Percutaneous Tracheostomy Insertion Research Articles

Percutaneous tracheostomy in the surgical management of oral malignancy: an emerging standard of care

Percutaneous tracheostomy insertion is commonly performed in the critical care setting. However, its applicability and safety in head and neck (H&N) surgery remains uncertain. This study aimed to compare complications and postoperative recovery for percutaneous tracheostomy versus surgical tracheostomy in H&N surgery. A total of 66 patients undergoing percutaneous tracheostomy as part of H&N microvascular surgery were identified retrospectively. A control cohort of 70 consecutive surgical tracheostomy cases performed by another surgical team in the same department was similarly determined. Generally, the complication rates in the percutaneous and surgical tracheostomy groups were similar, with overall rates being 42% and 31%, respectively. The percutaneous group experienced a higher rate of airway obstruction (15%), primarily due to tube displacement. Time to decannulation and duration of inpatient stay were similar in both groups. Notably, an analysis of tracheostomy tube displacement identified high body mass index (BMI) and bilateral neck dissection as potential risk factors, and all cases occurred on postoperative day one. To mitigate this risk we recommend implementation of a percutaneous tracheostomy management protocol, precise tube selection using preoperative imaging, and careful passage of the stoma intraoperatively. In conclusion, this study found that the percutaneous technique exhibited a similar complication profile. It remains unclear whether the rates of longer-term complications, such as delayed stoma healing and tracheal stenosis, differ between techniques. A future prospective study with appropriate elimination of selection and reporting bias would help address this and similar pertinent issues, including patients' perspectives.

The accurate identification of the percutaneous tracheostomy insertion site using digital palpation in children.

Percutaneous tracheostomy (PT) may be required frequently in long-term ventilated intensive care patients. Although the overall risks are low, serious complications may occur, especially in children. Hence, this study aimed to assess physician accuracy in identifying PT insertion sites by digital palpation in children aged between 5 and 13 years. Participants were asked to identify the needle entry point (interspace between 2nd and 3rd or 3rd and 4th tracheal rings) for PT using digital palpation. Then, a single operator scanned the neck of each child with a linear high-frequency transducer. An accurate estimation was defined as a mark made between the upper and lower borders of the tracheal rings within the midline. In the study including 104 patients, the PT insertion site was accurately identified with digital palpation in a total of 50.9% of patients, compared with sonographic findings. The time required to determine the PT entry point by USG was longer than the palpation technique (114.7 vs. 43.8 s, P<0.001). The mean distance between the entry points of both methods was 4.53±2.03 mm. The majority of inaccurate assessments (45%) was above the 2nd tracheal ring. The lower the skin-to-air-mucosal interface distance, the higher the success of the PT entry point detection with the digital palpation method. A one-unit increase in body mass index was related to increasing the risk of failure by 1.1 times (P=0.030). Significant physician inaccuracy exists in PT insertion sites in children aged between 5 and 13 years, especially as BMI increases. Pre-procedural USG may help identify the landmarks for PT.

Response to: Respiratory protection for airway operators – Response to “aerosol generation during percutaneous tracheostomy insertion”

Response to: Respiratory protection for airway operators – Response to “aerosol generation during percutaneous tracheostomy insertion”

Aerosol generation during percutaneous tracheostomy insertion.

Aerosol generation during percutaneous tracheostomy insertion.

A survey of airway management for percutaneous tracheostomy insertion

A survey of airway management for percutaneous tracheostomy insertion

The ultrasound neck imaging for tracheostomy study: A study prompting ultrasound screening prior to percutaneous tracheostomy procedures to improve patient outcomes.

Percutaneous tracheostomy procedures are commonplace in intensive care units worldwide. Haemorrhagic complications, though potentially fatal, are thought to be under-reported. Ultrasonography use has not established itself in these procedures. This study assesses the prevalence and characteristics of pre-tracheal blood vessels, to aid intensivists on potential procedural hazards. A retrospective, observational study was performed in the UK. Computed tomography angiograms from January 2012 to October 2014 were randomly retrieved and analysed for vessel data. A total of 343 adult patients were included (mean age: 65 (inter-quartile range 52-79), male: 63%). Forty-one percent of patients demonstrated a vessel overlying percutaneous tracheostomy insertion sites (C6-T1); veins were more common than arteries (69%, p = 0.001). Males were more likely to display veins (78 vs. 53%, p < 0.001). A substantial proportion of patients exhibited pre-tracheal vessels. Front-of-neck ultrasonography has huge potential to identify these. Based on these data, we believe ultrasonography may be an effective screening tool for percutaneous tracheostomy procedures to reduce complications. Further research is required to study outcomes.

