Highlight
- Open bedside surgical tracheostomy (OBST) is comparable to operating room-based tracheostomy (ORST) in operative time and complication rates.
- OBST offers a significant cost reduction of approximately 53.6% compared to ORST.
- Unfavorable neck anatomy, not the procedural setting, predicts intraoperative complications, while previous tracheostomy increases risk of major postoperative complications.
- Use of a Bjork flap is protective against complications in surgical tracheostomy.
Study Background
Tracheostomy, a common surgical procedure to establish a secure airway, is frequently performed on critically ill patients requiring prolonged ventilation. Traditionally, open surgical tracheostomy is carried out in the operating room (OR), which involves transporting often unstable patients. Bedside open surgical tracheostomy (OBST) performed in the intensive care unit (ICU) aims to mitigate transport risks, optimize resource utilization, and reduce healthcare costs. Despite these potential benefits, OBST remains underutilized, possibly due to concerns about safety and complication rates in the less controlled ICU environment. This study addresses the clinical outcomes and cost implications of OBST versus OR-based surgical tracheostomy (ORST) over a decade at a single institution, thus informing best clinical practices and healthcare policy.
Study Design
This is a retrospective cohort study including adult patients who underwent open surgical tracheostomy between 2014 and 2024 at a single tertiary care institution. Patients were divided into two groups based on the procedural setting: OBST performed at the bedside in the ICU and ORST conducted in the operating room. Demographic and clinical variables such as body mass index (BMI), age-adjusted Charlson comorbidity index (CCI), and history of prior tracheostomy were collected.
Procedural variables included operative time, surgeon experience, anatomical challenges (e.g., unfavorable neck anatomy), and use of surgical techniques such as the Bjork flap. Intraoperative and postoperative complications were carefully documented and graded using the standardized Clavien-Dindo (CD) classification system. The primary endpoints were rates of significant complications (CD grade ≥3) and overall procedural safety. Secondary endpoints included cost comparison between OBST and ORST.
Key Findings
Out of 420 patients, 199 (47.4%) underwent OBST and 221 (52.6%) ORST. Notable baseline differences showed OBST patients had higher BMI (p = 0.004) and lower CCI scores (p = 0.001), indicating relatively fewer comorbidities despite increased body mass. There were no statistically significant differences in operative time or surgeon experience between the groups, suggesting procedural consistency.
The frequency of both intraoperative and postoperative complications did not differ significantly between OBST and ORST groups. Multivariate logistic regression analysis identified previous tracheostomy as a significant predictor of moderate to severe postoperative complications (CD ≥3) with p = 0.017, whereas procedural setting (OBST vs. ORST) was not independently associated with complication risk (p = 0.497).
Unfavorable neck anatomy emerged as the only independent predictor of intraoperative complications (p = 0.045). This finding highlights the relevance of patient-specific anatomical considerations in surgical risk assessment. Notably, the application of the Bjork flap technique demonstrated a protective effect against all complications (p = 0.008), indicating a beneficial surgical modification to enhance safety.
Economically, OBST was linked to a substantial cost reduction of 53.6%, underscoring its value in resource-limited or high-demand healthcare environments. Cost savings are likely attributable to eliminating patient transport, operating room fees, and associated personnel utilization.
Expert Commentary
This study reinforces an accumulating body of evidence supporting the safety and efficacy of bedside surgical tracheostomy in ICU patients. The comparable complication rates between OBST and ORST underscore that with experienced surgical teams and appropriate patient selection, bedside procedures can match OR standards.
The finding that prior tracheostomy increases risk aligns with existing literature noting scar tissue and distorted anatomy as risk factors. Unfavorable neck anatomy as a driver of intraoperative complications is intuitive and highlights the need for thorough pre-procedural assessment. Surgeons should incorporate anatomical evaluations into decision-making algorithms to optimize outcomes.
Importantly, the use of the Bjork flap appears protective, possibly by securing the tracheostomy stoma and facilitating easier tube changes, which could minimize postoperative complications. This surgical nuance merits further prospective study.
The significant cost savings favor OBST especially in the context of increasing ICU demands and healthcare expenditure containment. Limitations include the retrospective design with potential selection bias—patients with severe comorbidities or complex anatomy might have preferentially undergone ORST. Additionally, the single-center experience may limit wider generalizability.
Conclusion
Open bedside surgical tracheostomy offers a safe and cost-effective alternative to traditional operating room procedures for critically ill adults requiring airway access. With no increased risk of significant complications, OBST should be considered the first-line approach wherever feasible, particularly to minimize ICU patient transport risks and reduce healthcare costs. Tailored patient assessment focusing on neck anatomy and prior tracheostomy history remains essential to optimize outcomes. Adoption of protective surgical techniques like the Bjork flap may further enhance safety. Future prospective controlled studies could validate these findings and help refine clinical guidelines.
Funding and Clinical Trials
The study did not specify external funding sources or clinical trial registration.
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