Recent developments in percutaneous tracheostomy: improving techniques and expanding roles

Assessment of the percutaneous dilatational tracheostomy technique in experimental manikins and canine cadavers

OBJECTIVE

To evaluate procedure time, ease of placement, and complication rates of percutaneous dilatational tracheostomy (PDT) compared to surgical tracheostomy (ST) in canine cadavers.

DESIGN

Randomized crossover experimental manikin and cadaver study involving 6 novice veterinary students.

SETTING

University teaching hospital.

ANIMALS

Canine tracheostomy training manikin, 24 canine cadavers.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

For training, each student performed 10 PDT and 10 ST procedures on a training manikin, followed by 2 PDT and 2 ST procedures on a canine cadaver. After each training procedure, feedback from bronchoscopy and observers was provided. Final PDT and ST tube placements using new equipment were performed in unused cadavers. Placements were timed, ease of placement was scored using visual analog scales (VAS, 0-10 cm), and complications were assessed by two independent observers using ordinal scales (0-3). Cadaver tracheas were explanted postprocedure to evaluate anatomical damage scores (0-3). Procedure time and VAS scores for PDT and ST procedures were analyzed using mixed-effects linear models, accounting for student, technique, and procedure number with post hoc pairwise comparisons. Data are presented as median (range). For the final cadaver placement, there were no significant differences in placement time (300 seconds [230-1020] vs 188 seconds [116-414], P = 0.210), ease of placement (3.8 cm [2.1-5.7] vs 1.9 cm [0-4.7], P = 0.132), anatomical damage score (1 [0-2] vs 0 [0-1], P = 0.063), or equipment complications score (0 [0-1] vs 0 [0-0], P = 1.000) between PDT and ST, respectively.

CONCLUSIONS

These data suggest that PDT can be performed as quickly, as easily, and as safely as ST in a canine cadaver by novice veterinary students following manikin training. Additional studies will be required to determine if these findings can be translated into veterinary clinical practice.

The Diagnostic Yield and Clinical Impact of a Chest X-Ray after Percutaneous Dilatational Tracheostomy: A Prospective Cohort Study

A chest X-ray (CXR) is routinely performed after percutaneous dilatational tracheostomy (PDT). The purpose of this study was to evaluate the diagnostic yield of routine CXR following PDT and its impact on patient management and to identify predictors of post-PDT CXR changes. Two-hundred-and-thirty-nine patients who underwent PDT in a 21-bed intensive care unit were included prospectively in the study. The following data were collected: patient demographics, APACHE III scores, pre-PDT FiO2 and PEEP, PDT technique, perioperative complications and the use of bronchoscopic guidance. We compared post-PDT CXR with the last pre-PDT CXR. We documented any post-PDT new radiographic findings including atelectasis, pneumothorax, pneumomediastinum, surgical emphysema, pulmonary infiltrates or tracheostomy tube malposition. We also recorded management modifications based on post-PDT radiographic changes, including increased PEEP, chest physiotherapy, therapeutic bronchoscopy or chest tube insertion. Atelectasis was the only new finding detected on post-PDT CXRs of 24 (10%) patients. The new radiographic findings resulted in a total of 14 modifications of management in 10 (4%) patients including increased PEEP in six, chest physiotherapy in six and bronchoscopy in two patients. Trauma and pre-PDT PEEP >5 cmH2O were independent predictors of post-PDT CXR changes. Routine CXR following PDT has a low diagnostic yield, detecting mainly atelectasis and leading to a change in the management in only a minority of patients. Routine CXR after apparently uncomplicated PDT performed by an experienced operator may not be necessary and selective use may improve its diagnostic yield. Further studies are required to validate the safety of selective versus routine post-PDT CXR.

