Dilatational Tracheostomy Research Articles

Fiberoptic bronchoscopic guidance in percutaneous dilational tracheotomy

ObjectiveBlind percutaneous dilational tracheotomy (PDT) holds a lot of peri-operative complications. A lot of assisting tools have long been used to facilitate guidance during PDT, e.g., laryngeal mask airway (LMA), ultrasound (US) imaging of the neck, light wand for trans-illumination of the soft tissues of the neck, and flexible fiberoptic bronchoscopy. The aim of this work was to compare between blind and fiberoptic bronchoscopic guided PDT as regards ease of the technique and complications of the procedure. DesignA randomized prospective comparative trial. SettingCritical care department, main Alexandria university hospital. PatientsThirty adult patients, requiring elective PDT, and need to maintain a secure airway. MethodsThey were randomly assigned to 2 groups; blind PDT group I and fiberoptic bronchoscopic guided PDT group II. Both groups used Griggs’ forceps technique for PDT. Post-operative complications were recorded. End point was 48-h after the procedure. ResultsNumber of trials was 1.27±0.46 and 1.00±0.00 for groups I and II, respectively. Success rate was 100% in both groups. Procedural duration (in minutes) was 2.93±1.10 in group I versus 3.93±1.10 in group II. Bleeding was found in 3 patients and 1 patient for groups I and II. Subcutaneous emphysema occurred in one patient in each group, while tube misplacement was recorded in 2 patients in group I and none in group II. Aspiration pneumonia was found in 2 patients in group I and none in group II. ConclusionUse of flexible bronchoscopy has succeeded in decreasing the number of trials of needle insertion and decreasing the incidence of overall complications, while blind technique was better in shortening procedural time and avoidance of hypercapnia.

Real time ultrasound guided balloon dilatational percutaneous tracheostomy is a safe procedure in critically ill patients – an evaluation study

Balloon dilatational percutaneous tracheostomy with radial outward dilation minimizes bleeding and injury to tracheal rings [1]. Using the bronchoscope during the puncture of the trachea holds a risk of inaccurate placement, of hypoventilation and of needle puncturing the bronchoscope. This study was conducted in order to evaluate the safety features and feasibility of combining real-time ultrasound-guided puncture of the trachea with visualization of the needle path during tracheal puncture [2]. We provide precise localization of tracheal cartilage and proper site puncture for the stoma by ultrasound, with subsequent performance of balloon dilatational percutaneous tracheostomy using the Blue dolphin technique.

Real-time ultrasound-guided balloon dilatational percutaneous tracheostomy is a safe procedure in critically ill patients: an evaluation study

Balloon dilatational percutaneous tracheostomy with radial outward dilation minimizes bleeding and injury to tracheal rings [1]. Using the bronchoscope during the puncture of the trachea holds a risk of inaccurate placement, of hypoventilation and of needle puncturing the bronchoscope. This study was conducted in order to evaluate the safety features and feasibility of combining real-time ultrasound-guided puncture of the trachea with visualization of the needle path during tracheal puncture [2]. We provide precise localization of tracheal cartilage and proper site puncture for the stoma by ultrasound, with subsequent performance of balloon dilatational percutaneous tracheostomy using the Blue dolphin technique.

Coagulation Disorders Do Not Increase the Risk for Bleeding during Percutaneous Dilatational Tracheotomy

