Just Because We Can Does Not Mean We Should: A Perspective on Combined Tracheostomy and Percutaneous Endoscopic Gastrostomy Tube Insertion

Abstract

We read with interest the article from Yarmus et al1Yarmus L Gilbert C Lechtzin N Imad M Ernst A Feller-Kopman D Safety and feasibility of interventional pulmonologists performing bedside percutaneous endoscopic gastrostomy tube placement.Chest. 2013; 144: 436-440Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar in CHEST (August 2013) about the feasibility of percutaneous endoscopic gastrostomy (PEG) tube insertion by interventional pulmonologists. For reasons that are unclear, a combination procedure of PEG and tracheostomy has been advocated by some. In the current work, more than one-half of the patients (n = 41) underwent a combined procedure. There is some historic observational data on the feasibility of this approach2Vaughan JR Scott JS Edelman DS Unger SW Tracheostomy. A new indication for percutaneous endoscopic gastrostomy tube placement.Am Surg. 1991; 57: 214-215PubMed Google Scholar, 3Moore FA Haenel JB Moore EE Read RA Percutaneous tracheostomy/gastrostomy in brain-injured patients—a minimally invasive alternative.J Trauma. 1992; 33: 435-439Crossref PubMed Scopus (61) Google Scholar; however, efficacy and safety of this approach has not been previously studied in prospective randomized trials. Consensus guidelines would suggest that PEG tube insertion be considered for patients who are likely to have a requirement for enteral nutrition of > 30 days.4Terragni PP Antonelli M Fumagalli R et al.Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: a randomized controlled trial.JAMA. 2010; 303: 1483-1489Crossref PubMed Scopus (359) Google Scholar PEG, while safe and reasonably well tolerated, is not a frivolous procedure. Thirty-day mortality after PEG tube insertion has been noted to range between 10% and 26% in some series, largely driven by poor patient selection.4Terragni PP Antonelli M Fumagalli R et al.Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: a randomized controlled trial.JAMA. 2010; 303: 1483-1489Crossref PubMed Scopus (359) Google Scholar, 5Leeds JS McAlindon ME Grant J Robson HE Lee FK Sanders DS Survival analysis after gastrostomy: a single-centre, observational study comparing radiological and endoscopic insertion.Eur J Gastroenterol Hepatol. 2010; 22: 591-596Crossref PubMed Scopus (29) Google Scholar Indeed, in one of the largest published series, a 1-week mortality of 43% was seen in a national confidential inquiry into patient deaths in the National Health Service, of which 19% of procedures were deemed futile upon expert review.6Johnston SD Tham TC Mason M Death after PEG: results of the National Confidential Enquiry into Patient Outcome and Death.Gastrointest Endosc. 2008; 68: 223-227Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar, 7Combes A Luyt CE Nieszkowska A Trouillet JL Gibert C Chastre J Is tracheostomy associated with better outcomes for patients requiring long-term mechanical ventilation?.Crit Care Med. 2007; 35: 802-807Crossref PubMed Scopus (98) Google Scholar It is with this knowledge that the selection of critically ill patients undergoing tracheostomy as suitable subjects for PEG tube insertion needs to be questioned. By virtue of their complex critical illness, patients undergoing tracheostomy insertion are sick and not optimal subjects. Reported 30-day mortality rates after tracheostomy insertion alone vary but have been reported to be on the order of 30%.6Johnston SD Tham TC Mason M Death after PEG: results of the National Confidential Enquiry into Patient Outcome and Death.Gastrointest Endosc. 2008; 68: 223-227Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar, 7Combes A Luyt CE Nieszkowska A Trouillet JL Gibert C Chastre J Is tracheostomy associated with better outcomes for patients requiring long-term mechanical ventilation?.Crit Care Med. 2007; 35: 802-807Crossref PubMed Scopus (98) Google Scholar, 8Young D Harrison DA Cuthbertson BH Rowan K Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial.JAMA. 2013; 309 (TracMan Collaborators): 2121-2129Crossref PubMed Scopus (402) Google Scholar For similar reasons, the policy of placing PEG tubes in patients early in the course of their critical illness (as early as 4 days in the current report) and prior to declaration of medical stability is questionable. In the current series, Yarmus et al1Yarmus L Gilbert C Lechtzin N Imad M Ernst A Feller-Kopman D Safety and feasibility of interventional pulmonologists performing bedside percutaneous endoscopic gastrostomy tube placement.Chest. 2013; 144: 436-440Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar reported mortality at 30 days of 11%. The mortality in the group that underwent simultaneous PEG and tracheostomy tube insertion was not reported; we would be interested to see these data. PEG tubes were removed in 73% of surviving patients within a median of 76 days (range, 24-611 days). This would seem to suggest that PEG tube insertion (and all of its attendant risks) may have been avoided completely in some patients by deferring simultaneous insertion. Nasogastric feeding tubes are widely regarded as safe and should be the preferred option for short-term nutrition delivery. We feel that the policy of simultaneous PEG and tracheostomy tube insertion should not be advocated until it has been proven to be superior to a watch-and-wait approach in prospective randomized trials. ResponseCHESTVol. 145Issue 2PreviewWe thank Drs Slattery and Seres for their interest in our article1 regarding the placement of percutaneous endoscopic gastrostomy (PEG) tubes by interventional pulmonologists. Although there are no prospective randomized trials addressing the efficacy and safety of combined tracheostomy/PEG within critically ill patients, to our knowledge, no randomized data have demonstrated it as unsafe/unfeasible, and designing noninferiority studies of this type would be extremely difficult and expensive. We agree that, like tracheostomy placement, decisions regarding timing for PEG tube placement remain difficult for providers; PEG tube placement should be reserved for those likely to need enteral nutrition for > 30 days. Full-Text PDF