Comparison of Percutaneous Dilatational Tracheostomy Guided by Ultrasound and Bronchoscopy in Critically Ill Obese Patients

Effectiveness of ultrasound-guided versus anatomical landmark-guided percutaneous dilatational tracheostomy: a systematic review and meta-analysis

BACKGROUND

Percutaneous dilatational tracheostomy (PDT) is increasingly used in intensive care units owing to its advantages of reduced surgical trauma and fewer complications. Recently, ultrasonography has become a potentially useful tool for assisting PDT.

OBJECTIVE

To compare ultrasound- and landmark-guided PDT for major bleeding, first-puncture success rates, periprocedural complications, and tracheotomy procedure times.

METHODS

Randomized controlled trials (RCTs) or non-RCTs comparing ultrasound- and landmark-guided PDT were searched for in PubMed, Web of Science, MEDLINE, CINAHL, Cochrane Library, Wanfang Data Knowledge Service Platform, China National Knowledge Infrastructure (CNKI) and the Chinese Biomedical Literature Service System (SinoMed). The primary outcomes were major bleeding and first puncture success rate. Secondary outcomes were periprocedural complications and the tracheotomy procedure time. The meta-analysis was performed using RevMan 5.3 software.

RESULTS

This meta-analysis included five RCTs and one non-RCT, with a total of 609 patients. Compared with landmark-guided PDT, ultrasound-guided PDT can reduce the incidence of major bleeding (odds ratio [OR] = 0.35, 95% confidence interval [CI; 0.14, 0.90], P = 0.03) and improved the success rate of first puncture (OR = 4.41, 95% CI [2.54, 7.65], P < 0.000001). Additionally, ultrasound-guided PDT is associated with a lower incidence of periprocedural complications (OR = 0.35, 95% CI [0.22, 0.54], P < 0.00001). However, there was no advantage in reducing the tracheotomy procedure time between the two methods (mean difference = - 0.64, 95% CI [-4.14, 2.85], P = 0.72).

CONCLUSION

Compared to landmark-guided PDT, ultrasound-guided PDT can reduce the incidence of major bleeding and periprocedural complications and increase the success rate of the first puncture. However, the advantage of ultrasound-guided PDT in reducing the tracheotomy procedure time is unclear.

Comparison of landmark guided and ultrasound guided percutaneous dilatational tracheostomy: Efficiency, efficacy and accuracy in critically ill patients

Background and Aims:

To overcome the procedure-related complications associated with landmark-guided percutaneous dilatational tracheostomy (PDT) ultrasound is emerging as a promising tool. Present study was designed to compare landmark-guided PDT and ultrasound-guided PDT in terms of efficiency, efficacy, and accuracy.

Material and Methods:

Hundred intensive care unit patients requiring prolonged mechanical ventilation were prospectively randomized into 2 groups of 50 patients each. In land mark guided (LMG) group, patients underwent landmark-guided PDT, whereas in ultrasound guided (USG) group, patients underwent ultrasound-guided PDT.

Results:

Both the groups were comparable in terms of demographic data, sequential organ failure assessment score, ventilator settings, and mean days on mechanical ventilation prior to PDT. The mean assessment time in the ultrasound-guided group (1.56 ± 1 min) was significantly more (P-value = 0.000) than in the landmark-guided group (0.84 ± 0.72 min). The mean total procedure time for the USG group (5.98 ± 10.23 min) was more than that for the LMG group (4.86 ± 8.03 min) (P-value 0.542). Deviation of puncture site from the midline was seen in two patients in group A as compared to none in the USG group (P-value = 0.153). The number of patients requiring more than one attempt for successful needle insertion was more (P-value = 0.148) in the LMG group (20%) as compared to USG group (8%). Incidence of complications, like bleeding and desaturation was more in the LMG group as compared to the USG group.

Conclusion:

Ultrasound-guided PDT is associated with reduction in periprocedural complications as compared to landmark technique, although it takes slightly longer time.

Comparative effectiveness of ultrasound-guided and anatomic landmark percutaneous dilatational tracheostomy: A systematic review and meta-analysis

Introduction

Ultrasound-guided tracheostomy (UGT) and bronchoscope-guided tracheostomy (BGT) have been well compared. However, the differences in benefits between UGT and landmark tracheostomy (LT) have not been addressed and, in particular, lack a detailed meta-analysis. We aimed to compare the first-pass success, complication rate, major bleeding rate, and tracheostomy procedure time between UGT and LT.