Percutaneous dilatational tracheotomy (PDT) is a common procedure. Coagulation disorders represent a relative contraindication for PDT and, therefore, normalization of hemostasis parameters is recommended. Especially patients undergoing cardiac surgery after valve replacement and with any kind of assist device need to require an adequate anticoagulation. This study investigated the impact of impaired hemostasis as a risk factor for bleeding complications retrospectively. Patients who underwent PDT (November 2007 to November 2010) were stratified into a high-risk (HR) and low-risk (LR) group in regard to bleeding complications. The following determining factors activated partial thromboplastin time (aPTT > 50 seconds, prothrombin time (PT < 50%), international normalized ratio (INR > 1.4), and platelet count (< 50,000/µL) were assessed. A total of 213 patients underwent PDT (HR = 5/85; LR = 8/128). There was no difference in demographics or intraoperative data. Patients of both groups showed mild bleeding without the need for surgical intervention or transfusion (p = 0.957). There were no severe bleeding nor other procedure-related complications. Percutaneous tracheotomy is a safe and feasible procedure in patients with coagulation disorders. Therefore, discontinuation of anticoagulation treatment or normalization of hemostasis prior to the procedure is not necessary.

Percutaneous Dilatational Tracheotomy in Non‐ICU Wards

Objective: To retrospectively assess the feasibility of bedside PDT in nonintensive care wards using a novel joint Otolaryngology-Intensive Care Team model. A control group composed of patients that underwent PDT in the ICU was used to assess the relative complication rate and outcome. Method: A working protocol was constructed defining all stages of the process. All early and late complications were recorded. Other parameters analyzed were patient epidemiology, preprocedure morbidity, staff learning curve, duration of procedure, anesthetics administered, interval from ventilation to weaning, and interval to decannulation. Endpoints were hospital discharge, decannulation, and death. Results: From September 2009 until July 2010 a total of 98 PDTs were performed; 48 PDTs were performed in the hospital wards, and 45 PDTs were performed in the ICU. No life-threatening complications were encountered in the non-ICU group and no significant difference in complication rate was observed between the 2 groups. Conclusion: Percutaneous tracheotomy is an available, safe, low cost procedure which may be safely performed bedside in non-ICU wards by a qualified team. This novel approach may greatly simplify the process of tracheotomy performance, eliminating much of the excess time, hassle, and cost without compromising safety and success rate.

Ultrasound-guided continuous paravertebral block in isolated thoracic trauma – providing sufficient analgesia for weaning and non-invasive-ventilation (NIV) on ICU for a 46 year old patient after high-speed trauma

After acute high-velocity injury it is desirable to avoid thoracic epidural analgesia to povide neurological examination of the spinal cord function. Systemic analgesia is often insufficient to tolerante non-invasive ventilation (NIV) in massive thoracic trauma and often leads to reintubation and subsequent dilation tracheotomy.

Is percutaneous dilational tracheotomy equivalent to traditional open surgical tracheotomy with regard to perioperative and postoperative complications?

BACKGROUND Tracheotomy is one of the most common procedures performed by otolaryngologists. The traditional method involves an open surgical technique (OST) performed in the operating room (OR). Since the mid-1980s, percutaneous dilational tracheotomies (PDT) have been performed by otolaryngologists and nonotolaryngologists with increasing frequency. An energized discussion in the literature has raised questions about the superiority of one technique versus the other in regard to the perioperative and long-term postoperative complications. Several prospective studies and meta-analysis reviews have addressed this question and compared OST with PDT. This review will summarize some of this literature to address the question of which technique is superior with respect to associated complications. It should be noted that the important discussion of medical economics related to tracheotomy is beyond the scope of this brief review.

