Percutaneous Tracheostomy Technique Research Articles

A modified technique for percutaneous dilatational tracheostomy

A modified technique for percutaneous dilatational tracheostomy

Tracheal Stenosis in Open Versus Percutaneous Tracheostomy.

This study aims to investigate if there is an increased risk of developing tracheal stenosis after tracheostomy with an open versus percutaneous tracheostomy. The patient cohort included patients receiving open or percutaneous tracheostomies at Catholic Health Initiatives Midwest facilities from January 2017 to June 2023. The primary aim was to compare the differences in the risk of developing tracheal stenosis between open and percutaneous tracheostomy techniques. Between-technique differences in the risk of developing tracheal stenosis were assessed via a Cox proportional hazard model. To account for death precluding patients from developing tracheal stenosis, death was considered a competing risk. A total of 828 patients met inclusion criteria (61.7% open, 38.3% percutaneous); 2.5% (N = 21) developed tracheal stenosis. The median number of days to develop tracheal stenosis was 84 (interquartile range: 60 to 243, range: 6 to 739). Tracheal stenosis was more frequent in patients who received a percutaneous tracheostomy (percutaneous: 3.5% vs. open: 2.0%); however, the risk of developing tracheal stenosis was statistically similar between open and percutaneous techniques (HR: 2.05, 95% CI: 0.86-4.94, p = 0.108). This study demonstrates no significant difference in the development of tracheal stenosis when performing an open versus a percutaneous tracheostomy. Tracheal stenosis is a long-term complication of tracheostomy and should not influence the decision about the surgical technique used.

A Pluridisciplinary Tracheostomy Weaning Protocol for Brain-Injured Patients, Outside of the Intensive Care Unit and Without Instrumental Assessment: Results of Pilot Study

AbstractConcurrently to the recent development of percutaneous tracheostomy techniques in the intensive care unit (ICU), the amount of tracheostomized brain-injured patients has increased. Despites its advantages, tracheostomy may represent an obstacle to their orientation towards conventional hospitalization or rehabilitation services. To date, there is no recommendation for tracheostomy weaning outside of the ICU. We created a pluridisciplinary tracheostomy weaning protocol relying on standardized criteria but adapted to each patient’s characteristics and that does not require instrumental assessment. It was tested in a prospective, single-centre, non-randomized cohort study. Inclusion criteria were age > 18 years, hospitalized for an acquired brain injury (ABI), tracheostomized during an ICU stay, and weaned from mechanical ventilation. The exclusion criterion was severe malnutrition. Decannulation failure was defined as recannulation within 96 h after decannulation. Thirty tracheostomized ABI patients from our neurosurgery department were successively and exhaustively included after ICU discharge. Twenty-six patients were decannulated (decannulation rate, 90%). None of them were recannulated (success rate, 100%). Two patients never reached the decannulation stage. Two patients died during the procedure. Mean tracheostomy weaning duration (inclusion to decannulation) was 7.6 (standard deviation [SD]: 4.6) days and mean total tracheostomy time (insertion to decannulation) was 42.5 (SD: 24.8) days. Our results demonstrate that our protocol might be able to determine without instrumental assessment which patient can be successfully decannulated. Therefore, it may be used safely outside ICU or a specialized unit. Moreover, our tracheostomy weaning duration is very short as compared to the current literature.

Fiberoptic Bronchoscope-guided vs Mini-surgical Technique of Percutaneous Dilatational Tracheostomy in Intensive Care Units: A Comment.

How to cite this article: Bandyopadhyay A, Puri S, Ashok V. Fiberoptic Bronchoscope-guided vs Mini-surgical Technique of Percutaneous Dilatational Tracheostomy in Intensive Care Units: A Comment. Indian J Crit Care Med 2023;27(1):78.

Modified Technique of Percutaneous Tracheostomy Using Borescope Camera: A Case Series.

Mustahsin M, Srivastava A, Manchanda J, Kaushik R. Modified Technique of Percutaneous Tracheostomy Using Borescope Camera: A Case Series. Indian J Crit Care Med 2022;26(7):881-883.