Methods

In a systematic review, relevant databases were searched for studies comparing UGT with LT in intubated patients. The primary outcome was the odds ratio (OR) of first-pass success. The secondary outcomes were the OR of complications, OR of major bleeding, and standardized mean difference (SMD) of the total tracheostomy procedure time.

Results

The meta-analysis included three randomized controlled studies (RCTs) and one nonrandomized controlled study (NRS), comprising 474 patients in total. Compared with LT, UGT increased first-pass success (OR: 4.287; 95% confidence interval [CI]: 2.308 to 7.964) and decreased complications (OR: 0.422; 95% CI: 0.249 to 0.718). However, compared with LT, UGT did not significantly reduce major bleeding (OR: 0.374; 95% CI: 0.112 to 1.251) or the total tracheostomy placement time (SMD: -0.335; 95% CI: -0.842 to 0.172).

Conclusions

Compared with LT, real-time UGT increases first-pass success and decreases complications. However, UGT was not associated with a significant reduction in the major bleeding rate. The total tracheostomy placement time comparison between UGI and LT was inconclusive.

Percutaneous ultrasound-guided versus bronchoscopy-guided dilatational tracheostomy after median sternotomy: A case-control study

Background

In this study, we aimed to compare ultrasoundguided versus bronchoscopy-guided percutaneous dilatational tracheostomy outcomes in critically ill adult patients undergoing a median sternotomy.

Methods

Between January 2015 and December 2020, a total of 54 patients (17 males, 37 females; mean age: 54.9±13.1 years; range, 39 to 77 years) who underwent elective ultrasound- or bronchoscopy-guided percutaneous dilatational tracheostomy after a median sternotomy were included. We compared the ultrasound-guided group (n=25) with the bronchoscopy-guided group (n=29) regarding all-cause mortality and complications. Safety assessments included major and minor bleeding, procedural hypoxic or hypotensive event, cardiac dysrhythmias, tracheal injury, damage to adjacent structures, and requirement of conversion to open surgical tracheostomy.

Results

No tracheostomy procedure-related death was observed in either group. The median time for tracheostomy was 13 (range, 8 to 17) min in the ultrasound-guided group and 10 (range, 7 to 15) min in the bronchoscopy-guided group (p=0.387). There was no need for conversion between the two methods or conversion to surgical tracheostomy for any patient. The overall complication rates did not significantly differ between the groups (p=0.15).

Conclusion

Ultrasound-guided percutaneous dilatational tracheostomy can be safely performed in patients undergoing sternotomy. Complication rates of the procedure are similar to those guided with bronchoscopy.

Ultrasound use in the ICU for interventional pulmonology procedures

Critical care ultrasound has shifted the paradigm of thoracic imaging by enabling the treating physician to acquire and interpret images essential for clinical decision-making, at the bedside, in real-time. Once considered impossible, lung ultrasound based on interpretation of artifacts along with true images, has gained momentum during the last decade, as an integral part of rapid evaluation algorithms for acute respiratory failure, shock and cardiac arrest. Procedural ultrasound image guidance is a standard of care for both common bedside procedures, and advanced procedures within interventional pulmonologist’s (IP’s) scope of practice. From IP’s perspective, the lung, pleural, and chest wall ultrasound expertise is a prerequisite for mastery in pleural drainage techniques and transthoracic biopsies. Another ultrasound application of interest to the IP in the intensive care unit (ICU) setting is during percutaneous dilatational tracheostomy (PDT). As ICU demographics shift towards older and sicker patients, the indications for closed pleural drainage procedures, bedside transthoracic biopsies, and percutaneous dilatational tracheostomies have dramatically increased. Although ultrasound expertise is considered an essential IP operator skill there is no validated curriculum developed to address this component. Further, there is a need for developing an educational tool that matches up with the curriculum and could be integrated real-time with ultrasound-guided procedures.

Ultrasound for assessment and follow-up of airway stenosis

BACKGROUND

Ultrasound is a reliable tool for airway assessment and management. We evaluated the accuracy of Ultrasound in the pre-procedure planning and follow-up evaluation of patients undergoing airway stenting for benign upper airway stenosis.

