Yoğun Bakımda Trakeostominin Güncel Yönetimi: Perkütan Dilatasyonel Teknikler, Klinik Sonuçlar ve Gelecek Perspektifleri

Öz

Amaç: Trakeostomi, yoğun bakım ünitelerinde uzun süreli mekanik ventilasyon gereksinimi olan veya üst hava yolu obstrüksiyonu bulunan hastalarda kalıcı bir hava yolu sağlamak için sık uygulanan bir girişimdir. Geçmişte cerrahi trakeostomi daha yaygınken, perkütan dilatasyonel trakeostomi (PDT) minimal invaziv yapısı, daha düşük komplikasyon oranları ve yatak başında uygulanabilmesi nedeniyle giderek tercih edilmektedir. Bu derleme, kritik bakımda trakeostomi konusunda güncel ve kanıta dayalı bir kaynak sunmayı ve en iyi uygulamaların standardizasyonuna yönelik çabaları desteklemeyi amaçlamaktadır. Materyal ve Metot: Bu derleme, trakeotomi/trakeostomi terminolojisi ile tarihsel evrimini özetlemekte; endikasyonlar, kontrendikasyonlar, teknik yaklaşımlar ve komplikasyon yönetimine ilişkin güncel literatürü irdelemektedir. Bulgular: Kanıtlar, trakeostominin entübasyondan itibaren <7–10 gün içinde gerçekleştirilmesinin ventilatör ilişkili pnömoni (VİP) insidansını azaltabileceğini ve YBÜ kalış süresini kısaltabileceğini göstermektedir; ancak karar her hasta özelinde değerlendirilmelidir. Ultrasonografi ve bronkoskopi gibi yardımcı görüntüleme modalitelerinin kullanımı PDT’nin güvenliğini artırabilir; bununla birlikte, işlem sonrası titiz bakım, trakeal stenoz, enfeksiyon veya trakeoözofageal fistül gibi komplikasyonların önlenmesi için esastır. Sonuç: Geleceğe bakıldığında robot-yardımlı teknikler, yüksek çözünürlüklü görüntü kılavuzluğu, hastaya özgü üç boyutlu (3B) baskılı trakeostomi tüpleri ve teletıp tabanlı takip gibi gelişen teknolojilerin trakeostomi yönetimine daha fazla entegre olması beklenmektedir.

Anahtar Kelimeler

• Trakeotomi
• Trakeostomi
• Perkütan Dilatasyonel Trakeostomi
• Yoğun Bakım
• Mekanik Ventilasyon

Current Management of Tracheostomy in İntensive Care: Percutaneous Dilatational Techniques, Clinical Outcomes and Future Perspectives

Öz

Objective: Tracheostomy is a widely utilized procedure in intensive care units (ICUs) to establish a secure long-term airway for patients requiring extended mechanical ventilation or those with upper airway obstruction. Historically, airway access was dominated by surgical tracheostomy techniques, but practice has shifted toward percutaneous dilatational tracheostomy (PDT) due to its minimally invasive approach, reduced complication rates, and the convenience of bedside performance. Materials and Methods: This review covers tracheostomy terminology and historical evolution, and examines current literature on indications, contraindications, technical approaches, and complication management in the ICU setting. Results: Performing a tracheostomy early (within 7–10 days of intubation) can significantly reduce ventilator-associated pneumonia (VAP) risk and shorten ICU length of stay. However, decisions must be individualized based on each patient’s clinical circumstances. Adjunctive use of ultrasound and bronchoscopy improves the safety and precision of PDT, and diligent post-procedure care is essential to prevent complications such as tracheal stenosis, infection, and tracheoesophageal fistula. Conclusions: The field of tracheostomy management is on the verge of transformation through emerging technologies. Innovations such as robotic-assisted techniques, high-resolution imaging guidance, custom-designed patient-specific 3D-printed tracheostomy tubes, and telemedicine follow-ups promise to enhance the safety, effectiveness, and accessibility of tracheostomy care, ultimately improving patient outcomes.

Anahtar Kelimeler

• Tracheotomy
• Tracheostomy
• Percutaneous Dilatational Tracheostomy
• Intensive Care
• Mechanical Ventilation

