In Reply

Tracheotomy-Related Deaths—A Systematic Review by Prof. Dr. med. habil. Eckart Klemm and Dr. med. Andreas Karl Nowak in issue 16/2017

Hoffmann and Greve are right to suspect selection bias regarding the indications for open surgical tracheotomy (OST) and percutaneous dilational tracheotomy (PDT). The current study did, however, not aim to weigh PDT and OST statistically against one another in terms of the question of which is the safer method (1). Both approaches come with risks and benefits, and are therefore subject to differential indications. Furthermore, no contraindication exists for OST—in contrast to PDT—in terms of being undertaken under general or local anesthesia in the operating room by an ear, nose, and throat surgeon, with all interdisciplinary safety measures in place. Whether the easier orientation of the surgically exposed area to be operated on in OST can balance out the possible problems of a puncturing procedure such as PDT in the sense of a risk reduction certainly requires further statistical studies that also consider the different techniques (2, 3) of OST. To avoid the numerous and severe changes to the tracheostoma and the cricoid cartilage after inexpertly done OST, and to avoid taking the wrong course when reinserting the cannula after a cannula loss, ENT surgeons for the longest time have demanded that an epithelialized stoma be formed as a tracheostomy, rather than a tracheotomy with an open wound canal.

We thank Lang and Dettmayer for publishing details of a typical tracheotomy-associated death as a late complication of this approach. The real number of such events can only be estimated. The fact that the results of a postmortem examination are reported in only 40 of 352 deaths was identified unequivocally as a limitation in our article. The reasons for why postmortem rates in Germany are comparatively low are well known (4). The aim is to secure funding for postmortem examinations in future by adding a quality premium for hospitals, so as to increase the currently only indirect economic/financial relevance of uncovering the correct main diagnosis and secondary diagnoses for the purposes of improving reimbursement for diagnosis related groups by the health insurers. Further advances in reducing tracheotomy-associated deaths may be possible by technically optimizing tracheal cannulas. This concerns questions of material selection as well as fluid dynamical considerations.

DOI: 10.3238/arztebl.2017.0604a

Prof. Dr. med. Eckart Klemm

Dr. med. Andreas Karl Nowak

Klinik für Anästhesiologie und Intensivmedizin,

Notfallmedizin und Schmerztherapie, Städtisches Klinikum Dresden

Conflict of interest statement

The authors of all contributions declare that no conflict of interest exists.

References

1. Klemm E, Nowak AK: Tracheotomy-related deaths—a systematic review. Dtsch Arztebl Int 2017; 114: 273–9

2. Bjork VO, Engstrom CG: The treatment of ventilatory insufficiency after pulmonary resection with tracheostomy and prolonged artificial ventilation. J Thorac Surg; 1955: 30: 356–67

3. Jung HP, Henker M, Klemm E: Langzeitergebnisse der intercartilaginären Visier-Tracheotomie. Mitteilungen Norddeutsche Gesellschaft für Otolaryngologie und zervikofaciale Chirurgie. Demeter Verlag 2004; 43–46

4. Jütte R, Dietel M, Rothschild MA: Autopsie: Lässt sich der Trend sinkender Sektionsraten umkehren? Dtsch Arztebl 2016; 113: 2094–10