Tracheal Flap after Percutaneous Dilatational Tracheotomy

A 66-YR-OLD male patient developed expiratory stridor shortly after decannulation. Bronchoscopy showed, at the stoma site, a large flap (fig. A and B, arrows) that moved synchronously with the respiratory cycle and obstructed more than 80% of the lumen during expiration (fig. B). The reinsertion of the tracheotomy tube trapped the flap between the tube itself and the anterior tracheal wall, and allowed airway patency to be reestablished and maintained. The flap was coagulated with argon-plasma and mechanically resected during rigid bronchoscopy under general anesthesia with spontaneous-assisted ventilation.The incidence of granulomas and other posttracheotomy obstructive lesions ranges from 1.5% to 56%, depending on the criteria for examination (surveillance vs. obstructive symptoms).1–3Unlike cicatritial stenosis, granulomas and flaps can be effectively removed during rigid bronchoscopy after coagulation with laser or argon-plasma.2General anesthesia with adequate muscle relaxation before intubation with the rigid scope is regarded as essential to avoid airway injury, and spontaneous-assisted or jet ventilation are the preferred methods to limit the risk of hypoxia and hypercapnia.For suprastomal obstructing lesions, the maintenance of the tracheostomy tube until the treatment is performed assures an unobstructed airway and offers a safe way to ventilate the patient during induction of general anesthesia.Even though not fail-safe, bronchoscopy performed before decannulation can help detect any tracheotomy-associated obstructive complication, especially if the tracheotomy tube is withdrawn as far out of the trachea as possible without losing the airway, to allow the examiner complete airway inspection.3

Percutaneous Dilational Tracheotomy for Airway Management in a Newborn With Pierre-Robin Syndrome and a Glossopharyngeal Web

Pierre-Robin syndrome (PRS) is often associated with difficulty in endotracheal intubation. We present the use of percutaneous dilational tracheotomy (PDT) for airway management of a newborn with PRS and a glossopharyngeal web. A 2-day-old term newborn with PRS and severe obstructive dyspnea was evaluated by the anesthesiology team for airway management. A direct laryngoscopy revealed a glossopharyngeal web extending from the base of the tongue to the posterior pharyngeal wall. The infant was spontaneously breathing through a 2 mm diameter fistula in the center of this web. It was decided that endotracheal intubation was impossible, and a PDT was planned. The trachea of the newborn was cannulated, using a 20 gauge peripheral venous catheter and a 0.71 mm guide wire was introduced through this catheter. Using 5 French, 7 French, 9 French, and 11 French central venous catheter kit dilators, staged tracheotomy stoma dilation was performed. By inserting a size 3.0 tracheotomy cannula, PDT was successfully completed in this newborn. This case describes the successful use of PDT for emergency airway management of a newborn with PRS and glossopharyngeal web.

Correction of subclinical coagulation disorders before percutaneous dilatational tracheotomy.

There is evidence that percutaneous dilatational tracheotomy (PDT) can be safely performed in patients with severe coagulation disorders if these are carefully corrected immediately before the procedure. However, it is currently unclear whether PDT can be performed safely in patients in an Intensive Care Unit (ICU) with uncorrected mild coagulation disorders. In a randomised controlled trial we determined the effect of correction of mild coagulation disorders on bleeding during and after PDT. ICU patients planned for bedside PDT with: (i) a prothrombin time (PT) between 14.7-20.0 seconds, (ii) a platelet count between 40-100×10(9)/L and/or (iii) active treatment with acetylsalicylic acid were randomised to receive infusion with fresh-frozen plasma (FFP) and/or platelets ("correction") versus no transfusion ("no correction") before PDT. We randomised 35 patients to the "correction" group and 37 patients to the "no correction" group. In patients who received FFP, the decrease in PT was marginal (mean decrease 0.40±0.56 seconds); the median increase in platelet counts after transfusion of platelets was 35 [11-47]x10(9)/L. The median blood loss was 3 [IQR: 1-6] grams in the "correction" group and 3 [IQR: 2-6] grams in the "no correction" group (P=0.96). Bleeding during and after bedside PDT in ICU patients with mild coagulation disorders is rare in our setting. Correction of subclinical coagulation disorders by transfusion of FFP and/or platelets does not affect bleeding.

