Bridging Breath and Survival: A Retrospective Analysis of Percutaneous Dilatational Tracheostomy in Critically Ill Patients

INTRODUCTION: Percutaneous Dilatational Tracheostomy (PDT) has gained widespread acceptance among critically ill patients requiring prolonged mechanical ventilation(MV) as a minimally invasive alternative to traditional surgical tracheostomy. PDT is relatively easy to perform with reduced procedural time, and has lower complication rates.(1–4) The need for long-term airway management is a global concern especially among critically ill patients. Studies suggest that up to 8-30% of mechanically ventilated patients in intensive care unit (ICU) require tracheostomy, with PDT being the preferred technique in many centres.(5,6) Despite its increasing utilization, there remains a dearth of comprehensive data on the clinical profiles and outcomes of patients undergoing PDT, particularly in the context of Nepal. OBJECTIVES: To characterize the indications, techniques and procedural complications of PDT and analyse clinical outcomes of those patients who underwent PDT in terms of length of mechanical ventilation, ICU stay, hospital stay and survival. MATERIALS AND METHODS: After ethical approval, this retrospective observational study was conducted in Level III intensive care units (ICU) of Tribhuvan University Teaching Hospital, Kathmandu, Nepal. Of the 3360 patients admitted during the three-year period from April 14, 2021 to April 13, 2024, 99 patients had undergone PDT. Outcome data were retrieved from individual data files which were available for 83 patients. (Fig. 1). RESULTS: Of the 99 patients, 65.6% were males and the median age at admission was 49 years (range 18-87 years). Neurological disorders were the primary admission diagnosis (64.6%, n=64), with intracranial hemorrhage being the most frequent diagnosis subtype. Of the 83 patients in whom outcome analysis was done, the median APACHE II score was 20.2±7.3. The mean duration of mechanical ventilation(MV) to PDT was 16 days (IQR 11-20). The main indications for tracheostomy were prolonged MV in 74.7% and inability to protect airways in 25.3%. Grigg's guidewire dilator forceps technique was the predominant method (92.7%). Immediate complications occurred in 14.5% of patients which included bleeding, transient hypotension, and subcutaneous emphysema. A total of 42 patients (50.6%) were successfully discharged from the hospital alive, of which 64% (29 patients) were decannulated before discharge. Among survivors, median MV duration was 28.5 days (IQR 20–41.5), median ICU length of stay was 32 days(IQR 22.3-44.8) and median hospital length of stay was 45.5 days (IQR 35-67). DISCUSSIONS: In this study, PDT was predominantly performed for prolonged mechanical ventilation using Grigg's technique, with acceptable immediate complication rates. The high proportion of neurological patients undergoing PDT suggests its critical role in managing neurological conditions requiring prolonged MV. The complication rate (14.5%) aligns with existing literature(7–9), demonstrating the procedure's safety when performed by experienced clinicians. This study provides valuable insights into PDT implementation in a Nepalese tertiary ICU care setting. The findings highlight the procedure's significance, particularly in neurological patients. CONCLUSIONS: PDT can be a safe procedure to bridge neurological patients requiring prolonged mechanical ventilation to survival.