Evaluation of Rigid Bronchoscopy–Guided Percutaneous Dilational Tracheostomy. A Pilot Study

Safety and Efficacy of Rigid Bronchoscopy-guided Percutaneous Dilational Tracheostomy: A Single-center Experience

BACKGROUND

Percutaneous dilational tracheostomy (PDT) is commonly performed by a broad spectrum of practitioners. Aside from relative contraindications such as morbid obesity, coagulopathy, and complex airway anatomy, it is preferred over surgical tracheostomy in the critically ill. Rigid bronchoscopy-guided (RBG) PDT provides a secure airway, allows for unobstructed ventilation, protects the posterior membrane from puncture, and increases suction capacity.

METHODS

This is a retrospective case series of patients who underwent RBG-PDT from 2008 to 2023 at Beth Israel Deaconess Medical Center. Electronic medical records were reviewed for preprocedural demographic data, procedural events, and postprocedural outcomes.

RESULTS

A total of 104 patients underwent RBG-PDT over a 15-year period. Median patient age was 61.95 (95% CI: 59.00-64.90), median BMI was 30.25 kg/m2 (IQR, 23.6 to 37.2) with 41.9% (32.5% to 51.3%) of patients included having a BMI over 30 kg/m2. PDT placement occurred in a mean of 13.7 days after intubation, with 70% due to prolonged mechanical ventilation resulting from ongoing respiratory failure. In all, 51.0% of patients had at least one increased bleeding risk factor, with an increased aPTT >36 seconds being the most common (36.5%). In all, 26.9% of patients underwent tracheostomy with ongoing therapeutic anticoagulation with heparin. In total, 60.6% of patients received concomitant percutaneous endoscopic gastrostomy (PEG) tube placement. No cases of pneumothorax or loss of the airway at the time of exchange of the endotracheal tube for rigid tracheoscopy were reported.

CONCLUSION

RBG-PDT is a safe and effective procedure extending the patient population appropriate for PDT when performed by an experienced Interventional Pulmonology team.

Equipment and procedural setup for interventional pulmonology procedures in the intensive care unit

Procedural setup is an important aspect of any procedure. Interventional pulmonologists provide a procedural practice and have additional expertise in performing high-risk procedures needed in the critically ill patients in intensive care. Taking the time to plan the procedure setup in advance and having all necessary equipment readily available at the patient's bedside is imperative for procedural services. This is especially essential to ensure patient safety, minimize risk of complications, and improve success for specialized procedures performed by interventional pulmonary in the intensive care unit. In this review we describe the equipment and procedural setup ideal for both pleural and airway procedures. These include flexible diagnostic and therapeutic bronchoscopy, ultrasound guided thoracentesis, chest tube insertion, difficult airway management, and bedside percutaneous dilatation tracheostomy. We provide a guide checklist for these procedures emphasizing the practical aspects of each procedure from selecting the appropriate size endotracheal tube to operator positioning to ensure efficiency and best access. The components of procedural setup are discussed in relation to patient factors that include patient positioning and anesthesia, personnel in the procedure team and the equipment itself. We further briefly describe the additional equipment needed for specialized techniques in therapeutic bronchoscopy used by interventional pulmonologists.

Rescue Tracheostomy for Patients with Unresectable Large Growing Neck Masses

Most patients with undifferentiated thyroid cancer have an unresectable disease with 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 reduced.

Bronchoscope-Guided Percutaneous Endoscopic Gastrostomy Tube Placement by Interventional Pulmonologists: A Feasibility and Safety Study

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) tube placement is a procedure frequently done in the intensive care unit. The use of a traditional endoscope can be difficult in cases of esophageal stenosis and theoretically confers an increased risk of infection due to its complex architecture. We describe a technique using the bronchoscope, which allows navigation through stenotic esophageal lesions and also minimizes the risk of endoscopy-associated infections.

METHODS

Prospective series of patients who had PEG tube placement guided by a bronchoscope. Procedural outcomes including successful placement, duration of the entire procedure, time needed for passage of the bronchoscope from the oropharynx to the major curvature, PEG tube removal rate, and mortality were collected. Procedural adverse events, including infections and long-term PEG-related complications, were recorded.

RESULTS

A total of 84 patients underwent bronchoscope-guided PEG tube placement. Percutaneous endoscopic gastrostomy tube insertion was completed successfully in 82 (97.6%) patients. Percutaneous endoscopic gastrostomy tube placement was performed immediately following percutaneous tracheostomy in 82.1%. Thirty-day mortality and 1-year mortality were 11.9% and 31%, respectively. Overall, minor complications occurred in 2.4% of patients, while there were no major complications. No serious infectious complications were identified and no endoscope-associated hospital acquired infections were documented.

CONCLUSIONS

The use of the bronchoscope can be safely and effectively used for PEG tube placement. The use of bronchoscope rather than a gastroscope has several advantages, which include the ease of navigating through complex aerodigestive disorders such as strictures and fistulas as well as decreased health-care utilization. In addition, it may have a theoretical advantage of minimizing infections related to complex endoscopes.

Percutaneous tracheostomy by Griggs technique under rigid bronchoscopic guidance is safe and feasible in children

OBJECTIVE

The aim of this study is to report prospective data of pediatric cases that underwent percutaneous tracheostomy (PT) to show that PT is a safe and feasible procedure in children even in small infants.

PATIENTS AND METHODS

PT was done in 51 consecutive patients. Demographic data, indications, complications and outcome were recorded prospectively. Initial 6 PT was done by Giaglia technique whereas the Griggs technique was used in the consecutive 45 patients.

RESULTS

Fifty-one patients with mean age of 38±54months (1month-17years) and, mean weight of 12.4±13kg underwent PT. The only major complication was perforation of esophagus (n=1, 2%) which was recognized early and immediately repaired by cervical approach. This complication occurred in the 6th case done with the Giaglia technique. After conversion to the Griggs technique no major complication was encountered in the consecutive 45 procedures. The mean period of follow up was 21±13.7months. Narrowing of the stoma site requiring simple dilation was developed in 3 (5.8%) patients.

CONCLUSION

PT is a safe and easy procedure and a less invasive alternative to surgical tracheostomy even in small infants. We strongly recommend PT done by Griggs technique in children. It is important that it should be done in an operating room setting and under rigid bronchoscopic guidance.