Quantification of the learning curve for percutaneous dilatational tracheotomy.

Abstract

Although numerous investigators have reported a bedside percutaneous dilatational tracheotomy (PDT) complication incidence similar to that of standard operative tracheostomy, others have proposed a "learning curve" for PDT resulting in increased complications early in individual or institutional experience with this procedure. The objective of this investigation is to characterize and quantify the proposed learning curve for PDT. Prospective analysis of complication incidence for the first 100 PDT procedures performed in a local community hospital Department of General Surgery. Demographic data, patient disease variables, and patient anatomic features, as well as perioperative, postoperative, and late complications, were recorded prospectively. Patients were divided into sequential cohorts of 20 and were evaluated for complications at regular intervals. Perioperative and late complication incidence was significantly higher in the first 20 patients who underwent PDT. However, postoperative complication incidence did not significantly vary with operator or institutional experience. In addition, patients with suboptimal anatomy were found to have a significantly increased complication incidence, independent of operator and institutional experience. Percutaneous dilational tracheotomy has an identifiable learning curve that is most prominent in the first 20 patients treated. Early experience with PDT should be obtained under controlled circumstances, ideally the operating suite. Although most complications occur during acquisition of early experience with PDT, certain life-threatening complications such as tube dislodgment or inability to complete procedure may occur even after extensive experience is obtained. Bedside PDT has an acceptable complication incidence, but any surgeon employing this technique must be prepared to perform immediate standard open tracheotomy to minimize potentially lethal complications of this elective procedure.