Quick Response Tracheotomy: A Novel Surgical Procedure

Quick response tracheostomy (QRT) is a novel open surgical technique to emergently establish an airway. The method is simple; the skills necessary to perform this procedure are rapidly acquired; and it is expedient, minimally traumatic, and remarkably devoid of complications often encountered with percutaneous dilatational tracheotomies, including those complications seen with cricothyroidotomies. Unlike all other tracheotomies in which considerable blunt dissection is required, QRT avoids tissue crushing because sharp dissection alone is used to acquire surgical access to the trachea. The QRT does not entail inserting a guidewire into the trachea, a standard feature for percutaneous tracheal access; it avoids any risk of unintended laceration of the posterior tracheal wall and proximal subjacent esophagus. The technique averts tracheal ring fracture and tracheoesophageal fistula complications. The QRT has a uniquely low incidence of inducing hemorrhage, and it requires no steps that cause temporary tracheal occlusion and will therefore not facilitate hypoxia. The QRT contributes minimally to conditions favorable for generating subglottic stenosis, and the procedure is swiftly executed with very low probability for external tracheal placement of the tracheostomy tube. The QRT is not a blind procedure. No special instruments are required for its execution nor is concurrent tracheoscopy required at any stage while performing a QRT as is specified for percutaneous tracheotomies.

Griggs percutaneous tracheostomy without bronchoscopic guidance is a safe method: A case series of 300 patients in a tertiary care Intensive Care Unit

Introduction:

Percutaneous tracheostomy (PCT) is being increasingly done by intensivists for critical care unit patients requiring either prolonged ventilation and/or for airway protection.[1] Bronchoscopic guidance considered a gold standard,[23] is not always possible due to logistic reasons and ventilation issues. We share our experience of Griggs PCT technique without bronchoscopic guidance with simple modifications to ensure safe execution of the procedure.

Objective:

The purpose of this study was to evaluate the safety issues and complications of PCT without bronchoscopic guidance in a multi-disciplinary tertiary Intensive Care Unit (ICU).

Materials and Methods:

A retrospective review of consecutive PCTs performed in our ICU between August 2010 and December 2013 by Griggs guide wire dilating forceps technique without bronchoscopic guidance is being presented. It is done by withdrawing endotracheal tube with inflated cuff while monitoring expired tidal volume on ventilator and ensuring the free mobility of guide wire during each step of the procedure, thereby ensuring a safe placement of the tracheostomy tube (TT) in trachea.

Results:

Analysis of 300 PCTs showed 26 patients (8.6%) had complications including 2 (0.6%) patients deteriorated neurologically and 2 (0.6%) deaths observed within 24 h following procedure. The median operating time was 3.5 min (range, 2.5–8 min). There were no TT placement problems in any case.

Conclusion:

Percutaneous tracheostomy can be safely performed without bronchoscopic guidance by adhering to simple steps as described.

Single dilator vs. guide wire dilating forceps tracheostomy: a meta-analysis of randomised trials

BACKGROUND

Single dilator technique (SDT) and guide wire dilating forceps (GWDF) are the two most commonly used techniques of percutaneous dilatational tracheostomy (PDT) in critically ill adult patients. We performed a meta-analysis of randomised, controlled trials comparing intraoperative, mid-term and late complications of these two techniques.

METHODS

Pertinent studies were searched in BioMedCentral, PubMed, Embase and the Cochrane Central Register of clinical trials. We selected all randomised studies comparing SDT and GWDF techniques in adult critically ill patients published in a peer-reviewed journal.

RESULTS

Among 1040 retrieved studies, five eligible studies randomising 363 patients (181 to GWDF, 182 to SDT) were identified. The incidence of the composite outcome difficult cannula insertion/difficult dilation or failure was higher with the GWDF technique (15.5% vs. 4.9 %, P = 0.02). Moreover, intraprocedural bleeding was more common in the GWDF group (19.3% vs. 7.6% in SDT group, P = 0.018). A trend towards an increased incidence of fracture of tracheal rings was noted in the SDT group (6.5% vs. 0.5% in the GWDF group, P = 0.13). No difference in mid-term or long-term complications was observed.

