Chest radiographs after dilatational percutaneous tracheotomy: Are they necessary?

Chest radiographs after dilatational percutaneous tracheotomy: Are they necessary? DAVID R. DONALDSON, MD, A. J. EMAMI, MD, and MARK K. WAX, MD, Buffalo, New York, Phoenix, Arizona,

and Portland, Oregon

BACKGROUND: The efficacy of routinely obtaining chest radiographs after standard open tracheotomy has been questioned. Recent literature would suggest that after a routine, uncomplicated tracheotomy, chest radiography is a low-yield procedure that incurs unnecessary expense. Percutaneous dilatational tracheotomy (PDT) is rapidly replacing open tracheotomy as the intensive care unit procedure of choice for airway management. Complication rates are equivalent between the two procedures. OBJECTIVE: We examined the value and cost-effectiveness of routine postoperative chest radiographs in patients undergoing PDT. STUDY DESIGN AND SETTING: The study was a prospective analysis of 54 consecutive PDTs performed at a tertiary care academic institution. RESULTS: Eighteen (33%) patients had chest radiographs obtained within 1 hour of PDT (6 at the request of the otolaryngology service); 35 (66%) underwent radiography more than 2 hours later at the request of the intensive care unit for reasons other than PDT. There were no incidents of pneumothorax, pneumomediastinum, or tracheotomy tube malposition in any patient. Patients undergoing chest radiography within 1 hour of the PDT also had chest radiographs within 12 hours at the request of ICU staff for their underlying disease. CONCLUSIONS: Routine chest radiography after PDT is of low yield. Because most of these patients require chest radiographs for their underlying dis-

From the Department of Otolaryngology–Head and Neck Surgery, State University of New York at Buffalo (Dr Donaldson); and the Department of Otolaryngology–Head and Neck Surgery, Oregon Health Sciences University (Dr Wax). Dr Emami is in private practice in Phoenix, AZ. Presented at the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery, New Orleans, LA, September 26-29, 1999. Reprint requests: Mark K. Wax, MD, Department of Otolaryngology–Head and Neck Surgery, Oregon Health Sciences University, 3181 Sam Jackson Park Rd, PV-01, Portland OR 97201-3098. Copyright © 2000 by the American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. 0194-5998/2000/$12.00 + 0 23/1/107455 doi:10.1067/mhn.2000.107455 236

ease within 12 hours, a cost savings of approximately $13,500 would be realized in this patient population. SIGNIFICANCE: Routine chest radiography after PDT is unwarranted in most cases. (Otolaryngol Head Neck Surg 2000;123:236-9.)

Attention in the health care industry has focused sharply on cost containment. In considering resource allocation, health care providers have begun to assess many routine practices in medicine with regard to costeffectiveness and outcomes-based justification. Many clinical guidelines used in medicine today, when practiced in a rote manner, may include methods that do not significantly alter patient care and are not cost-effective. Recently, tracheotomy has been identified as a primary determinant in resource utilization in head and neck surgery.1 As such, any adjunctive practice to tracheotomy—such as chest radiography (CXR)—will also contribute significantly to overall resource consumption and should be closely scrutinized for utility and necessity. The efficacy and utility of routinely obtaining chest radiographs after standard open tracheotomy has been questioned in the literature.2-5 Percutaneous dilatational tracheotomy (PDT) has been widely used among medical intensivists and trauma physicians as the method of choice for surgical airway procurement and is rapidly gaining popularity among surgeons in the surgical intensive care unit (ICU). Recent data from our institutional study of PDT in a residency training program6 found significant advantages of PDT over standard open tracheotomy in operative time, cost, and complications. The utility of obtaining routine chest radiographs after PDT has not been examined. METHODS AND MATERIAL From January 1996 to April 1998, 54 consecutive patients undergoing PDT at a tertiary care academic institution were prospectively analyzed. Appropriate review and approval by the local institutional review board were obtained. Patient demographic information, length of intubation, indication for tracheotomy, timing of postprocedural chest radiograph, radiologist interpretation of CXR findings, and any subsequent effects of CXR findings on patient care were tabulated and

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Table 1. Primary indication for tracheotomy Indication

Patient No.