Percutaneous dilational tracheostomy (PDT) and prevention of blood aspiration with superimposed high-frequency jet ventilation (SHFJV) using the tracheotomy-endoscope (TED): results of numerical and experimental simulations

We describe an innovative computer-based method for the analysis of gas flow using a modified airway management technique to perform percutaneous dilatational tracheotomy (PDT) with a rigid tracheotomy endoscope (TED). A test lung was connected via an artificial trachea with the tracheotomy endoscope and ventilated using superimposed high-frequency jet ventilation. Red packed cells were instilled during the puncture phase of a simulated percutaneous tracheotomy in a trachea model and migration of the red packed cells during breathing was continuously measured. Simultaneously, the calculation of the gas-flow within the endoscope was numerically simulated. In the experimental study, no backflow of blood occurred during the use of superimposed high-frequency jet ventilation (SHFJV) from the trachea into the endoscope nor did any transportation of blood into the lower respiratory tract occur. In parallel, the numerical simulations of the openings of TED show almost positive volume flows. Under the conditions investigated there is no risk of blood aspiration during PDT using the TED and simultaneous ventilation with SHFJV. In addition, no risk of impairment of endoscopic visibility exists through a backflow of blood into the TED. The method of numerical simulation offers excellent insight into the fluid flow even under highly transient conditions like jet ventilation.

Efficacy and Safety of Percutaneous Dilatation Tracheostomy (PDT) in Critically Ill Patients When Performed Bedside by an Intensivist With Flexible Bronchoscopy Assistance

PURPOSE: Intensive Care Unit (ICU) patients, mainly those in need of prolonged mechanical ventilation, may require a tracheotomy which once was done in the operating room. Percutaneous dilatational tracheotomy was first described in 1985 and now is a well-established procedure that can be performed at the bedside by an intensivist with less surgical equipment required. To evaluate the safety of performing a percutaneous dilatational tracheotomy (PDT) with fiberoptic bronchoscopy assistance in patients requiring prolonged mechanical ventilation.

Paratracheal placement of orotracheal tube: a complication when aborting percutaneous tracheotomy

Percutaneous dilatational tracheotomies (PT) are commonly performed in the ICU. The procedure carries the risk of complications, among them severe events as loss of airway or pneumothorax. In this case report we describe complications related to a PT procedure in the ICU. The procedure was performed with a single dilator kit, and by visual guidance of a bronchoscope. Because of difficulties with the insertion of the tracheal cannula, the procedure was aborted, and the endotracheal tube (ET) reinserted. After placement of the ET, subcutaneous emphysema emerged. Upon digital exploration in the tracheotomy incision the tube was found to exit from the trachea, the tube-tip being situated para-tracheally. The tube position was corrected using a finger in the incision, and the patient could again be ventilated. Poor visual conditions may occur during PT because of bleeding. Importantly, there is a risk for the ET to exit an incision in the trachea when reintubating during a PT procedure, or after decannulation. This can be prevented using digital occlusion of the tracheal opening.

Percutaneous dilatational tracheotomy in intensive care unit patients with increased bleeding risk or obesity. A prospective analysis of 1000 procedures

Percutaneous dilatational tracheotomy (PT) is safe and cost effective, and has become a routine method in intensive care units (ICU), but safety concerns persist for obese patients and for patients with a high risk of bleeding. In this prospective study of 1000 PTs, we have investigated whether such patient characteristics were associated with an increased procedural risk. We prospectively recorded all PTs performed in our ICU from 2001 to 2009. Data on blood transfusion were entered from a central database. The association of risk factors with bleeding and other complications was analysed with logistic regression. The total number of PTs and surgical tracheotomies was 1.454. The median number of days on a ventilator until PT was 6 in 2001, decreasing to 3 in 2009. A procedure-related complication was reported in 17.5%. There was no PT-related mortality. The rate of potentially life-threatening complications was 1.2%. Three patients developed pneumothorax and one of these had circulatory arrest and was successfully resuscitated. Three hundred and twelve patients had one or more units of blood transfused, but only 19 (1.9%) were PT related. Increased INR was the most important risk factor for bleeding [odds ratio (OR) 2.99], followed by low platelets (OR 1.99). The rate of complications in patients with high body mass index was not increased. PT is a safe procedure that can be performed with a low complication rate in patients with increased risk of bleeding as well as in obese patients.

