Tracheostomy Technique Research Articles

How to do a safe tracheostomy Technical note

A new technique of surgical tracheostomy is described. Prior to performing the tracheostomy, the endotracheal tube (ETT) is advanced further down the trachea so that the end of the tube is positioned just above the carina. Using the flexible endoscope within the ETT the positioning can be done with precision. This manoeuvre avoids the cuff of the ETT being perforated as it is well below the site of the tracheal window. Following the creation of an opening in the trachea, the patient continues to have a definitive airway. In this controlled environment, time is taken to obtain haemostasis at the tracheostomy site, place a rescue stitch and also suction above the cuff of the ETT. A study was carried out in a series of 15 patients by recording various measurements during the procedure to confirm the accuracy of this technique.

Infant Tracheotomy

To identify practice patterns regarding tracheotomy technique among pediatric otolaryngologists. Survey of physicians. Academic medical center. Members of the American Society of Pediatric Otolaryngology (ASPO) residing in the United States. Physician responses to survey questions, including both multiple choice and free-text responses. We used chi(2) tests to determine if demographic factors (pediatric otolaryngology fellowship training, the number of tracheotomies performed yearly) correlated with differences in the technique used to perform infant tracheotomies. A total of 168 of 225 surveys mailed to ASPO members (75%) were completed and returned. Most respondents (87%) report that they make a simple vertical incision in the trachea. An even greater number (94%) use stay sutures routinely. On other technical points, such as management of the thyroid gland, the subcutaneous fat, and the method of securing the tracheostomy tube, there was much greater variability: 22% of respondents reported having had a serious tracheotomy-related complication in the immediate postoperative period, and 58% of these physicians changed their technique as a result. In several areas, chi(2) analysis revealed statistically significant differences in technique that were dependent on both fellowship training and the number of tracheotomies performed (P < or = .05). Among ASPO members practicing in the United States, there is near-unanimity on certain technical points, with considerable divergence on others. A substantial percentage of our colleagues have experienced a tracheotomy-related complication in the early postoperative period. In many cases, these incidents led to changes in surgical technique.

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.

Intensive care unit tracheostomy: a snapshot of UK practice

Background and methodsTracheostomy is a common procedure in intensive care patient management. The aim of this study was to capture the practice of tracheostomy in Intensive Care Units in the United Kingdom. A postal survey was sent to the lead clinicians of 228 general intensive care units (ICUs) throughout the United Kingdom excluding specialist units. We aimed to identify the current practice of tracheostomy, including timing of insertion, equipment used and post-operative care and follow-up.ResultsA response rate of 86.84% was achieved. Percutaneous tracheostomy continues to be favoured over surgical tracheostomy with less than 8% of ICUs opting for surgical tracheostomies > 50% of the time. 89% of units required only 2 operators to perform the technique and single stage dilatation is the technique of choice in 83% of units. The Ciaglia technique, which was strongly favoured less than a decade ago, is currently practiced in less than 5% of ICUs. Bronchoscopic guidance is an important adjunct to the technique of percutaneous tracheostomy with 80% of units using it routinely. Follow-up care of patients remains poor with 59% of ICUs not having routine follow-up once the patient has left the unit.ConclusionThe practice of percutaneous tracheostomy remains the preferred technique within the UK. There seems to be a growing preference for single stage dilatational techniques. Timing of tracheostomy remains variable despite evidence to suggest benefit from an earlier procedure. Follow-up of tracheostomised patients after discharge from ICU is still low, which may mean significant morbidity from the procedure is being missed.

Percutaneous dilatation tracheostomy in critically ill patients with documented coagulopathy

Percutaneous tracheostomy techniques are gaining greater popularity in ICUs. Refinement of the percutaneous tracheostomy technique has made this a straightforward and safe procedure in appropriately selected patients. Generally, coagulopathy is a relative contraindication for surgical tracheotomy. We sought to determine its usage in high-risk patients with documented coagulopathy.

