Original contribution
Is tracheotomy on the decline in otolaryngology? A single institutional analysis

https://doi.org/10.1016/j.amjoto.2017.12.017Get rights and content

Abstract

Objective

A recent study reported decreasing trends in tracheotomy procedures by its otolaryngology service. We set out to determine whether the previously reported decrease in otolaryngology performed tracheotomies by one institution is a local or generalizable phenomenon.

Design

Retrospective cohort study from 2010 to 2015.

Setting

Tertiary care hospital and affiliated regional hospitals.

Subject and methods

All patients who received tracheotomy during the period of analysis were included. Performing specialty, surgical technique, and procedure location were recorded. Procedures were stratified by year and specialty to generate incidence rate ratios for otolaryngologists and non-otolaryngologists. Incidence rate ratios were estimated with negative binomial regression across services.

Results

The otolaryngology service demonstrated a yearly decrease of 3.4% in the total number of tracheotomies (95% CI − 7.9% to + 1.4, P = 0.17). While the thoracic service remained constant (+ 0.3%, 95% CI − 2.6% to + 3.3%, p = 0.83), general surgery demonstrated the greatest increase in procedures (+ 4.4%, 95% CI − 6.0% to + 15.8%, P = 0.42). Thoracic and general surgery both dramatically increased the number of percutaneous tracheotomies performed, with general surgery also performing a greater number of bedside procedures.

Conclusions and relevance

We observed a similar decline in the number of tracheotomies otolaryngology over six years. Our trend is likely due to changes in consultations patterns, increasing use of the percutaneous method, and an increase in adjunctive gastrostomy tube placements. Investigations on the impact of a greater number of non-otolaryngology performed tracheotomies on follow up care is warranted.

Introduction

The tracheotomy is a common surgical procedure performed through two different methods; the open surgical tracheotomy (OST) and the percutaneous dilatational tracheotomy (PDT). The OST is the older of the two methods and is traditionally performed in the operating room (OR) under general anesthesia [1]. With the OST, direct visualization of the trachea is obtained through surgical dissection of the overlying skin, strap muscles, and thyroid isthmus for placement of a tracheotomy tube [2]. The PDT is a more recent method performed via Seldinger technique with concurrent visualization of the airway lumen through bronchoscopy [3], [4]. Because of the shortened procedure time, ability to perform in the ICU setting, potentially cheaper cost, and a proven non-inferior safety profile compared to the OST, the PDT has become a common bedside procedure performed by otolaryngologists, appropriately trained intensivists, interventional pulmonologists, and other non-surgical specialties in the ICU [5], [6], [7].

There is concern within the otolaryngology community that with the advent of PDT, the procedure is gradually being performed less by the specialty. Patel et al.'s 2015 case series is the first piece of literature to describe such a trend. In their 14-year analysis of all tracheotomies performed at a single tertiary center, the authors reported a gradual decline in the overall number of tracheotomies performed by the otolaryngology service. At their hospital, thoracic and general surgery overtook otolaryngology in the total number of procedures performed, notably in both OST and PDT rates [8].

Patel et al. believe their findings reflect the general reluctance of the otolaryngology community to adopt the PDT compared to other surgical and non-surgical specialties. The literature supports this notion, as a 2009 survey of Head and Neck departments found that only 29% of otolaryngology programs are teaching their residents PDT regularly [9]. An explanation for why a decline in OST rates was observed remains unclear. Although Patel et al.’s study had significant findings, it appears to have gone largely unnoticed. When surveyed, most general surgery program directors believe otolaryngology performs the majority of open tracheotomies [10].

While the Patel et al. study covered a 14-year period, the number of tracheotomies was relatively small for any given year (an average of 164/year). As our institution provides care for a high volume of otolaryngology related cases both at our tertiary care center and our regional hospitals (an average of 659/year), a study comparing trends in the rate of procedures at our institution along with the findings of Patel et al.'s previous study could provide insight into whether this is a local or national phenomenon. We aim to determine whether otolaryngology is performing fewer tracheotomies compared to other surgical specialties through a retrospective analysis. We hypothesize that otolaryngology is performing the same amount of procedures as in the past. Ultimately, a correlation could provide the impetus for the otolaryngology community to come together and address the potential loss of this procedure from the specialty.

Section snippets

Study design

Approval from the Cleveland Clinic institutional review board was obtained and a retrospective chart review was performed on patients who received a tracheotomy procedure at either our tertiary care center or one of our regional hospitals from January 2010 to December 2015, a span of six contiguous years. A total list of all patients undergoing tracheotomy during this period, along with their respective operative report was generated using CPT codes and data from hospital billing records. The

Demographics

From January 2010 to December 2015, there was an average of 659 tracheotomies performed yearly (range 615–738), totaling 3957 procedures. The median age at the time of operation was 65 (range 10 days–97 years). 72% of individuals were white while 23% were African American. Four specialties performed tracheotomies (Fig. 1); otolaryngology, thoracic surgery, general surgery, and plastic surgery, although plastic surgery performed < 1% of all cases. During the entire study period, not one tracheotomy

Discussion

Patel et al.'s 14 year retrospective study on tracheotomies trends reported a 22% decline in procedures performed by otolaryngology over time (a decline of 3.8% yearly), with both general surgery and thoracic surgery performing a greater proportion [8]. The purpose of our study was to review tracheotomies at our high-volume institution to see if we identified similar trends. Indeed, over a six-year period, we observed a 20% decline in procedure performed by otolaryngology. This translates to a

Conclusion

We observed a decline in tracheotomy procedures among the otolaryngology service at our institution. These findings appear to confirm the previously published trends reported at another tertiary care hospital. We believe the decline in procedures is largely derived from a combination of factors, including the increasing use of the PDT among general surgery, and the increasing occurrence of combination tracheotomy/PEG tube procedures. As we believe our results confirm the findings of the Patel

Acknowledgements

We would like to thank Oleg Lisheba for the initial extraction of our data through eResearch services.

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Presented at the Combined Otolaryngology Spring Meetings, San Diego, California, USA, April 26–30, 2015.

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