External light guidance for percutaneous dilatational tracheotomy

Percutaneous dilatational tracheotomy (PDT) is considered a safe technique; however, there is still room for improvement. We present our initial experience with an external white light guide to position the endotracheal tube and guide needle placement during PDT. This is a retrospective series of 15 consecutive patients undergoing external light-guided PDT. A white light source was placed on the anterior trachea wall externally and the transmitted light was identified in the tracheal lumen with a bronchoscopic to predict the needle entrance point. The transmitted light was rapidly identified in all 15 patients, facilitated endotracheal tube tip placement in the subglottis in approximately 10 seconds in 13 of 15 patients, and predicted needle penetration into the trachea within 1 to 2 mm of the external light in all patients. External light guidance facilitates rapid, accurate placement of the needle through the tracheal wall and can reduce surgeon anxiety, especially in teaching situations.

Tracheostomy cannulas and voice prosthesis.

Cannulas and voice prostheses are mechanical aids for patients who had to undergo tracheotomy or laryngectomy for different reasons. For better understanding of the function of those artificial devices, first the indications and particularities of the previous surgical intervention are described in the context of this review. Despite the established procedure of percutaneous dilatation tracheotomy e.g. in intensive care units, the application of epithelised tracheostomas has its own position, especially when airway obstruction is persistent (e.g. caused by traumata, inflammations, or tumors) and a longer artificial ventilation or special care of the patient are required. In order to keep the airways open after tracheotomy, tracheostomy cannulas of different materials with different functions are available. For each patient the most appropriate type of cannula must be found. Voice prostheses are meanwhile the device of choice for rapid and efficient voice rehabilitation after laryngectomy. Individual sizes and materials allow adaptation of the voice prostheses to the individual anatomical situation of the patients. The combined application of voice prostheses with HME (Head and Moisture Exchanger) allows a good vocal as well as pulmonary rehabilitation. Precondition for efficient voice prosthesis is the observation of certain surgical principles during laryngectomy. The duration of the prosthesis mainly depends on material properties and biofilms, mostly consisting of funguses and bacteries. The quality of voice with valve prosthesis is clearly superior to esophagus prosthesis or electro-laryngeal voice. Whenever possible, tracheostoma valves for free-hand speech should be applied. Physicians taking care of patients with speech prostheses after laryngectomy should know exactly what to do in case the device fails or gets lost.

7-Year Survey After Percutaneous Dilatational Tracheotomy on a Medical Intensive Care Unit

PurposePercutaneous dilatational tracheotomy (PDT) is a well-established procedure in intensive care medicine. Several reports confirm a low acute and long-term complication rate. However, dilatational tracheotomy is still often postponed even...

Safety and Efficacy of GlideScope Video Laryngoscope-Assisted Percutaneous Dilatational Tracheotomy

PURPOSE: Critical care physicians can perform tracheotomy using percutaneous dilational technique (PDT) with similar safety as in “open― surgical tracheotomy, although the complication profile differs. Current endotracheal tube (ETT) cuff withdrawal techniques during PDT utilize bronchoscopic guidance or are done “blindly― through tactile feedback of the cuff touching the vocal cords. Bronchoscopy adds time, complexity, equipment and skilled manpower while “blind― withdrawal can lead to unplanned extubation and cuff rupture.

Bedside Percutaneous Dilatational Tracheotomy in Patients With Severe Respiratory Disease: The Benefits of a Novel Surgical Technique

Bedside Percutaneous Dilatational Tracheotomy in Patients With Severe Respiratory Disease: The Benefits of a Novel Surgical Technique

Percutaneous Tracheotomy

Tracheotomy is one of the most commonly performed procedures in critically ill patients. This article describes in particular the use of percutaneous dilatational tracheotomy. A brief history is included.