THIRTY SUCCESSFUL PERCUTANEOUS DILATIONAL TRACHEOSTOMY IN SURGICAL AND TRAUMA INTENSIVE CARE PATIENTS

Ahmed A.H.A. and El Boursaly I.
Department of Anesthesia, Hamad Medical Corporation, Doha, Qatar

Introduction:

Tracheostomy is a procedure commonly undertaken in critically ill patients since it has several advantages over prolonged translaryngeal intubation(1). For critically ill patients bedside tracheostomy can be performed by a percutaneous approach using either an incisional(2) or a dilatational technique(3). The major advantages of bedside percutaneous dilatational tracheostomy are that it is easy to perform, more rapid and less expensive(4).

Methods:

Initially patients were selected on the basis of apparently normal neck anatomy, normal stature, no bleeding tendency and an easily palpable cricoid cartilage and upper trachea. All percutaneous dilatational tracheostomies were performed in daylight hours as elective procedures and all were carried out by a consultant in the Intensive Care Units. The leading diagnoses for Surgical and Trauma Intensive Care Units are presented in the following Table.

All the patients were male, with ages ranging from 22-45 years. Tracheostomy was done after ten days of endotracheal intubation provided extubation was not expected within two days or the patient was difficult to wean from artificial ventilation.

The Seldinger technique guided the specially designed Guidewire Dilating Forceps into the trachea which were then used to dilate the trachea. A special kit contained a scalpel, 14 G intravenous cannula, 10cc syringe, guidewire with introducer, dilator, guidewire dilating forceps and tracheostomy tube and obturator with lumen. (Figure 1)

Fig.1

The procedure was performed with continuous electrocardiography, arterial blood pressure and end-tidal carbon dioxide monitoring and peripheral haemoglobin oxygen saturation measurement. A Respiratory Therapist constantly supervised the tracheal tube and ventilator attachment by remaining at the head of the bed. Patients received 100% oxygen and 10 minutes before the procedure the positive end-expiratory pressure (PEEP) was reduced to 5cm H2O. Figures 2-10 show the procedure step by step.

The neck of the patient was extended over a pillow and the anterior neck was prepared with sterile solutions and draped. Intravenous sedation, Fentanyl and Atracurium were given as required. The tracheal tube was withdrawn under visual control so that the tip remained below the level of the vocal cords. A fiber-optic endoscope was kept standby if needed. (Figure 2)

Fig. 2

The trachea was cannulated with a 14 G intravenous cannula between the first and second or second and third tracheal rings. Intratracheal placement was confirmed by aspiration of air in a saline filled syringe. (Figure 3)

Fig. 3

A J guidewire was passed into the tracheal lumen through the catheter which was then removed. (Figure 4)

Fig. 4

A 2cm transverse incision was made at this level and a dilator was passed over the guidewire to start stoma formation and was later removed. (Figure 5)

Fig. 5

The dilating forceps were advanced over the guidewire until resistance was felt. (Figure 6)

Fig. 6

Opening the forceps allowed dilatation of the soft pretracheal tissues. (Figure 7)

Fig. 7

The forceps were then reapplied to the guidewire and advanced until the jaws passed into the tracheal lumen. The handles of the forceps were raised to align the jaws in the long axis of the trachea. (Figure 8)

Fig. 8

One step dilatation of the trachea was achieved using two-handed opening of the forceps. (Figure 9)

Fig. 9

After removal of the forceps, the tracheostomy tube with its specially designed obturator was advanced over the guidewire into the trachea. After insertion, the obturator and guidewire were removed and tracheal suction performed (Figure 10). The cuff was inflated and the patient reconnected to the ventilator.

Fig. 10

Successful intratracheal placement of the tube was confirmed by auscultation, end tidal CO2 measurement and visualisation of the carina when using endoscopic guidance. A chest x-ray was performed to exclude a pneumothorax and surgical emphysema. Complications and technical difficulties were recorded prospectively. Loss of airway was defined as inadvertent extubation. Cannulation was considered “difficult” when more than one attempt was necessary.

Results:

The mean patient age was 34 years and the mean duration of endotracheal intubation before tracheostomy was 10 days. The mean time for completion of the procedure was 10 minutes ranging between 8 to 14 minutes. Difficulty in identifying anatomical landmarks was faced in three patients only and endoscopic guidance was used twice. No loss of airway occured in any patient and cannulation was considered “difficult” when more than one attempt was necessary. In three patients, a second attempt was needed. No major bleeding occurred in any patient. Hypertension was recorded in seven cases and was managed by giving more sedation and analgesia. Difficult dilatation happened once and there was also one case of false passage in which the guidewire went first towards the vocal cords. Temporary hypoxia, manifested by dropping of O2 saturation, occurred in six cases but corrected gradually after the end of procedure, with good suction and reconnection to the ventilator. Neither pneumothorax nor surgical emphysema were recorded in any patient. There were no reported cases of infection at the site of tracheostomy. Five patients died from their underlying diseases. The remainder were transferred from the Intensive Care Units after weaning from artificial ventilation and stabilisation of their general condition.

Discussion:

Percutaneous dilatation tracheostomy (PDT) has had a significant impact on practice in our Surgical and Trauma Intensive Care Units. It has been shown to be quicker and to be associated with a lower complication rate and a decreased risk of infection when compared with open tracheostomy(5). Early tracheostomy for critically ill patients may shorten both the duration of ventilation and the length of hospital stay(6). Also it may reflect a more aggressive approach to the management of trauma and other neurosurgical patients with fewer undergoing a trial of extubation and more requiring long term airway protection and ventilatory support. The difficulties previously associated with tracheostomy such as transfer of critically ill patients to an operating theatre, lack of operating time or an available surgeon and finally the larger number of patients admitted to Intensive Care Units increases the pressure on staff to discharge patients earlier thus allowing for new patients to be admitted. This may have influenced the decision to perform bedside tracheostomy as this will protect the patient’s airway and allow less sedation to be used permitting safer weaning and improved clearance of secretions(7). In the present study 20% of patients developed hypoxia which is recognised to be one of the most frequent complications of PDT(8). Van Heurn et al concluded that PDT should not be attempted in patients requiring ventilation with a high oxygen concentration or high PEEP(9). Apart from aspiration and bleeding, hypoventilation caused by an air leak following opening the trachea is probably the main cause of hypoxia. The incidence of hypoxia may be reduced by attention to some details. For example, an experienced Respiratory Therapist and 100% oxygen are necessary. Increasing the tidal volume compensates partly for the air leak created by the tracheal incision. It is very important that an adequately sized skin incision is made to facilitate tracheostomy tube insertion(10). Endoscopic guidance has been advocated to confirm the tracheostomy position, prevent paratracheal insertion and avoid other injuries such as damage to the posterior wall of the trachea(11) but Escarment et al. did not recommend its routine use because the larger soft tissue stoma created by the forceps allows easier identification of the tracheal level and the midline without additional blunt dissection(10).

Conclusion:

Our study suggests that bedside percutaneous, single-step dilatational tracheostomy is an easy and minimally invasive technique. Careful operator technique and airway management during the procedure are imperative for optimal safety.

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