COVID-19 Patients from Hospitalization to Tracheostomy, the Experience of a High-Volume Center

Background: Making decisions and planning about tracheostomy is not clear yet. Objectives: This study aimed to report intensive care unit (ICU) admission, intubation, and tracheostomy rates among patients in different settings and compare the outcomes of surgical and Percutaneous dilational tracheostomy (PDT) techniques between COVID-19 and non-COVID patients. Methods: Patients admitted to Masih Daneshvary hospital were assessed from February 2020 to May 2021 for intubation and tracheostomy rates. Different aspects and outcomes of two methods of tracheostomy, including surgical and PDT tracheostomy, were compared. Among non-COVID patients, 15 ICU admitted patients with different etiologies of pneumonia who required mechanical ventilation and tracheostomy were randomly selected and compared to COVID-19 patients. Results: A total of 7,748 COVID-19 patients were admitted, with 12.7% admitted to ICU with an intubation rate of 5.13%. Tracheostomy was performed for a total of 36 patients (0.46%) for prolonged intubation with a trend of 0.1% to 1.45% in 16 months. Regarding the technique of tracheostomy, 24% and 33.3% of patients survived in surgical and PDT groups, respectively (P=0.44). Surgical tracheostomy and PDT were performed in 26.5% and 40% of non-COVID patients, respectively (P=0.5). The mortality rate was 72.2% and 20% in the surgical tracheostomy and PDT groups, respectively (P=0.003). Conclusion: Given the study results, both surgical and percutaneous techniques are feasible for COVID-19 patients, and the decision about the optimal timing of intubation needs more inquiry.

Is HFJV a better alternative ventilation technique for percutaneous dilatational tracheostomy? A randomized trial.

High-frequency jet ventilation (HFJV) has been used for the treatment of tracheal lesions, airway surgery, and treatment of secondary lesions after tracheostomy for many years however, reports on the use of HFJV during percutaneous dilatational tracheostomy (PDT) are limited. This study compares the use of traditional method, ventilation with laryngeal mask airway (LMA), and HFJV through endotracheal tube (ETT) with respect to the duration of PDT procedure and complications. Seventy-five patients were randomized into one of the three groups with computer-generated random numbers: Group ETT (N.=25), group LMA (N.=25), and group HFJV (n=25). Demographic data, duration of PDT, complications such as ETT cuff puncture and tube transaction, accidental extubation, difficult cannula insertion, bleeding, desaturation during the procedure, arterial blood gases immediately before and after the procedure have been recorded. Mean time for successful PDT in group ETT was 5.9±1.35 minutes, in group LMA 4.96±0.78 minutes, and 3.88±0.78 minutes in group HFJV. PDT duration was shorter in the LMA group than in the ETT group (P<0.05). In the HFJV group, the PDT duration was shorter than the LMA group (P<0.05) and the ETT group (P<0.001). In terms of the total number of complications, significantly fewer complications were observed in the HFJV group compared with group ETT and group LMA. HFJV may be a more effective alternative method for airway management during PDT, facilitating and reducing the duration of the intervention.

Забезпечення респіраторної підтримки у пацієнтів відділення інтенсивної терапії: можливості черезшкірної дилатаційної трахеостомії

У статті аналізуються методи забезпечення респіраторної підтримки у пацієнтів відділення інтенсивної терапії, наведена техніка пункційно-дилатаційної трахеостомії (ПДТ), аналізуються її відмінності від класичної техніки трахеостомії. Автори приводять власний досвід проведення 196 трахеостомій методом ПДТ, вказують на можливі ускладнення цієї техніки, а також на переваги ПДТ перед методами класичної респіраторної підтримки.

Fiber-optic Bronchoscope-guided vs Mini-surgical Technique of Percutaneous Dilatational Tracheostomy in Intensive Care Units.

