Zusammenfassung
Ziel der Studie: Der optimale Zeitpunkt zur Tracheotomie beim langzeitbeatmeten Patienten wird kontrovers diskutiert. Die vorliegende Übersichtsarbeit versucht anhand der relevanten Literatur eine kritische Wertung des potenziellen Nutzens und der Risiken der Tracheotomie bei dieser Patientengruppe. Methodik: Literaturrecherche. Ergebnisse: Zu den Risiken einer Tracheotomie gehören Blutungen, Infektionen, Verletzungen benachbarter Strukturen und Spätschäden an der Trachea. Diese müssen den Komplikationen nach Intubation, wie Stimmband- und Larynxschäden oder subglottischen Stenosen, gegenübergestellt werden. Die möglichen Komplikationen der Tracheotomie reichen vom verfahrensassoziierten Tod bis zur störenden Narbenbildung. Die faktischen und potenziellen Vorteile des Verfahrens haben die Tracheotomie dennoch als künstlichen Luftweg der Wahl bei langzeitbeatmeten Patienten etabliert. Als Vorteile der Tracheotomie gelten: erhöhter Patientenkomfort, verringerter Atemwegswiderstand, verkleinerter Totraum, geringere Pneumonierate und verkürzte Beatmungs- und Krankenhausaufenthaltsdauer. Ein erhöhter Patientenkomfort konnte in Studien bisher nicht eindeutig nachgewiesen werden, einer möglichen Verringerung des Atemwegswiderstands kommt bei Einsatz moderner Respiratoren eine eher untergeordnete Bedeutung zu. Die Annahme, dass die Pneumonierate bei tracheotomierten Patienten geringer ist als bei intubierten, konnte bis heute nicht sicher belegt werden. Der Nachweis einer Verkürzung der Beatmungszeit nach Tracheotomie durch einen erleichterten Entwöhnungs-Prozess steht ebenfalls aus. Schlussfolgerungen: Beim Vergleich Tracheotomie versus Langzeitintubation besteht das Problem, dass positive klinische Erfahrungen, die mit der Tracheotomie gemacht werden, wissenschaftlich - zumindest derzeit - nicht zu bestätigen sind. Dies liegt jedoch an methodischen Schwierigkeiten und Unzulänglichkeiten der vorliegenden Studien und spricht deshalb nicht gegen die Tracheotomie als Methode. Perkutane Punktionstracheotomien scheinen gegenüber dem chirurgischen Vorgehen einige Vorteile zu bieten, die Langzeitergebnisse der neuen Verfahren müssen jedoch abgewartet werden.
Abstract
Objective: Tracheotomy is commonly performed in long-term ventilated patients. The aim of this review is to discuss the advantages and disadvantages of tracheotomy. Methods: Review of the literature. Results: Disadvantages of tracheotomy include the risk of bleeding, infection, injury of the truncus brachiocephalicus, and of long-term tracheal injury. These risks must be compared with the risk of vocal cord trauma, laryngeal trauma, and subglottic stenosis following translaryngeal intubation. Despite a number of disadvantages and potentially even life-threatening complications, however, tracheotomy is a well-established technique for long-term airway management in critically ill patients. Potential advantages of tracheotomy include enhanced patient comfort, reduced airway resistance and dead space, a lower incidence of ventilator-associated pneumonia and a shorter duration of mechanical ventilation and hospital stay. Patient comfort before and after tracheotomy has not yet been seriously evaluated, using modern ventilators airway resistance does not longer play a major role. No data from randomized controlled trials actually support the thesis that tracheotomy reduces the incidence of ventilator-associated pneumonia. There is weak evidence for the concept that the duration of mechanical ventilation can be reduced in patients while using tracheotomy. Patients undergoing percutaneous dilational tracheotomy seem to have a reduced risk of bleeding and site infection and a shorter duration of the procedure when compared to those with conventional surgical tracheotomy. Conclusions: Many clinicians perform tracheotomies on the basis of expert opinion and clinical experience. So far, the benefits, however, have not been proven in large-scale randomized trials. Many of these studies suffer from design flaws, insufficient randomization and the absence of blinding. On the other hand, the lack of positive results do not rule out that tracheotomy may be beneficial for the ventilator-dependent patient. Percutaneous tracheotomy procedures may be superior to conventional surgical tracheotomies. Long-term results, however, will have to prove this preliminary observation.
Schlüsselwörter
Intubation - Tracheotomie - endotracheal - perkutan - Punktionstracheotomie
Key words
Intubation - tracheotomy - endotracheal - dilational - percutaneous
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PD Dr. med. A. P. Klockgether-Radke
Zentrum Anästhesiologie, Rettungs- und Intensivmedizin · Georg-August-Universität Göttingen
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Email: Klockgether-Radke@gmx.de
