procedure, need for revision, granuloma and early dislodgement. Propensity score analysis was used to ensure that the relationship of not using RUSG with the probability of an adverse outcome was examined within groups of patients having similar covariate profiles. Covariates included were age, gender, body mass index, diagnosis, APACHE-2 score, timing of tracheostomy, positive end-expiratory pressure and presence of risk factors including coagulopathy, CSI and prior tracheostomy. A total of 200 patients underwent PDT during the specified period, and 107 received RUSG. Risk factors for PDT were present in 63 (32%). There were 9 complications in the group without RUSG- bleeding (n = 4), need for revision related to inability to ventilate or dislodgement (n = 3) and symptomatic granuloma (n = 2). There was one complication in the RUSG group (early dislodgement). The odds of having an adverse outcome for patients receiving RUSG were significantly lower (OR 0.08, 95%CI 0.009-0.811, p = 0.032) than for those receiving a standard technique while holding the propensity score quartile fixed. The use of real time ultrasound guidance during percutaneous dilatational tracheostomy was associated with a significant reduction in procedure-related complications.