ABSTRACTBackgroundPercutaneous dilatational tracheostomy (PCDT) using fiber-optic bronchoscope (FOB) is a widely practiced technique, but its availability and cost remain a concern in nations with limited resources. Mini-surgical technique of PCDT incorporating minimal blunt dissection has shown improved results even without the use of FOB. The study is primarily intended to compare these two techniques and establish a safer cost-effective alternative to FOB-guided PCDTs.Patients and methodsThis randomized comparative study [registered (CTRI/2018/04/013191)] was conducted on 120 mechanically ventilated patients. In 60 patients, mini-surgical PCDT (group-M) was performed with 2 cm longitudinal skin incision and blunt dissection till pretracheal fascia without FOB guidance using Portex-Ultraperc™ sets. In remaining 60 patients, PCDT was performed under FOB vision with similar skin incision (without blunt dissection) using Portex-Ultraperc™ sets (group-F). Two techniques were compared with regard to procedural time and percentage of complications occurred during or after the procedure.ResultsProcedure time [group-M: 6.30 ± 1.28 minutes; group-F: 14.43 ± 1.84 minutes (p <0.001)] and mean blood loss [group-M: 5.33 ± 1.69 mL; group-F: 6.87 ± 3.11 mL (p = 0.001)] was significantly less in group-M. Higher incidence of desaturation [group-M: 16.7%; group-F: 35% (p = 0.022)] was noted in group-F, whereas arrhythmias [group-M: 21.7%; group-F: 6.7% (p = 0.018)] were higher in group-M. There was no statistical difference in incidence of pneumothorax and subcutaneous emphysema. There was no incidence of posterior tracheal wall perforation in any of the patients.ConclusionMini-surgical technique is a faster alternative of FOB-guided PCDT with comparable incidence of complications. It can safely be used in intensive care units (ICUs) where FOB is not available.Clinical trial registration numberCTRI/2018/05/014307Name of registryClinical Trials Registry of India (CTRI), URL—http://ctri.nic.in How to cite this articleKumar A, Kohli A, Kachru N, Bhadoria P, Wadhawan S, Kumar D. Fiber-optic Bronchoscope-guided vs Mini-surgical Technique of Percutaneous Dilatational Tracheostomy in Intensive Care Units. Indian J Crit Care Med 2021;25(11):1269–1274.

Percutaneous tracheostomy in COVID-19 patients: a new apneic approach

BackgroundPercutaneous dilation tracheostomy is an aerosol-generating procedure carrying a documented infectious risk during respiratory virus pandemics. For this reason, during the COVID-19 outbreak, surgical tracheostomy was preferred to the percutaneous one, despite the technique related complications increased risk. MethodsWe describe a new sequence for percutaneous dilation tracheostomy procedure that could be considered safe both for patients and healthcare personnel. A fiberscope was connected to a video unit to allow bronchoscopy. Guidewire positioning was performed as usual. While the established standard procedure continues with the creation of the stoma without any change in mechanical ventilation, we retracted the bronchoscope until immediately after the access valve in the mount tube, allowing normal ventilation. After 3 minutes of ventilation with 100% oxygen, mechanical ventilation was stopped without disconnecting the circuit. During apnea, the stoma was created by dilating the trachea and the tracheostomy cannula was inserted. Ventilation was then resumed. We evaluated the safeness of the procedure by recording any severe desaturation and by performing serological tests to all personnel. ResultsThirty-six patients (38%) of 96 underwent tracheostomy; 22 (23%) percutaneous dilation tracheostomies with the new approach were performed without any desaturation. All personnel (150 operators) were evaluated for serological testing: 9 (6%) had positive serology but none of them had participated in tracheostomy procedures. ConclusionThis newly described percutaneous dilation tracheostomy technique was not related to severe desaturation events and we did not observe any positive serological test in health workers who performed the tracheostomies.