Kaynakça

1. Durbin CG Jr. Tracheostomy: why, when, and how? Respir Care. 2010 Aug;55(8):1056-68. PMID: 20667153.
2. Mallick A, Bodenham AR. Tracheostomy in critically ill patients. Eur J Anaesthesiol. 2010 Aug;27(8):676-82. doi: 10.1097/EJA.0b013e32833b1ba0. PMID: 20523214
3. Rumbak MJ, Newton M, Truncale T, Schwartz SW, Adams JW, Hazard PB. A prospective, randomized study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients. Crit Care Med. 2004 Aug;32(8):1689-94. doi: 10.1097/01.ccm.0000134835.05161.b6. Erratum in: Crit Care Med. 2004 Dec;32(12):2566. PMID: 15286545
4. Ambesh SP, Pandey CK, Srivastava S, Agarwal A, Singh DK. Percutaneous tracheostomy with single dilatation technique: a prospective, randomized comparison of Ciaglia blue rhino versus Griggs’ guidewire dilating forceps. Anesth Analg. 2002 Dec;95(6):1739-45, table of contents. doi: 10.1097/00000539- 200212000-00050. PMID: 12456450.
5. Terragni PP, Antonelli M, Fumagalli R, Faggiano C, Berardino M, Pallavicini FB, Miletto A, Mangione S, Sinardi AU, Pastorelli M, Vivaldi N, Pasetto A, Della Rocca G, Urbino R, Filippini C, Pagano E, Evangelista A, Ciccone G, Mascia L, Ranieri VM. Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: a randomized controlled trial. JAMA. 2010 Apr 21;303(15):1483-9. doi: 10.1001/jama.2010.447. PMID: 20407057
6. Pratt LW, Ferlito A, Rinaldo A. Tracheotomy: historical review. Laryngoscope. 2008 Sep;118(9):1597-606. doi: 10.1097/MLG.0b013e3181783a4c. PMID: 18596476
7. Raimondi N, Vial MR, Calleja J, et al. Evidence-based guidelines for the use of tracheostomy in critically ill patients. J Crit Care. 2017;38:304-318. doi:10.1016/j.jcrc.2016.10.009
8. Simon M, Metschke M, Braune SA, Püschel K, Kluge S. Death after percutaneous dilatational tracheostomy: a systematic review and analysis of risk factors. Crit Care. 2013;17(5):R258. Published 2013 Oct 29. doi:10.1186/cc13085

9. Ciaglia P, Firsching R, Syniec C. Elective percutaneous dilatational tracheostomy. A new simple bedside procedure; preliminary report. Chest. 1985 Jun;87(6):715-9. doi: 10.1378/chest.87.6.715. PMID: 3996056.
10. Freeman BD, Isabella K, Lin N, Buchman TG. A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients. Chest. 2000 Nov;118(5):1412-8. doi: 10.1378/chest.118.5.1412. PMID: 11083694
11. Halum SL, Ting JY, Plowman EK, et al. A multi-institutional analysis of tracheotomy complications. Laryngoscope. 2012;122(1):38-45. doi:10.1002/lary.22364
12. Kanschik D, Bruno RR, Wolff G, Kelm M, Jung C. Virtual and augmented reality in intensive care medicine: a systematic review. Ann Intensive Care. 2023;13(1):81. Published 2023 Sep 11. doi:10.1186/s13613-023-01176-z Al-Ansari MA, Hijazi MH. Clinical review: percutaneous dilatational tracheostomy. Crit Care. 2006 Feb;10(1):202. doi: 10.1186/cc3900. PMID: 16356203; PMCID: PMC1550816
13. Young D, Harrison DA, Cuthbertson BH, Rowan K; TracMan Collaborators. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial. JAMA. 2013;309(20):2121-2129. doi:10.1001/jama.2013.5154 Gobatto ALN, Besen BAMP, Cestari M, Pelosi P, Malbouisson LMS. Ultrasound-Guided Percutaneous Dilational Tracheostomy: A Systematic Review of Randomized Controlled Trials and Meta-Analysis. J Intensive Care Med. 2020;35(5):445-452. doi:10.1177/0885066618755334
14. Pandian V, Brenner M. Tracheostomy in the Digital Age: How Artificial Intelligence and Immersive Technologies Are Redefining Airway Care. Tracheostomy. 2025;2(1):23-32. doi:10.62905/001c.133583
15. Sarıtaş A, Kurnaz MM. Comparison of Bronchoscopy-Guided and Real-Time Ultrasound-Guided Percutaneous Dilatational Tracheostomy: Safety, Complications, and Effectiveness in Critically Ill Patients. J Intensive Care Med. 2019;34(3):191-196. doi:10.1177/0885066617705641
16. Belsterling C. University Hospitals implants first in human patient specific 3D printed tracheal T tube. University Hospitals Newsroom. Published July 23, 2024. Accessed July 7, 2025. https://news.uhhospitals.org/news-releases/articles/2024/07/uh-implants-first-in-human-3d-printed-t-tube
17. Jung H, Lee JS, Lee JH, Park KJ, Lee JJ, Park HS. A Feasibility Study for 3D-printed Poly(methyl methacrylate)-resin Tracheostomy Tube Using a Hamster Cheek Pouch Model. In Vivo. 2020;34(4):1749-1758. doi:10.21873/ invivo.11968