Pulmonary Cardiac Neurologic Neoplasm

20 16 13 5

analyzed. Intraoperative and postoperative complications and rendered treatment were also recorded. All patients were intubated and received an intravenous sedative and narcotic plus neuromuscular blockade (n = 51) for bedside procedures, or a combination of general anesthesia and narcotic (n = 3) for operating room procedures. Fifty-three patients underwent either immediate (within 1 hour) or delayed (after 1 hour) CXR after PDT. Obtaining posttracheotomy chest radiographs after uncomplicated procedures was not our standard practice if the physical examination was appropriate. Our indications for immediate post-PDT CXR were (1) unfavorable anatomy, (2) complicated or difficult insertions, or (3) significant positive ventilator support because of underlying illness. Six (11%) patients fit these criteria. Twelve others had CXR within 1 hour (immediate) of PDT at the discretion of the ICU staff, for a total of 33%. These were obtained as part of routine posttracheotomy care. The remaining 35 (66%) patients had CXR performed at variable times more than 2 hours after surgery (delayed), again at the discretion of the ICU staff as part of routine posttracheotomy care. Overall, 47 CXR films were requested by the ICU staff (88%), versus 6 (11%) by the surgical team. All patients who underwent immediate postPDT CXR had a further radiograph within 12 hours. RESULTS

The study population consisted of adults with a mean age of 64 years and a male/female ratio of 3:1 (39/13). Average time of intubation before PDT was 11 (±6.3) days. Four procedures were performed in the operating room in conjunction with other procedures, whereas the remaining 50 were performed in the ICU at the bedside. The primary underlying systemic diseases leading to tracheotomy are summarized in Table 1. Pulmonary complications predominated and included prolonged intubation, failure to wean from ventilatory support, and need for greater pulmonary toilet. There were no cases of emergent PDT in this series. Complications occurred in 11% of patients and are listed in Table 2. Included are 4 episodes of postoperative bleeding, 3 of which required no intervention and spontaneously resolved within 24 hours. One patient underwent bedside cautery of a persistently oozing skinedge vessel. The endoscopist recognized one case of initial misplacement of the tracheotomy tube immediately,

Fig 1. Distribution of CXR timing.

and correct placement ensued without sequelae. A single death occurred in a patient with a history of recurrent pneumothoraces who was comatose after a massive cerebrovascular accident. He had standing do not resuscitate orders. Tracheotomy had been requested for pulmonary toilet and as a comfort measure. Shortly after an uneventful PDT, cardiorespiratory arrest occurred, and he died. Distribution of CXR timing is outlined in Fig 1. Six post-PDT CXR films (11%) were requested by the surgical team, 5 for difficult tracheotomy tube insertion and 1 for a patient with abnormal local anatomy who had had a previous tracheotomy. The remaining 47 (88%) post-PDT CXR films were ordered by the ICU staff as part of their standard procedure. Eighteen (33%) chest radiographs were obtained immediately (within 1 hour) after PDT. Sixty-six percent were obtained at a later time, ranging from 2 to 12 hours after PDT. There were no incidents of pneumothorax, pneumomediastinum, or tracheotomy tube malposition reported in 53 postprocedural chest radiographs. On the basis of the post-PDT chest radiograph readings, no significant clinical interventions or treatment plan changes were instituted. DISCUSSION

The effectiveness of routine, daily CXR (not postprocedural) in certain patient populations has been established in the literature as effective in discovering new anomalies and altering subsequent patient care. In their study of medical ICU and surgical ICU patients with predominantly cardiopulmonary processes, Henschke et al7 examined 1132 chest radiographs in 140 medical ICU and surgical ICU patients. They found that 65% of these patients exhibited moderate or marked cardiopulmonary abnormalities or device malpositioning. This incidence varied from 55% to 70% on a daily basis, prompting care management changes. Specific device anomalies included malposition of pulmonary artery catheters (38%), endotracheal tubes

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Table 2. Complications associated with PDT in our patients

Table 4. Estimated cost of unnecessary chest radiographs

Complication

No. of patients (%)

Barlow et al2

Smith et al5

Park and Smith4

Present study

Hemorrhage Malinsertion Infection Pneumothorax Pneumomediastinum Malposition Death

4 (7.4) 1 (1.8) 0 0 0 0 1 (1.8) 6 (11)

$10,020

$66,000

$20,000

$13,500

TOTAL

Table 3. Indications for posttracheotomy CXR Barlow et al2 Pediatric patient Emergent procedure Displaced tube Clinical indications (pneumothorax) Difficult procedure Smith et al5 Pediatric patient Urgent/emergent procedure Difficult procedure Park and Smith4 Local anesthesia Emergent procedure Uncontrolled procedure