Safety and practicability of percutaneous translaryngeal tracheotomy (Fantoni technique) in surgery of maxillofacial and oropharyngeal tumours – Own results and review of the literature

The study examines the suitability of the Fantoni method of translaryngeal tracheotomy (TLT) for airway management after surgery due to oropharyngeal and maxillofacial tumours. During a 4-year period, 156 translaryngeal pull-through tracheotomies were performed in 145 patients. This method is the only puncture tracheotomy technique that involves a dilatation process from inside the trachea to the outside through the skin and differs from other established puncture methods regarding practicability and frequency of complications. The mean puncture time (from puncture of the trachea to correct tube placement) was 10.1+/-4.8 min. With an oxygen supply of FiO(2)=1.0 the oxygen saturation prior to TLT was 98.4+/-1.29%, and the lowest median saturation value during the TLT procedure was 96.7+/-3.9%. No serious complications such as bleeding, loss of airway, pneumothorax or death were observed. Complications occurring during the TLT procedure were exclusively technical and at no time were they life-threatening. TLT is a technique with few complications and a straightforward procedure for those familiar with the method. It has some advantages compared with other puncture techniques which appear to commend TLT in terms of safety for the patient.

Surgical management of severe suprastomal cricotracheal collapse complicating pediatric tracheostomy

Suprastomal tracheal collapse may interfere with decannulation in tracheostomized patients. The purposes of the study are to evaluate the role of tracheotomy technique in the ethiology of suprastomal cricotracheal collapse and to report our results in the treatment of this complication. A retrospective review of children showing severe suprastomal collapse during the period 1990-2007, in a tertiary care children's hospital, was performed. Medical records were assessed for the following data: sex, age, original indication for tracheotomy, surgical technique, endoscopic findings, type of surgical correction, complications, result, and follow-up. Fourteen patients were included in the study, nine girls and five boys. Average age at tracheotomy was 17 months (range: 21 days-8 years), and prolonged ventilatory support was the most common indication (57%). Horizontal H-type tracheotomy was the most frequent technique in patients with suprastomal collapse (n=9), whereas only one patient with a vertical tracheotomy showed this complication (p<0.05). In every case bronchoscopy disclosed a suprastomal tracheal obstruction of at least 50% of the lumen. Mean age at surgical decannulation was 38 months (range: 12-147 months). Two surgical techniques have been used in the treatment of suprastomal collapse: anterior cricotracheal suspension (n=13) and reconstruction with autologous cartilage graft (n=1). All the patients were successfully decannulated although in one case two procedures were required. No recurrence has been observed during long-term follow-up (mean: 8.6 years). Endoscopical examination is essential for the diagnosis of suprastomal collapse and to rule out other causes of decannulation failure. In our experience, the tracheotomy technique seems to have an ethiologic role, and anterior cricotracheal suspension is a simple and effective procedure in the treatment of this tracheostomy related complication.

How to do a safe tracheostomy—a novel technique

Introduction: Tracheostomy is a common procedure. Complications are common and can be dramatic. During tracheostomy, there is increased risk of aspiration, loss of positive pressure ventilation, inadequate oxygenation and sometimes hypercarbia due to rupture of the endotracheal tube (ETT) cuff. A technique is described to avoid this. Various measurements were recorded to substantiate the value of the technique. Methodology: Twenty patients had a modified surgical tracheostomy technique by positioning the end of the ETT at the level of the carina.

Percutaneous Versus Surgical Tracheotomy: An Updated Meta‐Analysis

Perform an updated meta-analysis investigating differences in complication rates, procedure times, and costs between percutaneous dilational tracheotomy (PDT), operating room surgical tracheotomy (ST), and bedside surgical tracheotomy (BST). Meta-analysis using the Mantel-Haenszel fixed effects model. Prospective and randomized trials comparing ST with PDT from 1999 to present were identified through two independent searches. Outcome measures analyzed included mortality, early complications, late complications, procedure times, and cost. Fourteen studies were identified (1,273 patients) that satisfied the search criteria. Analysis of randomized studies demonstrated significantly more minor early complications with PDT compared with ST (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.01-2.66). Randomized studies comparing PDT with BST demonstrated significantly more early complications with PDT (OR, 4.66; 95% CI, 1.46-14.91). There was no significant difference in late serious complications in studies that randomized patients to ST or PDT (OR, 1.39; 95% CI, 0-16,000). PDT is significantly faster to perform than ST (OR, 0.51; 95% CI, 95% 0.49-0.53). BST and PDT have similar costs, and both are less expensive than ST. Although significantly faster than ST, PDT has more early complications compared with open tracheotomy in the operating room or at the bedside. The long-term complications of the two techniques appear comparable but have not been thoroughly investigated. These findings suggest that a team approach between surgeons and critical care specialists is essential to select the appropriate tracheotomy technique for a given patient.

