1
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Shin D, Ma A, Chan Y. A Retrospective Review of 589 Percutaneous Tracheostomies in a Canadian Community Teaching Hospital. EAR, NOSE & THROAT JOURNAL 2023; 102:NP474-NP480. [PMID: 34134536 DOI: 10.1177/01455613211025744] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The primary objective of this study was to review the complication rate of percutaneous tracheostomies performed by a single surgeon in a community teaching hospital. METHODS This retrospective study reviewed the patients who underwent percutaneous tracheostomy with bronchoscopic guidance in a community hospital setting between 2009 and 2017. Patients older than the age of 18 requiring percutaneous tracheostomy were chosen for this retrospective study. Patients who were medically unstable, had no palpable neck landmarks, and inadequate neck extension were excluded. Indications for percutaneous tracheostomy included patients who had failed to wean from mechanical ventilation, required pulmonary toileting, or in whom airway protection was required. RESULTS Of the 600 patients who received percutaneous tracheostomy, 589 patients were included in the study. Intraoperative complication (2.6%) and postoperative complication rates (11.4%) compared similarly to literature reported rates. The most common intraoperative complications were bleeding, technical difficulties, and accidental extubation. Bleeding, tube obstruction, and infection were the most common postoperative complications. Overall burden of comorbidity, defined by Charlson Comorbidity Index, and coagulopathy were also found to be associated with higher complication rates. The decannulation rate at discharge was 46.3%. CONCLUSION Percutaneous tracheostomy is a safe alternative to open tracheostomies in the community setting for appropriately selected patients.
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Affiliation(s)
- Dongho Shin
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Mississauga, Ontario, Canada
| | - Andrew Ma
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Mississauga, Ontario, Canada
- Division of Otolaryngology-Head and Neck Surgery, University of Toronto, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Yvonne Chan
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Mississauga, Ontario, Canada
- Division of Otolaryngology-Head and Neck Surgery, University of Toronto, Trillium Health Partners, Mississauga, Ontario, Canada
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2
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Bini G, Russo E, Antonini MV, Pirini E, Brunelli V, Zumbo F, Pronti G, Rasi A, Agnoletti V. Impact of early percutaneous dilatative tracheostomy in patients with subarachnoid hemorrhage on main cerebral, hemodynamic, and respiratory variables: A prospective observational study. Front Neurol 2023; 14:1105568. [PMID: 37051061 PMCID: PMC10083491 DOI: 10.3389/fneur.2023.1105568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 03/02/2023] [Indexed: 03/29/2023] Open
Abstract
Introduction Patients with poor-grade subarachnoid hemorrhage (SAH) admitted to the intensive care unit (ICU) often require prolonged invasive mechanical ventilation due to prolonged time to obtain neurological recovery. Impairment of consciousness and airway protective mechanisms usually require tracheostomy during the ICU stay to facilitate weaning from sedation, promote neurological assessment, and reduce mechanical ventilation (MV) duration and associated complications. Percutaneous dilatational tracheostomy (PDT) is the technique of choice for performing a tracheostomy. However, it could be associated with particular risks in neurocritical care patients, potentially increasing the risk of secondary brain damage. Methods We conducted a single-center, prospective, observational study aimed to assess PDT-associated variations in main cerebral, hemodynamic, and respiratory variables, the occurrence of tracheostomy-related complications, and their relationship with outcomes in adult patients with SAH admitted to the ICU of a neurosurgery/neurocritical care hub center after aneurysm control through clipping or coiling and undergoing early PDT. Results We observed a temporary increase in ICP during early PDT; this increase was statistically significant in patients presenting with higher therapy intensity level (TIL) at the time of the procedural. The episodes of intracranial hypertension were brief, and appeared mainly due to the activation of cerebral autoregulatory mechanisms in patients with impaired compensatory mechanisms and compliance. Discussion The low number of observed complications might be related to our organizational strategy, all based on a dedicated "tracheo-team" implementing both PDT following a strictly defined protocol and accurate follow-up.