(12%), thoracostomy tubes (10%), and central venous catheters (9%). Tracheostomy tubes were not specifically addressed. In an earlier work Greenbaum and Marschall8 demonstrated similar findings with a 43% rate of CXR abnormalities altering the care of ICU patients. The role of postprocedural (nontracheotomy) CXR is controversial. Obtaining routine CXR films after endotracheal intubation and placement of thoracostomy tubes is supported based on the incidence of tube malposition (20% and 29%, respectively), as well as the reported difficulty in clinical detection of endotracheal tube misplacement.9,10 Central arterial and venous catheterization has been associated with CXR-documented misplacement in nearly 6% of cases,11 whereas others have found this rate can be dropped to essentially nil with meticulous attention to technique and thorough postprocedure physical examination.12 In the past, posttracheotomy CXR was considered essential13 to detect serious complications such as pneumothorax and pneumomediastinum as well as to confirm correct tube placement. However, recent studies2-5 have challenged this practice in standard open tracheotomy.

All concluded that the routine use of posttracheotomy CXR in uncomplicated cases is unwarranted. A universally agreed upon indication for post-tracheotomy CXR is the pediatric patient. Children have a higher incidence of tracheotomy-associated pneumothorax (10%-19%) because of their high-riding pleural domes.14-16 Other indications are less clear. Barlow et al2 cited their indications for posttracheotomy CXR, which included procedures in children, emergent procedures, displaced tubes, signs or symptoms of pneumothorax, and difficult tracheotomies. Indications for Park and Smith4 included procedures performed with the patient under local anesthesia or uncontrolled, emergent procedures. Similarly, Smith et al5 included children and the performance of urgent, emergent, or difficult procedures as criteria for obtaining posttracheotomy CXR. These studies found that routine CXR after tracheotomy in uncomplicated cases did not alter patient management and unnecessarily consumed $10,000 to $66,000 in health care resources. Indications for posttracheotomy CXR in these studies are summarized in Table 3. Potential estimated cost savings by not obtaining unnecessary posttracheotomy CXR are tabulated in Table 4. The most critical finding on a posttracheotomy CXR is pneumothorax. Historically, its detection is the main indication for obtaining post-tracheotomy CXR. The routine use of CXR as a screening tool has not been shown to be cost-effective. The incidence of pneumothorax in uncomplicated adult tracheotomy is low. The reported incidence of posttracheotomy pneumothorax ranges from 0% to 17%.2 Four recent studies2-5 of adult tracheotomy reported an incidence of pneumothorax ranging from 0.3% to 2%. Taken together, these represented a total of 7 patients. Two of these pneumothoraces were incidental findings in asymptomatic patients and were observed. One patient had 1 episode of posttracheotomy tachycardia, and incidentally, a small apical pneumothorax was diagnosed on CXR, which was observed and resolved. The remaining 4 patients all had clearly identifiable risk factors such as an urgent or emergent procedure or difficult insertion, and they exhibited signs and symptoms of pneumothorax immediately or shortly after the procedure. All had thoracostomy tubes placed and did well. In none of these patients did the posttracheotomy CXR alter man-

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agement even when pneumothorax was present. Pneumothorax is a diagnosis that should be made clinically based on typical signs and symptoms. The most common of these are tachycardia and desaturation.7 Other clinical indicators for suspicion of pneumothorax include dyspnea, decreased breath sounds, chest pain, and subcutaneous emphysema. The aforementioned studies have all been conducted on the basis of adult standard open tracheotomy. Recently, PDT has gained popularity in both medical and surgical intensivist settings and is becoming the procedure of choice for airway management in many centers. Its appeal lies in its bedside application, decreased cost and comparable rates of complication. Powell et al17 reviewed 27 series of PDT from the literature and found an overall mean complication rate of 7.6%, with a mean incidence of pneumothorax of 0.6%. Pneumothorax, pneumomediastinum, and tube malposition were not identified clinically or radiographically in this series. All patients in our series received CXR within 12 hours as part of the standard ICU protocol. Those CXR films obtained during the immediate post-PDT period did not reveal any clinically significant findings and subsequently did not alter patient management. None of the delayed CXR films reveal findings either, which changed the clinical course or management of these patients up to 12 hours after surgery. Given these facts and excluding the 6 immediate post-PDT CXR films requested by the surgical service, we estimate a savings of approximately $13,500 ($287/radiograph) would have been realized had the remaining CXR films not been routinely ordered as part of the post-PDT course. The ideal time for ordering daily CXR films for ICU patients is controversial, but these and other studies’ findings with regard to open tracheotomy support the contention that the routine use of post-PDT CXR in uncomplicated cases does not alter patient care and is not cost-effective. In our series, post-PDT CXR was indicated in patients who underwent difficult tube insertions or who had significantly altered anatomy. We also would routinely image patients who underwent emergent PDT or who relied on high levels of pressure support ventilation. The comfort level in deciding to obtain a post-PDT CXR is influenced by our routine use of continuous flexible bronchoscopic monitoring during the procedure. This allows immediate detection of nearly all potential complications, aids any necessary correction, and immediately identifies correct tube placement.

