Safety and Feasibility of Percutaneous Tracheostomy in Patients with Traditional Contraindications: A Systematic Review of 2232 Cases.

Abstract

PurposePercutaneous dilational tracheostomy (PDT) is a widely performed procedure. However, it is sometimes contraindicated based on manufacturer guidelines and existing literature. This study evaluates the safety and feasibility of performing PDT in patients with documented contraindications.MethodsA systematic review was conducted using PubMed and TDNet, following Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) reporting guidelines. Studies describing PDT performed in the presence of absolute or relative contraindications were included. The literature search included studies published between 1991 and 2024. Data on patient demographics, contraindications, complications, and clinical outcomes were extracted. Statistical analysis incorporated findings from both the included studies and our case series.ResultsA total of 76 studies, along with our case series, included 2232 patients with a mean age of 48.5 years. The most common contraindications were bleeding diathesis (n = 947, 42.4%), and morbid obesity (n = 360, 16.1%). Many patients presented with multiple contraindications. The primary indications for tracheostomy were anticipated prolonged intubation, airway obstruction, and trauma. Bronchoscopic guidance was used in 45.6% of cases, and ultrasound guidance in 24.6%. The most frequently reported complication was bleeding (5.96%), followed by stoma narrowing (0.67%) and infection (0.63%). The overall procedural failure rate was 0.36%, and procedural mortality was rare (0.13%).ConclusionThis review suggests that PDT may be safely performed in carefully selected patients with traditional contraindications when conducted by experienced teams with appropriate backup. These findings do not support the routine use of PDT in all patients with traditional contraindications, but rather highlight its feasibility in carefully selected cases managed by appropriately skilled teams. Future controlled studies are warranted to re-evaluate current contraindications guidelines.