METHODS

This was a retrospective single center study on patients with benign upper airway stenosis treated with airway stenting. Ultrasound evaluated the characteristics of the stenosis (distance from vocal folds, diameter and length) before treatment and any complications after treatment; these results were then statistically compared with those obtained by computed tomography, taking the endoscopy as the reference method.

RESULTS

Twenty-seven patients were evaluated. Ultrasound was significantly correlated with endoscopy and computed tomography scan measurements as distance of stenosis from vocal folds (r=0.88; p<0.001 and r=0.87; p<0.001, respectively); diameter of the stenosis (r=0.97; p<0.001 and r=0.97; p<0.001, respectively); and length of the stenosis (r=0.97; p<0.001 and r=0.97; p<0.001, respectively). Four out of 27 (15%) patients presented complications after treatment as stent migration (n=2; 7%); stent obstruction (n=1; 4%), and granulation of vocal fold (n=1; 4%). All complications but granulation of vocal fold were correctly depicted by Ultrasound and Computed Tomography without significant difference in comparison to endoscopy (p=0.87) CONCLUSIONS: Ultrasound is a promising tool in assessment of airway stenosis and follow-up of patients after stenting; it may be routinely used in adjunction to computed tomography and/or endoscopy in this setting, if our results are corroborated by future larger study.

Tracheostomy during SARS-CoV-2 pandemic: Recommendations from the New York Head and Neck Society

The rapid spread of SARS‐CoV‐2 in 2019 and 2020 has resulted in a worldwide pandemic characterized by severe pulmonary inflammation, effusions, and rapid respiratory compromise. The result of this pandemic is a large and increasing number of patients requiring endotracheal intubation and prolonged ventilator support. The rapid rise in endotracheal intubations coupled with prolonged ventilation requirements will certainly lead to an increase in tracheostomy procedures in the coming weeks and months. Performing tracheostomy in the setting of active SARS‐CoV‐2, when necessary, poses a unique situation, with unique risks and benefits for both the patient and the health care providers. The New York Head and Neck Society has collaborated on this document to provide guidance on the performance of tracheostomies during the SARS‐CoV‐2 pandemic.

Tracheostomy in Adult Intensive Care Unit: An ISCCM Expert Panel Practice Recommendations

BACKGROUND AND AIM

Critically ill patients on mechanical ventilation undergo tracheostomy to facilitate weaning. The practice in India may be different from the rest of the world and therefore, in order to understand this, ISCCM conducted a multicentric observational study "DIlatational percutaneous vs Surgical tracheoStomy in intEnsive Care uniT: A practice pattern observational multicenter study (DISSECT Study)" followed by an ISCCM Expert Panel committee meeting to formulate Practice recommendations pertinent to Indian ICUs.

MATERIALS AND METHODS

All existing International guidelines on the topic, various randomized controlled trials, meta-analysis, systematic reviews, retrospective studies were taken into account to formulate the guidelines. Wherever Indian data was not available, international data was analysed. A modified Grade system was followed for grading the recommendation.

RESULTS

After analyzing the entire available data, the recommendations were made by the grading system agreed by the Expert Panel. The recommendations took into account the indications and contraindications of tracheostomy; effect of timing of tracheostomy on incidence of ventilator associated pneumonia, ICU length of stay, ventilator free days & Mortality; comparison of surgical and percutaneous dilatational tracheostomy (PDT) in terms of incidence of complications and cost to the patient; Comparison of various techniques of PDT; Use of fiberoptic bronchoscope and ultrasound in PDT; experience of the operator and qualification; certain special conditions like coagulopathy and morbid obesity.

CONCLUSION

This document presents the first Indian recommendations on tracheostomy in adult critically ill patients based on the practices of the country. These guidelines are expected to improve the safety and extend the indications of tracheostomy in critically ill patients.

HOW TO CITE THIS ARTICLE

Gupta S, Dixit S, Choudhry D, Govil D, Mishra RC, Samavedam S, Tracheostomy in Adult Intensive Care Unit: An ISCCM Expert Panel Practice Recommendations. Indian J Crit Care Med 2020;24(Suppl 1):S31-S42.