CONCLUSION

GWDF technique is associated with a higher incidence of intraprocedural bleeding and of technical difficulties in completing the procedure (difficult cannula insertions/difficult dilations or failures) compared with the SDT technique. No differences were identified in mid-term and long-term complications. Further studies comparing SDT and GWDF in the general population and in subgroups of high-risk patients (like obese or hypoxaemic patients) are warranted.

Percutaneous tracheostomy: a new approach to the emergency airway

BACKGROUND

Endotracheal intubation is the preferred method of airway control. Current surgical standard of care for the emergent airway when endotracheal intubation cannot be performed is cricothyroidotomy. Percutaneous tracheostomy (PT) is a widely accepted technique for elective long-term airway management in the critical care setting. We describe our experience with successful placement of PT for emergency airway control.

METHODS

After institutional review board approval was obtained, patients were identified retrospectively from January 2003 to present that had emergency PT performed as identified by the DRG International Classification of Diseases--9th Rev. procedure code (31.1). Data included demographics, body mass index, admitting service, size of tracheostomy tube, reason for urgent airway access, duration PT was required, unit, time and hospital day performed, and complications.

RESULTS

Eighteen patients underwent emergency PT; 61% were male, and age range was 21 years to 86 years. Indications for PT included respiratory failure associated with anaphylaxis, supraglottic edema, cardiac arrest, and blood or edema blocking the airway preventing intubation. PT was performed in various departments throughout the hospital. Admitting services included critical care intensivist (44.4%), trauma surgery (27.7%), cardiology (11.1%), medicine (11.1%), and neurology (5.5%). Most of the tracheostomy tube sizes were no. 8 (61.1%), followed by no. 7 (22.2%), no. 6 (5.5%), and no. 9 (5.5%). All PTs were successfully placed, and there were no complications. Ten of our patients had no airway in place at the time of procedure. Six patients had emergency esophageal-tracheal airways in place. Two patients had a cricothyroidotomy that was not functioning adequately. Nine patients had body mass indexes ranging from 30 kg/m² to 112 kg/m².

CONCLUSION

PT provided a safe, effective emergency airway in adult patients who presented with a variety of indications, in varying locations throughout the hospital. PT performed by appropriately trained personnel may be a potential adjunct for emergent airway control in diverse settings.

Percutaneous tracheostomy, a systematic review

BACKGROUND

Percutaneous dilatational tracheostomy (PDT) is a common procedure in intensive care units and the identification of the best technique is very important. We performed a systematic review and meta-analysis of randomized studies comparing different PDT techniques in critically ill adult patients to investigate if one technique is superior to the others with regard to major and minor intraprocedural complications.

METHODS

BioMedCentral and other database of clinical trials were searched for pertinent studies. Inclusion criterion was random allocation to at least two PDT techniques. Exclusion criteria were duplicate publications, nonadult studies, and absence of outcome data.

STUDY DESIGN

Population, clinical setting, and complications were extracted.

RESULTS

Data from 1130 patients in 13 randomized trials were analyzed. Multiple dilators, single-step dilatation, guide wire dilating forceps, rotational dilation, retrograde tracheostomy, and balloon dilation techniques were always performed in the intensive care unit. The different techniques and devices appeared largely equivalent, with the exception of retrograde tracheostomy, which was associated with more severe complications and more frequent need of conversion to other techniques when compared with guide wire dilating forceps and single-step dilatation techniques. Single-step dilatation technique was associated with fewer failures than rotational dilation, and fewer mild complications in comparison with balloon dilation and guide wire dilating forceps (all P < 0.05).

CONCLUSIONS

Among the six analyzed techniques, single-step dilatation technique appeared the most reliable in terms of safety and success rate. However, the number of available randomized trials was insufficient to confidently assess the best PDT technique.