A Simplified Technique for Translaryngeal Tracheostomy (TLT). A Preliminary Report

In this prospective observational study we present preliminary results of a modification of the translaryngeal tracheostomy technique that was introduced by Fantoni in 1997. The study was conducted in a five-bed surgical intensive care unit of a university teaching hospital. The study included 14 consecutive surgical patients (8 men, 6 women) who underwent a modified translaryngeal tracheostomy in a 6-month period. In our modification of the technique, we keep the basic principle of the inside-to-outside approach of the Fantoni technique, and combine it with a blind needle insertion, as reported in the classic subcricoid retrograde intubation technique. The technique that we use involves two medical doctors and a nurse. Mean patient age was 68.9 years (range: 31-85 years) and mean APACHE II score was 15.8 (range: 6-31). Mean operative time for the procedure was 15.2 min (range: 11.5-22 min). Eight of the patients died during the postoperative course in the ICU from causes relevant to their surgical pathology. One patient survived to be discharged from the ICU but died of an acute myocardial infraction later in the same hospital stay. Five patients survived to be discharged from the hospital. The modified translaryngeal tracheostomy seems to be as reliable and safe as the original technique. In addition, the modified technique is faster and can be performed without the use of an endoscope.

Translaryngeal tracheotomy

Translaryngeal tracheotomy (TLT) is a retrograde, one-step technique of percutaneous tracheotomy, creating a stoma from inside the trachea to the outside by means of a special cone cannula. After tracheal puncture, a guidewire is inserted and advanced cephalad. Thereafter, the cone cannula is connected to the guidewire and, by pulling the neck end of the wire, advanced through pharynx and larynx into the trachea. The sharp metal cone penetrates the anterior tracheal wall, soft tissues, and skin. The final steps comprise cutting off the cone, straightening and rotating the cannula by 180°, then pushing it down the trachea. Although a meta-analysis did not favor a specific percutaneous tracheotomy technique in terms of overall complications, TLT has specific advantages in high-risk intensive care unit patients, such as in those with critical coagulopathy or severe respiratory failure. Pediatric TLT sets are available; however, clinical experience with TLT in children and infants is still very limited. Translaryngeal tracheotomy (TLT) is a retrograde, one-step technique of percutaneous tracheotomy, creating a stoma from inside the trachea to the outside by means of a special cone cannula. After tracheal puncture, a guidewire is inserted and advanced cephalad. Thereafter, the cone cannula is connected to the guidewire and, by pulling the neck end of the wire, advanced through pharynx and larynx into the trachea. The sharp metal cone penetrates the anterior tracheal wall, soft tissues, and skin. The final steps comprise cutting off the cone, straightening and rotating the cannula by 180°, then pushing it down the trachea. Although a meta-analysis did not favor a specific percutaneous tracheotomy technique in terms of overall complications, TLT has specific advantages in high-risk intensive care unit patients, such as in those with critical coagulopathy or severe respiratory failure. Pediatric TLT sets are available; however, clinical experience with TLT in children and infants is still very limited.

PercuTwist

Tracheostomy is one of the most common procedures in intensive care units worldwide. In this study we aimed to compare three different tracheostomy techniques with respect to duration of procedure and complications. One hundred and thirty patients requiring endotracheal intubation for more than 10 days due to acute respiratory distress syndrome, infections or cerebrovascular events were consecutively selected to undergo the percutaneous dilatational tracheostomy technique (PDT n = 44), the guide-wire dilating forceps technique group (GWDF n = 41) or the PercuTwist technique (n = 45). The time taken to perform the procedure (skin incision to successful placement of tracheostomy tube) and complications were recorded. The operating times were found to be 9.9 +/- 1.1, 6.2 +/-1.4 and 5.4 +/- 1.2 min in PDT, GWDF and PercuTwist groups, respectively. The duration of the procedure was significantly shorter in the PercuTwist group as compared to the percutaneous dilatational tracheostomy (P < 0.01) and guide-wire dilating forceps (P < 0.05) groups. During postoperative bronchoscopy, eight cases of longitudinal tracheal abrasion (four in the PDT group, two in the GWDF group and two in the PercuTwist group), two cases of posterior tracheal wall injury (one in PDT and one in GWDF) and one case of tracheal ring rupture in the PDT group were seen. Percutaneous tracheostomy techniques have their own advantages and complications. PercuTwist, a new controlled rotating dilatation method, was associated with minimal complications, appears to be easy to perform and a practical alternative to percutaneous dilatational tracheostomy and guide-wire dilating forceps techniques.

