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A time-limited trial (TLT) is an option to deal with scarce ICU-beds. A TLT is an agreement made at an early stage of ICU-admission to initiate treatment for a certain period of time to gain a realistic understanding of the patient's chances of a meaningful recovery. If the patient improves, treatment will be continued. However, if treatment goals are not achieved, palliative care is initiated. Chang et. al. investigated the efficacy of introduction of this method. The study was conducted in 2017-2019 and consisted of the structural introduction of TLTs for ICU-patients at risk for non-beneficial ICU-treatments. The main outcome of the study is that after introduction of TLTs, the median stay at the ICU or in the hospital significantly decreased without an increase in mortality. A TLT can be of added value in Dutch ICUs, provided that the staff fully supports the method and is properly trained before implementation.

Part 1: To describe cases of emphysema (subcutaneous and/or mediastinal) and pneumothorax after percutaneous dilational tracheostomy (PDT) in a series of 326 patients, and to review the existing literature describing the incidence and possible mechanisms. Part 2: To analyze the potential mechanisms for the development of emphysema and pneumothorax in human cadaver models.A retrospective analysis of PDTs, in combination with an anatomic study in human cadavers.Part 1: All ICU patients who underwent PDT between 1997 and 2002 were enrolled in the study. We analyzed the cases of emphysema and pneumothorax. Similar cases were retrieved from the literature and underwent a systematic review. Part 2: The relevant anatomic structures were studied. We simulated the clinical situation after PDT in a human pathologic study in order to induce subcutaneous emphysema and pneumothorax.Part 1: Five cases of subcutaneous emphysema (1.5%) and two cases of pneumothorax (0.6%) are described. In the literature search, we found 41 cases of emphysema (1.4%) and 25 cases of pneumothorax (0.8%) in a total of 3,012 patients. Part 2: Subcutaneous emphysema could easily be induced in a human cadaver model by inflating air in the pretracheal tissues and after posterior tracheal wall laceration. Air leakage was also possible through a fenestrated cannula via the space between the inner nonfenestrated cannula and outer cannula and then through the fenestration.We conclude that one mechanism for the development of emphysema is an imperfect positioning of the fenestrated cannula, whereby the fenestration is extraluminal. For this reason, fenestrated cannulas should not be used immediately after placement of a PDT. Posterior tracheal wall laceration is another mechanism responsible for emphysema after PDT. After perforation of the posterior tracheal wall, the pleural space can be reached easily. This may result in a pneumothorax.

To evaluate and compare the peri-operative and postoperative complications of the two most frequently used percutaneous tracheostomy techniques, namely guide wire dilating forceps (GWDF) and Ciaglia Blue Rhino (CBR).A sequential cohort study with comparison of short-term and long-term peri-operative and postoperative complications was performed in the intensive care unit of the University Medical Centre in Nijmegen, The Netherlands. In the period 1997-2000, 171 patients underwent a tracheostomy with the GWDF technique and, in the period 2000-2003, a further 171 patients with the CBR technique. All complications were prospectively registered on a standard form.There was no significant difference in major complications, either peri-operative or postoperative. We found a significant difference in minor peri-operative complications (P0.01) and minor late complications (P0.05).Despite a difference in minor complications between GWDF and CBR, both techniques seem equally reliable.