Tracheostomy in critically ill patients

Tracheostomy is performed in about a quarter of ICU patients requiring prolonged mechanical ventilation, weaning from assisted ventilation, airway suction and airway protection. Tracheostomy improves patient comfort compared with standard intubation. Tracheostomy performed early upon ICU admission has not shown survival benefits. Percutaneous dilatational techniques are commonly used because the procedure can be performed at the bedside. Surgical tracheostomy is often reserved for cases with abnormal anatomy or failed percutaneous tracheostomy. It is not known which of the percutaneous techniques is safer in terms of perioperative complications. Ultrasound scanning of the neck and routine endoscopy during the procedure appear to reduce early complications. Decannulation is often delayed and an intensivist-led follow-up may facilitate timely removal of tracheostomy tubes in step down areas or wards.

Bedside Percutaneous Tracheostomy: A Prospective Randomised Comparison of PercuTwist® versus Griggs’ Forceps Dilational Tracheostomy

Tracheostomy is considered the airway management of choice for patients who require prolonged mechanical ventilation. The development of percutaneous techniques offers many advantages including the ability to perform the procedure in the intensive care unit. The aim of this study was to compare the controlled rotating dilation method (PercuTwist®) and the Griggs’ forceps dilational tracheostomy.

Patients over 18 years of age undergoing tracheostomy in the intensive care unit were included in the study. They were divided in two random samples – either PercuTwist or forceps dilational tracheostomy. Data collected prospectively included demographic characteristics, procedure duration, blood gas analysis, intracranial pressure, arterial blood pressure and heart rate before and after the procedure. Any complications during or after the procedure due to the tracheostomy were also recorded.

Contrary to the main hypothesis, PercuTwist technique took significantly longer to perform than forceps dilational tracheostomy technique (five minutes [2 to 25] vs three minutes [1 to 17][P=0.006]). A significant increase in PaCO2 and decrease in arterial pH were observed in both groups between the pre-tracheostomy and post-tracheostomy blood gas analysis. Haemodynamic tolerance was good. Our results show that intracranial pressure is affected by the procedure whatever the technique used. However we did not observe a decrease in cerebral perfusion pressure. The incidence of complications was 23% (20/87). These complications were minor in 18/20 and were not significantly different between the two groups.

In conclusion, we consider that the PercuTwist technique is safe despite the longer duration of the procedure. Nevertheless the forceps dilational technique remains our routine procedure.

Swallowing dysfunction in nonneurologic critically ill patients who require percutaneous dilatational tracheostomy

BACKGROUND

The aim of this study was to determine the incidence of swallowing dysfunction in nonneurologic critically ill patients who require percutaneous dilatational tracheostomy (PDT) for prolonged mechanical ventilation (MV) and to compare the duration of the cannulation period and length of stay in the critical care unit (CCU) in patients with and without swallowing dysfunction.

METHODS

A total of 40 consecutive patients without neurologic disorders who require PDT for prolonged MV were included. Previous to the tracheostomy decannulation process, an otolaryngologist performed a fiberoptic endoscopic evaluation of swallowing (FEES). We used analysis of variance for the analysis; the results are presented as mean values +/- SD.

RESULTS

Mean age was 62 +/- 15 years. Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores were 21 +/- 2 and 9 +/- 1, respectively. Time of MV previous to PDT was 20 +/- 11 days, total MV duration was 38 +/- 16 days, and CCU stay was 63 +/- 27 days. The incidence of swallowing dysfunction in this group of patients was 38% (15/40). No difference was found in the age or time period of MV previous to PDT between groups. The time period between FEES to tracheostomy decannulation process was 19 +/- 11 days in patients with swallowing dysfunction vs 2 +/- 4 days in those patients without dysfunction (P < .001). Patients who developed swallowing dysfunction stayed longer in the CCU (69 +/- 23 vs 47 +/- 19 days, P < .01).

CONCLUSIONS

Nearly 40% of nonneurologic critically ill patients requiring PDT for prolonged MV presented swallowing dysfunction and experienced a significant delay in their tracheostomy decannulation process.

