Safety and Feasibility of Very Early Bronchoscopy-assisted Percutaneous Dilatational Tracheostomy in Anterior Cervical Spine Fixation Patients

Background

Anterior cervical spine fixation (ACSF) is a common mode of stabilization of cervical spine injuries. These patients usually need a prolonged mechanical ventilation, so an early tracheostomy is beneficial for them. However, it is often delayed due to the close proximity to the surgical site, due to the concerns of infection, and increased bleeding. Percutaneous dilatational tracheostomy (PDT) is also considered a relative contraindication due to the inability to achieve adequate neck extension.

Objectives

The objectives of our study are to assess the:Feasibility of performing a very early percutaneous dilatational tracheostomy in cervical spine injury patients, post-anterior cervical spine fixation.Safety in doing so with regard to surgical-site infection, early, and late complications.Benefits with regard to outcome measures like ventilator days and length of stay (LOS) in the intensive care unit (ICU) and hospital.

Materials and methods

We performed a retrospective review of all patients who underwent anterior cervical spine fixation and bedside percutaneous dilatational tracheostomy in our ICU from 1st January 2015 to 31st March 2021.

Results

Out of the 269 patients admitted to our ICU with cervical spine pathology, 84 were included in the study. About 40.4% patients had injury above C5 level (n-34) and 59.5% had below C5 level. About 86.9% patients had ASIA-A neurology. In our study, percutaneous tracheostomy was done at an average of 2.8 days from the cervical spine fixation. Average length of ventilator days post-tracheostomy was 8.32 days, ICU stay was 10.5 days, and hospital stay was 28.6 days. One patient developed anterior surgical-site infection.

Conclusion

We conclude from our study that a very early percutaneous dilatational tracheostomy can be done in post-anterior cervical spine fixation patients as early as within 3 days without significant complications.

How to cite this article

Paul AL, Varaham R, Balaraman K, Rajasekaran S, Balasubramani VM. Safety and Feasibility of Very Early Bronchoscopy-assisted Percutaneous Dilatational Tracheostomy in Anterior Cervical Spine Fixation Patients. Indian J Crit Care Med 2022;26(10):1086-1090.

Navigation system for percutaneous tracheotomy

BACKGROUND

Percutaneous dilatational tracheotomy (PDT) is a well-established method. The prerequisite is to identify anatomical landmarks of the neck. We introduce a three-dimensional navigation system - SafeTrach.

AIMS/OBJECTIVES

We present an alternative technique using internal landmarks that can be used in patients with difficult anatomy.

MATERIAL AND METHODS

The device is a forceps-like instrument with an outer and an inner shank. The later serves as a ventilation lumen and stabilizes the orotracheal tube in the midline of trachea. The outer shank acts as a three-dimensional guide for the puncturing needle.

RESULTS

Out of 48 patients we have determined the level of puncture in 20 patients by using intraoperative measurements. The distance from the vocal cords to the puncture site was about 50 mm for men and 40 mm for women. In 13 of the patients who had had CT scans, we studied the distance between the vocal cords and the optimal puncture site and found the median distance for men 45 mm and for women 42 mm.

CONCLUSIONS AND SIGNIFICANCE

With the studied navigation system one may use external or internal landmarks to indicate the puncture level in PDT. The device may minimize the risk of injuring the posterior tracheal wall.

Can we improve teaching and learning of percutaneous dilatational tracheostomy's bronchoscopic guidance?

Percutaneous dilatational tracheostomy has become the technique of choice in multiple intensive care units. Among innovations to improve procedural safety and success, bronchoscopic guidance of percutaneous dilatational tracheostomy has been advocated and successfully implemented by multiple groups. Most published literature focuses on the percutaneous dilatational tracheostomy operator, with scarce descriptions of the bronchoscopic particularities of the procedure. In this article, we provide 10 suggestions to enhance specific procedural aspects of bronchoscopic guidance of percutaneous dilatational tracheostomy, and strategies to optimize its teaching and learning, in order to promote learners' competence acquisition and increase patient safety.

Development of a comprehensive Percutaneous Dilatational Tracheostomy process model for procedural training: A Delphi-based experts consensus

BACKGROUND

Deconstructing a complex procedure improves skills learning, but no model has covered all relevant Percutaneous Dilatational Tracheostomy (PDT) procedural aspects. Moreover, the heterogeneity of techniques described may hinder trainees' competency acquisition. Our objective was to develop a PDT model for procedural training that includes a comprehensive step-by-step design.