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CONCLUSION

The practice of routinely obtaining CXR after uncomplicated PDT and in the absence of a clinical indicator of a complication yields little information and is not cost-effective. We recommend obtaining post-PDT CXR in cases of urgent or emergent procedures, difficult procedures, or altered or abnormal anatomic findings or in patients requiring high levels of positive-pressure ventilation. We thank Kimberly Reed and Shirley Green, RN, for their administrative and clinical assistance in the preparation of this work. REFERENCES 1. Cohen JI, Andersen P, Wax MK, et al. Microvascular reconstruction and tracheotomy are primary determinants of resource utilization in head and neck surgery. Arch Otolaryngol Head Neck Surg. In press. 2. Barlow DW, Weymuller EA, Wood DE. Tracheotomy and the role of postoperative chest radiography in adult patients. Ann Otol Rhinol Laryngol 1994;103:665-8. 3. Tarnoff M, Moncure M, Jones F, et al. The value of routine posttracheostomy chest radiography. Chest 1998;113:1647-9. 4. Park SY, Smith RV. Comparison of postoperative cardiopulmonary examinations and chest radiographs to detect pulmonary complications after adult tracheotomy. Otolaryngol Head Neck Surg 1999;121:274-6. 5. Smith DK, Grillone A, Fuleihan N. Use of postoperative chest xray after elective adult tracheotomy. Otolaryngol Head Neck Surg 1999;120:848-51. 6. Donaldson DR, Emami AJ, Wax MK. Endoscopically monitored percutaneous dilatational tracheostomy in a residency program. Laryngoscope 2000;110:1142-6. 7. Henschke CI, Pasternack GS, Schroeder S, et al. Bedside chest radiography: diagnostic efficacy. Radiology 1983;149:23-6. 8. Greenbaum DM, Marschall KE. The value of routine daily chest x-rays on intubated patients in the medical intensive care unit. Crit Care Med 1982;10:29-30. 9. Brunel W, Coleman DL, Schwartz DE, et al. Assessment of routine chest roentgenograms and the physical examination to confirm endotracheal tube position. Chest 1989;96:1043-5. 10. Maurer JR, Friedman PJ, Wing VW. Thoracostomy tube in an interlobar fissure: radiologic recognition of a potential problem. Am J Radiol 1982;139:1155-61. 11. Bekemeyer WB, Crapo RO, Calhoon S, et al. Efficacy of chest radiography in a respiratory intensive care unit. Chest 1985;88: 691-6. 12. Gray P, Sullivan G, Ostryzniuk P, et al. Value of post procedural chest radiograph in the adult intensive care unit. Crit Care Med 1992;20:1513-6. 13. Stemmer DA, Oliver C, Carey JP, et al. Fatal complications of tracheotomy. Am J Surg 1976;131:288-90. 14. Berg LF, Mafee MF, Campos M, et al. Mechanisms of pneumothorax following tracheal intubation. Ann Otol Rhinol Laryngol 1988;97:500-5. 15. Oliver P, Richardson JR, Clubb RW, et al. Tracheotomy in children. N Engl J Med 1962;267:631-7. 16. Rabuzzi DD, Reed GF. Intrathoracic complications following tracheotomy in children. Laryngoscope 1971;81:939-46. 17. Powell DM, Price PD, Forrest LA. Review of percutaneous tracheostomy. Laryngoscope 1998;108:170-7.