Fiberoptic bronchoscopy-assisted percutaneous tracheostomy is safe in obese critically ill patients: a prospective and comparative study

BACKGROUND

Obesity has reached epidemic proportions worldwide. In Latin America, 10% to 35% of the population is obese. Obese critically ill patients are at greater risk for requiring intubation and prolonged mechanical ventilation; and in some cases, it is necessary to perform a tracheostomy.

OBJECTIVE

The objective of the study was to compare the incidence of perioperative complications associated with percutaneous tracheostomy (PT) using the fiberoptic bronchoscopy-assisted Ciaglia Blue Rhino technique (Cook Critical Care, Bloomington, IN) in obese vs nonobese critically ill patients.

PATIENTS AND METHOD

A prospective evaluation was made of 120 patients who underwent PT because of prolonged mechanical ventilation. An analysis of the incidence of operative and early postoperative complications was performed comparing an obese patient group (n = 25) with a nonobese patient group (n = 80). Obesity was defined by a body mass index of at least 30 kg/m(2).

RESULTS

The 2 groups had no significant differences in their demographic characteristics. The average body mass index for the obese patient group was 38 +/- 9 kg/m(2) vs 22 +/- 3 kg/m(2) for the nonobese patient group (P < .001). The obese patients required 18 +/- 7 days of mechanical ventilation, on average, before PT vs 16 +/- 7 days for the nonobese patients (P = .15). The incidence of operative complications for the obese patients vs nonobese patients was 8% and 7.5%, respectively (P = 1). The incidence of early postoperative complications was 8% for the obese patients vs 2.5% for the nonobese patients (P = .2).

CONCLUSION

Percutaneous tracheostomy using the fiberoptic bronchoscopy-assisted Ciaglia Blue Rhino technique is safe for obese critically ill patients when performed by an experienced intensivist.

Safety of percutaneous tracheostomy in obese critically ill patients: a prospective cohort study

Obesity has been described as a relative contraindication for percutaneous tracheostomy. The objective of our study was to examine the safety and complications of percutaneous tracheostomy in obese patients. We conducted a prospective cohort study of all consecutive patients who underwent percutaneous tracheostomy at a tertiary medical-surgical intensive care unit between May 2004 and October 2005. We compared percutaneous tracheostomy in obese patients (body mass index > or = 30 kg/m2) to non-obese patients. We documented the occurrence of the following complications: aborting the procedure, accidental extubation, conversion to surgical tracheostomy, paratracheal placement, the development of pneumothorax, major bleeding (requiring blood product transfusion or surgical intervention) or death. We also documented hypoxia, minor bleeding (requiring pressure dressing or suturing), subcutaneous emphysema and transient hypotension. During the study period, 227 percutaneous tracheostomies were performed. There were 50 percutaneous tracheostomies in the obese group and 177 in the non-obese group. In 45 obese patients, percutaneous tracheostomy was performed without bronchoscopic guidance. Major complications were significantly higher in obese patients (12% vs. 2%, P = 0.04), while the rate of minor complications was not significantly different between the two groups. There were no instances of death or pneumothorax, subcutaneous emphysema or need for surgical intervention during or in the postoperative period in either group. Our study suggests that percutaneous tracheostomy can be performed safely in the majority of obese patients.

Role of ultrasound in the airway management of critically ill patients

Ultrasound imaging of the upper airway in critically ill patients offers a number of attractive advantages compared with competitive imaging techniques or endoscopy. It is widely available, portable, repeatable, relatively inexpensive, pain-free, and safe. In this review article, I describe ultrasonographic anatomy of the upper respiratory organs and present the main potential applications of ultrasonography in airway management. The role of ultrasound in endotracheal tube placement, including preintubation assessment, verification of tube position, double-lumen intubation, and extubation outcome, are explained. Also, ultrasound-guided percutaneous tracheostomy, the role of ultrasound in using the laryngeal mask airway, and upper airway anesthesia are described.