A novel percutaneous tracheostomy technique to reduce aerosolisation during the COVID-19 pandemic: A description and case series

BackgroundCOVID-19 is a global pandemic with many patients requiring prolonged mechanical ventilation. COVID-19 is associated with laryngeal oedema and a high rate of reintubation and difficult airway. Tracheostomy insertion is an aerosol generating procedure, so we strived to make our novel technique safe for operator and patient. AimTo share our experience of a novel percutaneous tracheostomy technique, based on a case series of 18 patients with COVID-19 pneumonitis. MethodOur novel percutaneous tracheostomy technique is a landmark-based approach without bronchoscopic confirmation of the correct needle placement. Blunt dissection using tracheal dilators onto the tracheal rings facilitates first pass needle insertion into the trachea. The tracheal tube is retracted into the supraglottic airway, the cuff overinflated, and a wet throat pack inserted to reduce aerosolisation. ResultsFrom March 2020 to May 2020, 38 patients with suspected or confirmed COVID-19 presented to Royal Bolton Hospital requiring invasive ventilation. 18 patients underwent percutaneous tracheostomy. 6 patients have been decannulated, 12 patients died. Mean time from intubation to tracheostomy was 6.1 days and from tracheostomy to decannulation 20.6 days. No operator developed COVID-19 symptoms. ConclusionsDespite the low numbers our novel technique appears to be safe, but confirmation requires a larger controlled trial. As an institution we have avoided difficulties with reintubation and reduced our drug usage.

Rescue Tracheostomy for Patients With Unresectable Large Growing Neck Masses

Most patients with undifferentiated thyroid cancer have unresectable disease with a very high rate of airway compromise. Tracheostomy typically entails technical issues in these cases. In fact, it can be very difficult to expose or simply locate the trachea beneath the mass, and the extensive soft tissue involvement can force the surgeon to cut the tumor to place the tracheostomy tube. The combined use of rigid bronchoscopy and percutaneous tracheostomy techniques, applied in an open surgical procedure, can greatly simplify the procedure. Furthermore, by this method, the airways are quickly secured and the risk of intraoperative bleeding is reduced.

Aclinical retrospective study of percutaneous dilatational tracheostomy without guide wire for critically ill patients.

This study aimed to introduce anovel tracheostomy method, the non-guide-wire percutaneous dilatational tracheostomy (NGPDT) technique, and evaluate its effectiveness for critically ill patients undergoing neurosurgery under special conditions. The clinical data of 48critically ill patients who underwent NGPDT under special conditions with controlled steps were analyzed retrospectively. The patients' demographic, preoperative state of illness, and diagnosis data were collected. Moreover, their intraoperative and postoperative variables were accessed, e.g., operation times, bleeding, saturation of pulse oxygen (SPO2), and early and late complications related to NGPDT. The mean patient age was 47.7 ± 13.7years. The mean GCS (Glasgow Coma Scale) was 8.1 ± 2.9, and the mean BMI (Body Mass Index) was 25.2 ± 5.6. There were 38patients with an endotracheal tube. The mean duration of onset to NGPDT was 4.0 ± 1.3days. The mean operation time was 4.2 ± 1.9 min. There were 41patients with mild intraoperative bleeding, 5with moderate bleeding, and 2with severe bleeding as well as 46with mild postoperative bleeding and 2with moderate bleeding. Additionally, 41patients required complete extubation after NGPDT. The mean duration of incision healing was 4.8 ± 3.1days. There was 1 patient with adecrease of SPO2 ≥ 10%. Three patients presented with atransient violent cough at the primary tracheostomy stage; however, no patients suffered from pneumothorax, subcutaneous emphysema, false passage, or surgery-related death during this procedure. Overall, NGPDT with controlled steps is afast, safe, and microinvasive procedure. It mildly stimulates the trachea with alow rate of complications.

Modified percutaneous tracheostomy in patients with COVID-19

BackgroundPatients hospitalized with COVID-19 are at risk of developing hypoxic respiratory failure and often require prolonged mechanical ventilation. Indication and timing to perform tracheostomy is controversial in patients with COVID-19.MethodsThis...