経皮的気管切開と輪状甲状膜切開 : その手技と問題点

経皮的気管切開や輪状甲状膜切開のキットは集中治療の領域で広く普及している。簡便ではあるが, 方法として未完成な部分もあり, 手技上注意すべき点も多い。経皮的気管切開における大きな問題点の一つは, 既存の気管チューブの位置についてである。すなわち, 内視鏡による手技確認と気管内スペースの確保のために気管チューブを抜いてくると, 気道確保と換気の維持を保証できなくなるというジレンマがあることである。もう一つの大きな問題点は, 気管切開チューブの挿入時の抵抗であり, イントロデューサと気管切開チューブ先端の成形に工夫の余地があると思われる。Griggs法では鉗子操作の巧拙が気管切開チューブの挿入の難易と合併症の有無, 程度に影響する。気管切開に比し手技的に容易と思われる輪状甲状膜切開のキットにも注意すべき点がある。セルジンガー法によるキットでは気管切開と同様, イントロデューサとカニューレとの段差のため, 挿入時の抵抗が比較的大きい。

The Use of the Laryngeal Mask Airway During Guidewire Dilating Forceps Tracheostomy

Percutaneous tracheostomy has become a common alternative to the classical open tracheostomy because of its convenience, cost effectiveness, and decreased complication rates. We retrospectively reviewed our intensive care practice using a guidewire dilatating forceps percutaneous tracheostomy technique with an endotracheal tube, as compared with the Classic Laryngeal Mask Airway (LMA) for these procedures. From 1998 to 2004, 274 patients underwent a tracheostomy procedure. Two-hundred-fifty-four (92.7%) of these patients underwent a guidewire dilatating forceps tracheostomy and 20 (7.3%) underwent a surgical tracheostomy. In the guidewire dilatating forceps group, 188 (74%) were performed by endoscopy via LMA-guided bronchoscopy, and 66 (26%) were performed through an endotracheal tube. Endoscopic views obtained via the LMA were subjectively better than those obtained with the endotracheal tube. Acute complications were significantly more frequent when using an endotracheal tube as compared with the LMA (6 of 66 versus 4 of 188; P = 0.022 Fisher's exact test, odds ratio = 4.6). There was a significant difference in terms of acute (10 of 254 versus 6 of 20; P < 0.001, odds ratio = 10.5) and chronic (0 of 254 versus 4 of 20; P < 0.001) complications between the 2 groups. There were no ventilatory complications or reports of gastric aspiration. The LMA provides a safe and effective alternative to an endotracheal tube for airway management during guidewire dilatating forceps tracheostomies in selected patients.

A Survey of Tracheostomy Practice in a Cardiothoracic Intensive Care Unit

The purpose of this study was to assess current practice of performing tracheostomies in critically ill cardiac surgical patients, to establish complication rates, and to identify areas of this clinical practice that could be improved. Retrospective observational study. A cardiothoracic intensive care unit in a teaching hospital. The most recent series of 100 tracheostomies performed in patients admitted to the intensive care unit. Percutaneous or surgical tracheostomy for respiratory management. A total of 95 patients had 1 tracheostomy performed. One patient had a tracheostomy performed twice, and 1 patient had a tracheostomy performed 3 times; these repetitions were caused by recurrent respiratory failure. The median time from tracheal intubation to tracheostomy was 5 days (range, 1-23 days; interquartile range, 4-8 days), and median period between insertion and decannulation was 20 days (range, 2-77 days; interquartile range, 12-25 days). The most common reason for insertion was an anticipated long weaning time (55%) followed by insertion after failed extubation (32%). The Ciaglia percutaneous dilational technique was used for 89% of tracheostomies, whereas surgical techniques were used for 8%. The most common complication was either complete or partial obstruction of the tracheostomy tube (24%) followed by infection of the tracheostomy site in 18% (17/94) and bleeding at the time of insertion (11%). The percutaneous dilational technique of tracheostomy was used predominantly in this unit. The median time from tracheal intubation to tracheostomy was 5 days. The most common complications were bleeding at the time of insertion, obstruction of the tracheostomy tube, and stomal infection.