Bleeding Complications Associated With Percutaneous Tracheostomy Insertion in Patients Supported With Venovenous Extracorporeal Membrane Oxygen Support: A 10-Year Institutional Experience

To evaluate the bleeding complications associated with percutaneous tracheostomy while a patient is receiving venovenous extracorporeal membrane oxygen (VV ECMO) support. Retrospective, observational analysis. Single-center, tertiary, academic institution. All consecutive patients on VV ECMO over a 10 year-period undergoing percutaneous tracheostomy. Percutaneous tracheostomy. Fifty percutaneous tracheostomies were performed in patients requiring VV ECMO support over the 10-year period. The authors observed a 40% incidence of bleeding, with 32% of these incidences characterized as minor (self-limiting, localized stomal ooze) and 8% characterized as significant (necessitating surgical control and frequent packing or accompanied by a decrease in hemoglobin >20%). Bleeding is associated with percutaneous tracheostomy and is self-limiting in the majority of patients.

Inadvertent passage of a tracheostomy tube through Murphy's eye during percutaneous tracheostomy tube insertion

SummaryPercutaneous tracheostomies are commonly performed at the bedside in Critical Care Units. The use of bronchoscopy during the procedure is variable. We describe a case of inadvertent cannulation of Murphy's eye with a tracheostomy which initially went unrecognised. Recommendations from the NCEPOD report “On the right Trach” related to the use of bronchoscopy during percutaneous tracheostomy insertion and awareness of the nuances of different endotracheal tubes may have prevented this complication.

Evolutional trends in the management of tracheal and bronchial injuries.

Tracheal and Bronchial injuries are potentially life threatening complications which require urgent diagnosis and therapeutic intervention. They typically occur in association with blunt and penetrating chest trauma although they are increasingly being encountered in patients following endobronchial intervention and percutaneous tracheostomy insertion. Their precise incidence is unknown. Presenting features include dyspnoea, stridor, respiratory and haemodynamic compromise, haemoptysis, surgical emphysema, pneumothorax and persistent significant airleak. There may be other additional injuries to consider in trauma patients with large airway injury. Familiarity with the diagnosis and management of large airway injuries is important for medical teams engaged in emergency medicine, thoracic surgery and medicine, anaesthesia and intensive care. Although early surgical intervention is the mainstay of treatment, endobronchial manoeuvres to seal defects are receiving increasing attention particularly for patients with medical co-morbidities which may contraindicate formal surgery or transfer or where local surgical expertise is not available.

Computed tomography of the chest: I. Basic principles

### Key points The conventional chest radiograph superimposes a three-dimensional image onto a two-dimensional surface, so limiting its clinical usefulness. Since its introduction in 1971, X-ray computed tomography (CT) has rapidly evolved into an essential diagnostic imaging tool that forms a cross-sectional image, avoiding the super-imposition of structures that occurs in conventional chest imaging, with a >10-fold increase in attenuation sensitivity. Although CT imaging is reported by radiologists, it is important for both anaesthetists and intensivists to be able to interpret the scans, as reporting facilities may not be immediately available. Furthermore, the radiologist may not fully report all facets of a detailed scan and further information may be acquired by a physician with the ability to interpret CT scans. This is the first in a series of two articles written for anaesthetists and intensivists covering both thoracic anatomy and pathology as it relates to CT. A CT scanner makes many measurements, from different rotational angles, of X-ray attenuation ( weakening in force or intensity ) through the cross-sectional plane of the thorax. It then uses these data to reconstruct a digital representation of the cross-section with …

P200 Six Year Experience with Rigid Bronchoscopy: Complications, Indications and Changing Referral Patterns

Introduction and ObjectivesThe objective of this study was to determine the indications and outcomes of the last 500 referrals for rigid bronchoscopy at a tertiary referral centre and to review...