Pre-procedural ultrasound assessment as a step towards the safety of percutaneous dilatational tracheostomy: a comparative study

Background: Percutaneous dilatational tracheostomy (PDT) is an inevitable procedure indicated for mechanically ventilated critically ill patients. Ultrasound (US) assisted PDT has emerged increasing safety issues. Case series were reported to confirm the advantages of USPDT. Aim: The present study aimed to compare patients subjected to USPDT with those subjected to bronchoscope guided PDT only, regarding the easiness of technique, efficacy and safety. Materials and Methods: A prospective, randomized, comparative clinical study carried on 49 adults mechanically ventilated critically ill patients in need to maintain a secure airway through elective PDT, using Ciaglia’s Blue Rhino percutaneous dilatational tracheostomy technique. 5 patients were excluded for surgical conversion, and the remaining 44 were randomly divided into 2 groups; PDT group: patients subjected to fiber optic guided PDT, and USPDT group: patients underwent pre-procedural US imaging followed by fiber optic guided PDT. Time of the technique, procedure failure, procedure difficulty, and complications were documented, our follow up ends 24-hours after the technique. Results: Pre-procedural US guided PDT was found to be easier (P<0.05), 1 puncture was needed in the USPDT group (P<0.05) with shorter time (P<0.001). The puncture site was changed in 31.8% of the PDT group of patients but not in the USPDT group. The pre-procedural US group showed less bleeding, transient hypoxemia (P<0.05) and total number of patients with minor complications (P<0.05). Conclusion: Pre-procedural ultrasound assessment of trachea and Para-tracheal soft tissues can be considered as a reliable tool to increase safety and improve outcomes of percutaneous tracheostomy

A Technique to Minimize Aerosolization During Percutaneous Tracheostomy in COVID-19 Patients.

The SARS-CoV-2 pandemic has caused respiratory failure in many patients. With no effective treatment or vaccine, prolonged mechanical ventilation is common in survivors. Timing and performance of tracheostomy, for both patient and surgical team safety, remains a question. Here within, we report our experience with percutaneous dilatational tracheostomy with modification to minimize aerosolization. A modified percutaneous dilatational tracheostomy technique is described. The technique was performed on 10 patients in the surgical intensive care unit. Ten patients underwent percutaneous dilatational tracheostomy. There were 7 males, and the average age for the group was 60.8 years. The average number of ventilator days before the operation was 26.3. All procedures were successful, and no patient had any procedure-related complications. The procedure described was successful in our patient population. We believe that this approach is safe for patients with coronavirus disease 2019 and limits aerosolization during the operation. Level IV, case series.

Suspension laryngoscopy-assisted percutaneous dilatational tracheostomy

We describe an endoscopic-guided, suspension laryngoscopy-assisted percutaneous dilatational tracheostomy technique, which can be performed by all otolaryngologists and is suitable for any patient requiring tracheostomy. It can be performed in the context of elective surgery or as an emergency procedure. This technique was developed using suspension laryngoscopy and ENT endoscopy equipment, as well as a percutaneous dilatational tracheostomy kit. It has the advantage of ensuring optimal control of the patient's ventilation and haemostasis throughout the procedure. The good quality endoscopic vision and easy access to the airway provided by suspension laryngoscopy allow tracheostomy to be performed under optimal safety conditions.

Evaluation of percutaneous dilatational tracheostomy under laryngosuspension.