Comparison of Open Dilatational Tracheostomy with Conventional Pediatric Tracheostomy in a Growing Animal Model

To compare the tracheal changes after applying a new open dilatational tracheostomy (ODT) technique with those from a conventional open tracheostomy (COT) with vertical cartilage incision in a growing animal model. Prospective, experimental investigation in a rabbit model. Thirteen New Zealand white rabbits as a pediatric model were divided into three groups: six rabbits had COT (n = 6), another six underwent an ODT (n = 6), and one rabbit acted as a control. Each rabbit underwent tracheostomy by assigned procedures on the first day. On day 8, they were decannulated. On day 15, their tracheas were harvested. We examined the gross findings and histologic changes of each tracheal segment at the stomal level. In addition, we analyzed three parameters: the quotient of the stomal and nonstomal segment in sagittal diameter, coronal diameter, and cross-sectional area. The framework of cartilages at the stomal level were more distorted in the COT group. Histologic examination also showed buckling of the anterior tracheal wall, loss of cartilage, infiltration by many polymorphonuclear neutrophils, and the marked ingrowth of fibrous tissue in the COT group. Sagittal and coronal diameters and cross-sectional areas were significantly affected more severely after a COT than after an ODT. Our new modification of percutaneous dilatational tracheostomy, named "open dilatational tracheostomy," was successfully applied to a small, growing animal model and showed more favorable and consistent healing of trachea compared with COT. Therefore, the authors' new tracheostomy procedure could be applied to children who require short-term tracheostomy at any age in clinical settings.

Unilateral subcutaneous emphysema after percutaneous tracheostomy

Percutaneous tracheostomy techniques are widely used in intensive care units. Subcutaneous emphysema is a rare but well recognized complication associated with this procedure. We report an unusual presentation of sc emphysema after percutaneous tracheostomy. The clinical features, diagnosis and postulated mechanism are discussed. A 39-yr-old man had percutaneous tracheostomy done after prolonged intubation in the intensive care unit. Subcutaneous emphysema developed over the right neck fever mimicking deep sc infection resulted in neck exploration. No obvious lesion was found in the tracheobronchial tree. Subcutaneous emphysema occurring after percutaneous tracheostomy could occur without significant injury to the tracheobronchial tree. We postulate that air leaking from the tracheostomy site might have been prevented by the snug fit between the tracheostomy tube and the skin, resulting in accumulation in the neck. Asymmetric dilatation of the trachea may explain the unilateral localization of the sc emphysema.

Balloon-Facilitated Percutaneous Dilational Tracheostomy Tube Placement: Preliminary Report of a Novel Technique

To describe a novel technique for percutaneous tracheotomy (PT) that could be an alternative to current dilational techniques.An observational animal study of PT was performed using the Seldinger guide wire technique with a tracheostomy tube preloaded onto a dilational balloon catheter. A small skin incision was done with an 11-blade scalpel, but no blunt subcutaneous tissue dissection was performed.Animal laboratory in a university hospital.Seven adult pigs (approximate weight, 16 to 21 kg).Successful tracheostomy was accomplished in all seven pigs without apparent complication. Vital signs and oximetry results remained unchanged throughout the procedure. The mean duration of the procedure was 5.5 min from tracheal puncture to ventilation.This novel procedure is a simple and effective means of PT tube placement without subcutaneous tissue dissection and could potentially have decreased complications when compared to the standard methods of PT currently employed in humans. Human studies are pending.

IS PERCUTANEOUS TRACHEOSTOMY MORE LIKELY TO CAUSE TRACHEAL STRICTURE THAN OPEN TRACHEOSTOMY?

PURPOSE: Tracheostomies are often done to facilitate weaning from the ventilator, or to prevent tracheal strictures from prolonged intubation. After the technique of open tracheostomy was developed, reports of strictures were found in the literature, and techniques to avoid those strictures were developed. Percutaneous tracheostomy allows bedside tracheostomy in the ICU, and thus avoid transporting a sick patient. After finding tracheal strictures in several patients who had undergone percutaneous tracheostomy we evaluated our experience in tracheal resections after tracheostomy.

Tracheostomy

The technique of percutaneous tracheostomy is described in detail. The benefits, contraindications and complications of the technique are listed.