Early experience with percutaneous tracheotomy

Tracheotomy and the intensive care unit patient

Transportation of the intensive care unit (ICU) patient to the operating room for tracheotomy has been implicated as an unnecessary source of complications and has been cited as a relative indication for percutaneous tracheotomy. However, there is very little evidence in the literature to support this claim. We evaluated 100 consecutive patients who were transported from the ICU to the operating room for tracheotomy. There were no complications related to patient transportation. A total of five complications occurred, all unrelated to patient transportation. Two patients receiving pressure control ventilation developed a pneumothorax on postoperative days 7 and 8, respectively. There were three minor complications directly related to the tracheotomy: peristomal cellulitis, tracheitis, and hemorrhage of less than 25 cc on postoperative day 1. The minor complications were treated appropriately and resolved without any adverse sequelae. We provide a detailed review of 100 consecutive ICU patient tracheotomy cases and compare this with 109 tracheotomies in non-ICU patients. Transportation of the ICU patient does not appear to increase the risk of complications during tracheotomy and should not be cited as a cause of complications in the percutaneous tracheotomy literature. The results with standard surgical tracheotomy in the controlled setting of the operating room should serve as the standard by which other procedures are judged.

Comparison of percutaneous and surgical tracheostomies

OBJECTIVE

To compare the safety and efficacy of percutaneous dilational tracheostomy (PDT) with surgical tracheostomy (ST).

DESIGN

Prospective randomized trial.

SETTING

Public urban teaching hospital.

PATIENTS

Twenty-six patients were randomized to undergo PDT and 27 patients to ST.

RESULTS

The time from randomization into the study until tracheostomy was performed was 28.5 +/- 27.9 h in the PDT group and 100.4 +/- 95.0 h in the ST group (p < 0.001). PDT was performed in 8.2 +/- 4.9 min vs 33.9 +/- 14.0 min for ST (p < 0.0001). There was no significant difference in intraprocedural complications between the groups. Postprocedural complication rates were 12% for PDT and 41% for ST (p = 0.008).

CONCLUSION

PDT is superior to ST logistically. PDT can be performed at the bedside eliminating the risk of patient transport. Because operating room scheduling is not necessary, PDT can be performed earlier once the decision to do a tracheostomy is made, which will improve ICU utilization. PDT is a faster procedure to perform and has fewer postprocedural complications.

Percutaneous dilatational tracheostomy

METHODS

Fifteen patients electively selected for percutaneous dilatational tracheostomy as performed with the Ciaglia Percutaneous Tracheostomy Introducer Set are reported in this preliminary study.

RESULTS

The median time for insertion of the tracheostomy tube was 13.9 min. Complications were cuff puncture of the translaryngeal tube at an early stage of the procedure in one case, and minor bleeding controllable by the compressible effect of the dilatational procedure in three cases. During the posttracheostomy period, complications were one case of minor bleeding controllable by digital compression and one case of minor infection, i.e. cellulitis in a few millimetres around the stoma without purulent secretion.

CONCLUSIONS

Our preliminary results indicate the technique as performed with the Ciaglia Introducer Set to be effective and safe with only minor complications. Furthermore, we now use it as a bedside procedure in the ICU, thus avoiding the transportation of critically ill patients to the operating theatre. The conclusion of the superiority of percutaneous tracheostomy to dissectional tracheostomy has to await clinical randomized studies, including more patients.

Percutaneous subcricoid minitracheostomy: report of 50 procedures

A minitracheostomy is a small cannula in the trachea that allows permanent access to the tracheal lumen and that is used for the evacuation of bronchial secretions. It generally is performed through the cricothyroid membrane. We used a Seldinger technique in 50 patients to insert a minitracheostomy cannula in the subcricoid position. This technique proved to be easy to perform in translaryngeally intubated patients, both under local anesthesia and under general anesthesia. Operative complications occurred in 5 patients (10%), all of which were minor. The pros and cons of a minitracheostomy in the subcricoid position are discussed.

Experience with percutaneous tracheostomy in intensive care: the technique of choice?

The technique of percutaneous tracheostomy is described, the experience of 77 such procedures in a single intensive care unit over 2 years is reported, and the literature reviewed. Percutaneous tracheostomy is a safe, effective, simple and rapid technique for intubated patients receiving intensive care. It can be carried out by non-surgeons and has several advantages over conventional tracheostomy in these patients. It may in the future prove to be the technique of choice for elective tracheostomy in other groups of patients, including those undergoing faciomaxillary procedures.

Percutaneous dilational tracheostomy: report of 141 cases

Tracheostomy is indicated frequently in the treatment of critically ill patients who require prolonged mechanical ventilation. The purpose of this prospective study was to evaluate our initial experience with 141 cases of percutaneous dilational tracheostomy (PDT) performed over a 2-year period. One hundred twenty PDTs (85%) were placed at the bedside, and 21 (15%) were performed in the operating room in conjunction with other procedures. The procedural complication rate was 11% (16 of 141). Most complications were easily recognized and did not preclude the completion of PDT. One death occurred secondary to severe bronchospasm. The postoperative complication rate was 8% (11 of 141). The most frequent complication was peristomal oozing. The average duration of follow-up after decannulation for patients discharged alive and decannulated was 36 +/- 27 weeks. There were 3 recognized cases of clinically symptomatic tracheal stenosis. We conclude that PDT is comparable with the open method and can be performed rapidly and safely at the patient's bedside.

Laryngotracheal stenosis: a serious complication of percutaneous tracheostomy

Tracheostomy in patients requiring prolonged artificial ventilation in intensive care is increasingly being performed by a percutaneous dilatational technique, in preference to the standard surgical method. Since its introduction numerous series have reported favourably on its general safety in the short-term, but there have been few reports of longer term follow-up of patients. We present four cases of laryngotracheal stenosis, a previously unreported complication associated with the technique, and discuss the relevance of these to the future practice of percutaneous tracheostomy.

Bedside percutaneous tracheostomy in critically ill patients

Bedside percutaneous dilational tracheostomy was performed by critical care attending physicians or supervised pulmonary and critical care fellows on 100 patients in the ICU at Cook County Hospital, Chicago, over a 3-year period. A needle is inserted in the first or second tracheal interspace followed by a guidewire. The tract is enlarged with a series of dilators to allow placement of a standard tracheostomy tube. Average procedure duration for 46 patients was 6.7 +/- 2.9 min. The intraoperative complication rate was 8 percent: transient oxygen desaturation (4 percent), transient hypotension (3 percent), and paratracheal insertion (1 percent). The postoperative complication rate was 10 percent: bleeding (5 percent), stomal infection (3 percent), and subcutaneous emphysema (2 percent). One patient died of presumed innominate artery rupture. Fifteen of 37 patients who survived hospitalization were decannulated. Stomal closure occurred in 13 of these 15 patients within 3 days with a minimal residual scar. Comparison of percutaneous dilational tracheostomy with two other techniques of percutaneous tracheostomy reveals a similar success rate with a lower incidence of serious complications. Bedside percutaneous dilational tracheostomy can be performed in the ICU by trained physicians with a low complication rate. We believe it to be the procedure of choice for many critically ill patients who require tracheostomies.