Abstract
BackgroundPercutaneous dilatational tracheostomy (PDT) in critically ill patients often involves bronchoscopic optical guidance. However, this procedure is not without disadvantages. Therefore, we aimed to study a recently introduced endotracheal tube-mounted camera (VivaSightTM-SL tube [VST]; ETView, Misgav, Israel) for guiding PDT.MethodsThis was a randomized controlled trial involving 46 critically ill patients who received PDT using optical guidance with a VST or with bronchoscopy. The primary outcome measure was visualization of the tracheal structures (i.e., identification and monitoring of the thyroid, cricoid, and tracheal cartilage and the posterior wall) rated on 4-point Likert scales. Secondary measures were the quality of ventilation (before puncture and during the tracheostomy procedure rated on 4-point Likert scales) and blood gases sampled at standardized time points.ResultsThe mean ratings for visualization (lower values better; values given for per-protocol analysis) were 5.4 (95% CI 4.5–6.3) for the VST group and 4.0 (95% CI 4.0–4.0) for the bronchoscopy group (p < 0.001). Mean ventilation ratings were 2.5 (95% CI 2.1–2.9) for VST and 5.0 (95% CI 4.4–5.7) for bronchoscopy (p < 0.001). Arterial carbon dioxide increased to 5.9 (95% CI 5.4–6.5) kPa in the VST group vs. 8.3 (95% CI 7.2–9.5) kPa in the bronchoscopy group (p < 0.001), and pH decreased to 7.40 (95% CI 7.36–7.43) in the VST group vs. 7.26 (95% CI 7.22–7.30) in the bronchoscopy group (p < 0.001), at the end of the intervention.ConclusionsVisualization of PDT with the VST is not noninferior to guidance by bronchoscopy. Ventilation is superior with less hypercarbia with the VST. Because visualization is not a prerequisite for PDT, patients requiring stable ventilation with normocarbia may benefit from PDT with the VST.Trial registrationClinicalTrials.gov, NCT02861001. Registered on 13 June 2016.
Highlights
Percutaneous dilatational tracheostomy (PDT) in critically ill patients often involves bronchoscopic optical guidance
As we have shown before, PDT with this tube is a feasible alternative to bronchoscopic guidance and might improve patients’ gas exchange, airway pressures, and ventilation compared with PDT with bronchoscopic guidance [12]
For item B, the VivaSightTM-SL endotracheal tube (VST) group was inferior to the bronchoscopy group and for item D, no noninferiority could be established for the VST group
Summary
Percutaneous dilatational tracheostomy (PDT) in critically ill patients often involves bronchoscopic optical guidance. Bronchoscopic guidance of the PDT is frequently used as a safety measure facilitating the choice of the correct tracheostomy site, verification of the intratracheal guidewire and dilator placements, and positioning of the tracheal cannula [5]. The role of bronchoscopy in PDT has been questioned, and the use of neck ultrasound has been suggested [9]. It has been shown that ultrasound is not inferior to bronchoscopy in terms of major complications and procedure duration, but this technique does not provide a view of the posterior wall of the trachea [10]
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