METHODS

Procedural descriptions were retrieved after a structured search in medical databases. Activities were extracted and the adherence to McKinley's dimensions of procedural competence was analyzed. We developed a comprehensive PDT model, which was further validated through a Delphi-based consensus of Spanish-speaking international experts.

RESULTS

The 14 descriptions retrieved for analysis presented a median [interquartile range] of 18 [11-22] steps, covering 3 [2-4] of McKinley's dimensions. The Delphi panel's first model included all McKinley's dimensions, and was answered by 25 experts from nine countries, ending in the second round. The final model included 59 activities divided into six stages (51 from the initial model and eight proposed by experts) and performed by two operators (bronchoscopy and tracheostomy).

CONCLUSIONS

We have presented a PDT model that includes necessary competence dimensions to be considered complete. The model was validated by an experts' consensus, allowing to improve procedural training to promote safer patient care.

Tracheostomy care: the role of the nurse before, during and after insertion

A tracheostomy is a surgical procedure that involves creating an opening and inserting a tube in the trachea to enable air transit from the external atmosphere to the lungs. The insertion of a tracheostomy is a common procedure used to wean patients from mechanical ventilation and to manage patients with upper respiratory tract complications. Furthermore, the coronavirus disease 2019 (COVID-19) pandemic has resulted in many patients requiring a tracheostomy as part of respiratory management. The two most commonly used tracheostomy insertion procedures are the open surgical tracheostomy and the percutaneous dilatation tracheostomy, both of which are associated with a range of complications. This article outlines the indications, benefits and complications of tracheostomy insertion, as well as the various types of tracheostomy tube that may be used. It also explains the role of the nurse in caring for patients before, during and after tracheostomy insertion, including the management of tracheostomy-related complications and emergencies.

Design and Evaluation of a Low-Cost Bronchoscopy-Guided Percutaneous Dilatational Tracheostomy Simulator

Supplemental digital content is available in the text.

Introduction

Bronchoscopy-guided percutaneous dilatational tracheostomy (BG-PDT) is an invasive procedure regularly performed in the intensive care unit. Risk of serious complications have been estimated in up to 5%, focused during the learning phase. We have not found any published formal training protocols, and commercial simulators are costly and not widely available in some countries. The objective of this study was to present the design and simulator performance of a low-cost BG-PDT simulator.

Methods

A simulator was designed with materials available in a hardware store, synthetic skin pads, ex vivo bovine tracheas, and a pipe inspection camera. The simulator was tested in 8 experts and 9 novices. Sessions were video recorded, and participants were equipped with the Imperial College Surgical Device, a hand motion–tracking device. Performance was evaluated with a multimodal approach, including first attempt success rate, global success rate, total procedural time, Imperial College Surgical Device–derived proficiency parameters, and global rating scale applied blindly by 2 expert observers. A satisfaction survey was applied after the procedure.

Results

A simulator was successfully constructed, allowing multiple iterations per assembly, with a fixed cost of US $30 and $4 per use. Experts had greater global and first attempt success rate, performed the procedure faster, and with greater proficiency. It presented high user satisfaction and fidelity.

Conclusions

A low-cost BG-PDT simulator was successfully constructed, with the ability to discriminate between experts and novices, and with high fidelity. Considering its ease of construction and cost, it can be replicated in almost any intensive care unit.

A new safe and cost-effective percutaneous dilatational tracheotomy: SafeTrach

Conclusion SafeTrach is a new simplified and safe technique to perform percutaneous dilatational tracheotomy (PDT) that eliminates known risk factors compared with existing percutaneous techniques. In the present clinical study, also patients with disadvantageous anatomy not suitable for conventional PDT (CPDT) were treated without complications using SafeTrach. PDT with SafeTrach (STPDT) offers an excellent solution for patients who need tracheotomy in connection with elective ear, nose, and throat (ENT) surgery. Objectives To assess a new technique for percutaneous tracheotomy. Methods Seventeen patients were tracheotomized with STPDT using SafeTrach for the initial penetration sequence and single step dilatational techniques for the dilatational sequence. The patients represented a variety of different neck anatomies. Fifteen patients were head- and neck cancer patients that were subjects of free flap transplants. Results This study showed that STPDT was safe and easy to perform and time-efficient. The median duration of the procedure was 11.5 min and the puncture was in all cases located in the midline of the trachea either between the 2nd and 3rd tracheal ring (n = 13) or between the 3rd and 4th ring (n = 4).