A prospective, randomized study comparing percutaneous with surgical tracheostomy in critically ill patients

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Abstract

Objective

To determine the relative cost-effectiveness of percutaneous dilational tracheostomy (PDT) and surgical tracheostomy (ST) in critically ill patients.

Design

Prospective randomized study.

Setting

Medical, surgical, and coronary intensive care units at Barnes-Jewish Hospital, a tertiary care medical center.

Patients

Eighty critically ill mechanically ventilated patients requiring elective tracheostomy.

Interventions

Randomization to either PDT performed in the intensive care unit or ST performed in the operating room.

Measurements and Main Results

Treatment groups were well matched with respect to age (PDT, 65.44 ± 2.82 [mean ± se] years; ST, 61.4 ± 2.89 years, p = Ns), gender (PDT, 45% males; ST, 47.5% males, p = NS), severity of illness (Acute Physiology and Chronic Health Evaluation II score: PDT, 16.87 ± 0.84; ST, 17.88 ± 0.92, p = NS), and principle diagnosis. PDT was performed more quickly (PDT, 20.1 ± 2.0 mins; ST, 41.7 ± 3.9 mins, p < .0001) and was associated with lower patient charges than ST (total patient charges: PDT, $1,569 ± $157 vs. ST, $3,172 ± $114; equipment/supply charges: PDT, $688 ± $103 vs. ST, $1,526 ± $87; professional charges: PDT, $880 ± $ 54 vs. ST, $1,647 ± $50;p < .0001 for all). There were no differences in days intubated before tracheostomy (PDT, 12.7 ± 1.1 days; ST, 15.6 ± 1.9, p = .20), intensive care unit length of stay (PDT, 24.5 ± 2.5 days; ST, 28.5 ± 3.1 days, p = .33), or hospital length of stay (PDT 49.7 ± 4.2 days; ST, 43.7 ± 3.5 days, p = .28) when we compared these two techniques.

Conclusions

PDT is a cost-effective alternative to ST. The reduction in patient charges associated with PDT in this study resulted from the procedure being performed in the intensive care unit, thus eliminating the need for operating room facilities and personnel. PDT may become the procedure of choice for electively establishing tracheostomy in the appropriately selected patient who requires long-term mechanical ventilation.

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