PurposeTo describe the technique and outcomes of percutaneous tracheostomy under laryngosuspension.MethodsA consecutive series of patients who underwent percutaneous tracheostomy under laryngosuspension were reviewed for outcomes. The procedure is performed under general anesthesia and laryngosuspension. An 8.5 oral endotracheal tube is inserted and the cuff is inflated in the supraglottis, allowing access to the whole trachea and subglottis. The tube is taped to the laryngoscope. A rigid endoscope is inserted in the endotracheal tube through a swivel connector connected to the tube and the ventilation circuit. Percutaneous tracheostomy kit is used to perform dilatational tracheostomy at the desired level of the trachea under direct visual endoscopic control.ResultsForty-eight patients underwent percutaneous tracheostomy under laryngosuspension. Thirty-two cases were performed in an emergency after securing the airway with endotracheal intubation. In all other cases, tracheostomy was performed as a part of an elective procedure affecting the airway or in patients requiring prolonged ventilation. More than half of patients were considered high risk by virtue of one or more of the following: morbid obesity, prior neck surgery, prior neck radiotherapy, progressive head and neck cancer, or laryngotracheal stenosis. Complications occurred in seven cases.ConclusionPercutaneous tracheostomy under laryngosuspension has the advantage of optimal control of patient ventilation and hemostasis throughout the procedure. High-quality endoscopic vision and easy access to the airway under laryngosuspension allow tracheostomy to be performed with maximum safety.

Outcomes After Tracheostomy in COVID-19 Patients.

Objective:To determine the outcomes of patients undergoing tracheostomy for COVID-19 and of healthcare workers performing these procedures.Background:Tracheostomy is often performed for prolonged endotracheal intubation in critically ill patients. However, in the context of COVID-19, tracheostomy placement pathways have been altered due to the poor prognosis of intubated patients and the risk of transmission to providers through this highly aerosolizing procedure.Methods:A prospective single-system multi-center observational cohort study was performed on patients who underwent tracheostomy after acute respiratory failure secondary to COVID-19.Results:Of the 53 patients who underwent tracheostomy, the average time from endotracheal intubation to tracheostomy was 19.7 days ± 6.9 days. The most common indication for tracheostomy was acute respiratory distress syndrome, followed by failure to wean ventilation and post-extracorporeal membrane oxygenation decannulation. Thirty patients (56.6%) were liberated from the ventilator, 16 (30.2%) have been discharged alive, 7 (13.2%) have been decannulated, and 6 (11.3%) died. The average time from tracheostomy to ventilator liberation was 11.8 days ± 6.9 days (range 2–32 days). Both open surgical and percutaneous dilational tracheostomy techniques were performed utilizing methods to mitigate aerosols. No healthcare worker transmissions resulted from performing the procedure.Conclusions:Alterations to tracheostomy practices and processes were successfully instituted. Following these steps, tracheostomy in COVID-19 intubated patients seems safe for both patients and healthcare workers performing the procedure.

Novel Percutaneous Tracheostomy for Critically Ill Patients With COVID-19

BackgroundCoronavirus 2019 (COVID-19) is a worldwide pandemic, with many patients requiring prolonged mechanical ventilation. Tracheostomy is not recommended by current guidelines as it is considered a superspreading event owing to aerosolization that unduly risks health care workers.MethodsPatients with severe COVID-19 who were on mechanical ventilation for 5 days or longer were evaluated for percutaneous dilational tracheostomy. We developed a novel percutaneous tracheostomy technique that placed the bronchoscope alongside the endotracheal tube, not inside it. That improved visualization during the procedure and continued standard mechanical ventilation after positioning the inflated endotracheal tube cuff in the distal trachea. This technique offers a significant mitigation for the risk of virus aerosolization during the procedure.ResultsFrom March 10 to April 15, 2020, 270 patients with COVID-19 required invasive mechanical ventilation at New York University Langone Health Manhattan’s campus; of those, 98 patients underwent percutaneous dilational tracheostomy. The mean time from intubation to the procedure was 10.6 ± 5 days. Currently, 32 patients (33%) do not require mechanical ventilatory support, 19 (19%) have their tracheostomy tube downsized, and 8 (8%) were decannulated. Forty patients (41%) remain on full ventilator support, and 19 (19%) are weaning from mechanical ventilation. Seven patients (7%) died as a result of respiratory and multiorgan failure. Tracheostomy-related bleeding was the most common complication (5 patients). None of health care providers has had symptoms or tested positive for COVID-19.ConclusionsOur percutaneous tracheostomy technique appears to be safe and effective for COVID-19 patients and safe for health care workers.