Antibiotic Prophylaxis for Percutaneous Tracheostomy: A Survey of Current Practice in the UK

Percutaneous tracheostomy (PT) is a commonly-performed invasive procedure in intensive care units. Infections (including bacteraemia and nosocomial pneumonia) are recognised complications that occur following PT. The recently published document ‘Standards for care of adult patients with temporary tracheostomies' produced by the Intensive Care Society UK (ICS) made no recommendations regarding antibiotic prophylaxis (AP) for PT, and we were unaware of whether AP is used for this procedure in the UK. We therefore conducted a survey of the current practice in 130 critical care units; 65 responded. None gave antibiotics for routine PT, but in the presence of known colonisation with methicillin-resistant Staphyloccocus aureus (MRSA), six units (9%) would give antibiotic prophylaxis. Only three units (5%) had a policy for antibiotic prophylaxis. Twenty-six critical care units (40%) reported infectious complications occurring following PT. Despite a high level of awareness among clinicians that PT is associated with a significant risk of infective complications, only a small number administer AP prior to PT insertion even in patients colonised with MRSA and those with positive sputum cultures. The majority of units do not have a policy or guidelines for administration of AP prior to PT despite the fact that administration of appropriate antibiotics has been shown to reduce perioperative infectious complications for this procedure.

Bilateral Tension Pneumothoraces following Percutaneous Tracheostomy

Percutaneous tracheostomy is a relatively safe bedside alternative to surgical tracheostomy. However, there are significant risks and complications, such as pneumothorax. This case report describes what is believed to be the first example of bilateral tension pneumothorax secondary to percutaneous tracheostomy insertion which occurred despite bronchoscopic guidance.

Survey of Percutaneous Tracheostomy Practice in UK Intensive Care Units

In order to assess current practice of percutaneous tracheostomy (PT) in UK intensive care units (ICUs), we created a web-based survey by e-mail invitation to the clinical directors of 184 ICUs taking part in the ICNARC case-mix programme. The response rate was 46% (n=85). Most units performed 100 or fewer PTs each year. Just over half, 55.3%, had access to resident on-site surgical backup with ENT being the most common specialty providing this. Nearly one third, 30.6%, performed PTs out of routine hours; 30.6% used ultrasound to visualise potential problematic vessels. Bronchoscopy was used by 81.7% of units for all PTs performed, and conical dilation was the most popular technique. Fifteen units, 8.2%, did not routinely perform chest X-ray after PT insertion, but 49.4% of respondents did not feel that chest X-ray was mandatory after routine uncomplicated PT insertion. Despite certain trends in practice, there is still disparity in the practice of PT among ICUs in the UK. Ultrasound examination for problematic blood vessels prior to PT should be considered, bronchoscopy should be readily available and the use of routine chest X-ray after uncomplicated PT insertion should be questioned.

Pitfalls in Percutaneous Dilational Tracheostomy Using the Ciaglia® One-Step Technique

Surgical tracheostomy was first described in 1909. Since then, it has become a standard procedure for patients requiring prolonged mechanical ventilation. More recently, bedside percutaneous tracheostomy has been shown to be as safe and effective as the surgical technique, but with the added advantage of also being technically straightforward and cost-efficient. Partly because of this, percutaneous tracheostomy is now being performed by nonsurgeon intensivists. However, the relative ease of the procedure may mask many potential pitfalls that can result in morbidity. As such, it is important for all intensivists to be familiar with the steps and potential pitfalls of this procedure. This is an evidence-based review of the common pitfalls associated with the Ciaglia one-step percutaneous tracheostomy technique, the method most commonly utilized for percutaneous tracheostomy insertion in the United States.

Mortality from percutaneous dilatational tracheostomy. A report of three cases*

We report three deaths following percutaneous dilatational tracheostomy in a series of 1187 procedures undertaken in a single intensive care unit over a 13-year period. All deaths were due to severe haemorrhage. The first patient died during the procedure from uncontrollable haemorrhage from the innominate vein. Delayed haemorrhage in the other two patients was caused by the tracheostomy tube eroding into the aorta in one patient and into the innominate vein in the other. In both these patients, the tracheal stoma was found at postmortem to be sited unexpectedly low. Fatal haemorrhage is a rare complication of percutaneous tracheostomy (0.25% in this series), but is probably under-reported. While bronchoscopy is now used routinely during percutaneous tracheostomy insertion in most units, we speculate that ultrasound examination of the neck is more likely to identify major vascular structures at risk. However, whilst intuitive, there is little evidence that either bronchoscopy or ultrasound scanning reduces the incidence of complications. Magnetic resonance images of normal subjects are presented to demonstrate the anatomical relations of the trachea to major vascular structures and their variability.

Percutaneous tracheostomy insertion can be difficult

Percutaneous tracheostomy insertion can be difficult