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Affiliation(s)
- Giovanni Bini
- Department of Emergency Surgery and Trauma, Anesthesia and Intensive Care Unit, M Bufalini Hospital, Azienda Unità Sanitaria Locale (AUSL) della Romagna, Cesena, Italy
| | - Emanuele Russo
- Department of Emergency Surgery and Trauma, Anesthesia and Intensive Care Unit, M Bufalini Hospital, Azienda Unità Sanitaria Locale (AUSL) della Romagna, Cesena, Italy
| | - Marta Velia Antonini
- Department of Emergency Surgery and Trauma, Anesthesia and Intensive Care Unit, M Bufalini Hospital, Azienda Unità Sanitaria Locale (AUSL) della Romagna, Cesena, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Emilia-Romagna, Italy
| | - Erika Pirini
- Department of Emergency Surgery and Trauma, Anesthesia and Intensive Care Unit, M Bufalini Hospital, Azienda Unità Sanitaria Locale (AUSL) della Romagna, Cesena, Italy
| | - Valentina Brunelli
- Department of Emergency Surgery and Trauma, Anesthesia and Intensive Care Unit, M Bufalini Hospital, Azienda Unità Sanitaria Locale (AUSL) della Romagna, Cesena, Italy
| | - Fabrizio Zumbo
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giorgia Pronti
- Department of Anesthesia and Intensive Care, Osspedale degli Infermi, Rimini, Italy
| | - Alice Rasi
- Department of Pediatrics, Ospedale Bufalini, Cesena (FC), Italy
| | - Vanni Agnoletti
- Department of Emergency Surgery and Trauma, Anesthesia and Intensive Care Unit, M Bufalini Hospital, Azienda Unità Sanitaria Locale (AUSL) della Romagna, Cesena, Italy
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3
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Kim JE, Lee DH. The feasibility and safety of percutaneous dilatational tracheostomy without endotracheal guidance in the intensive care unit. Acute Crit Care 2022; 37:101-107. [PMID: 35172525 PMCID: PMC8918715 DOI: 10.4266/acc.2021.00906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 09/14/2021] [Indexed: 11/30/2022] Open
Abstract
Background Percutaneous dilatational tracheostomy (PDT) is a common procedure in intensive care units (ICUs). Although it is thought to be safe and easily performed at the bedside, PDT usually requires endotracheal guidance, such as bronchoscopy. Here, we assessed the clinical outcomes and safety of PDT conducted without endotracheal guidance. Methods In the ICU and coronary ICU at a tertiary hospital, PDT was routinely performed without endotracheal guidance by a single medical intensivist using the Griggs technique PDT kit (Portex Percutaneous Tracheostomy Kit). We retrospectively reviewed the electronic medical records of patients who underwent PDT without endotracheal guidance. Results From January 1 to December 31, 2018, 78 patients underwent PDT without endotracheal guidance in the ICU and coronary ICU. The mean age of these subjects was 71.9±11.5 years, and 29 (37.2%) were female. The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 25.9±5.8. Fifty patients (64.1%) were on mechanical ventilation during PDT. Failure of the initial PDT attempt occurred in four patients (5.1%). In two of them, PDT was aborted and converted to surgical tracheostomy; in the other two patients, PDT was reattempted after endotracheal reintubation, with success. Minor bleeding at the tracheostomy site requiring gauze changes was observed in five patients (6.4%). There were no airway problems requiring therapeutic interventions or procedure-related sequelae. Conclusion PDT without endotracheal guidance can be considered safe and feasible.
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Affiliation(s)
- Ji Eun Kim
- Department of Emergency Medicine, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Dong Hyun Lee
- Department of Intensive Care Medicine, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
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4
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Ullman J, Karling J, Bark R, Nelson D, Wanecek M, Margolin G. Navigation system for percutaneous tracheotomy. Acta Otolaryngol 2021; 141:953-959. [PMID: 34570658 DOI: 10.1080/00016489.2021.1982147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Johan Ullman
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Jonas Karling
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Rusana Bark
- Division of ENT Diseases, Department of Clinical Sciences, Intervention and Technology, Karolinska institutet, Stockholm, Sweden
- Department of Otorhinolaryngology, Head and Neck Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - David Nelson
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Michael Wanecek
- Intensive Care Unit, Capio Saint Göran’s Hospital, Stockholm, Sweden
| | - Gregori Margolin
- Division of ENT Diseases, Department of Clinical Sciences, Intervention and Technology, Karolinska institutet, Stockholm, Sweden
- Department of Otorhinolaryngology, Head and Neck Surgery, Karolinska University Hospital, Stockholm, Sweden
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5
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Añón JM, Arellano MS, Pérez-Márquez M, Díaz-Alvariño C, Márquez-Alonso JA, Rodríguez-Peláez J, Nanwani-Nanwani K, Martín-Pellicer A, Civantos B, López-Fernández A, Seises I, García-Nerín J, Figueira JC, Casero H, Vejo J, Agrifoglio A, Cachafeiro L, Díaz-Almirón M, Villar J. The role of routine FIBERoptic bronchoscopy monitoring during percutaneous dilatational TRACHeostomy (FIBERTRACH): a study protocol for a randomized, controlled clinical trial. Trials 2021; 22:423. [PMID: 34187554 PMCID: PMC8240418 DOI: 10.1186/s13063-021-05370-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 06/11/2021] [Indexed: 12/03/2022] Open
Abstract
Background Tracheostomy is one of the most frequent techniques in intensive care units (ICU). Fiberoptic bronchoscopy (FB) is a safety measure when performing a percutaneous dilatational tracheostomy (PDT), but the controversy surrounding the routine use of FB as part of the procedure remains open. National surveys in some European countries showed that the use of FB is non-standardized. Retrospective studies have not shown a significant difference in complications between procedures performed with or without a bronchoscope. International guidelines have not been able to establish recommendations regarding the use of FB in PDT due to lack of evidence. Design This is a multicenter (three centers at the time of publishing this paper) randomized controlled clinical trial to examine the safety of percutaneous tracheostomy using FB. We will include all consecutive adult patients admitted to the ICU in whom percutaneous tracheostomy for prolonged mechanical ventilation is indicated and with no exclusion criteria for using FB. Eligible patients will be randomly assigned to receive blind PDT or PDT under endoscopic guidance. All procedures will be performed by experienced intensivists in PDT and FB. A Data Safety and Monitoring Board (DSMB) will monitor the trial. The primary outcome is the incidence of perioperative complications. Discussion FB is a safe technique when performing PDT although its use is not universally accepted in all ICUs as a routine practice. Should PDT be monitored routinely with endoscopic guidance? This study will assess the role of FB monitoring during PDT. Trial registration ClinicalTrials.gov NCT04265625. Registered on February 11, 2020 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05370-x.
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Affiliation(s)
- José M Añón
- Intensive Care Unit, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain. .,Instituto de Investigación del Hospital Universitario La Paz (IdiPAZ), Madrid, Spain. .,CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.
| | - María Soledad Arellano
- Intensive Care Unit, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain
| | | | - Claudia Díaz-Alvariño
- Intensive Care Unit, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain
| | | | - Jorge Rodríguez-Peláez
- Intensive Care Unit, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Kapil Nanwani-Nanwani
- Intensive Care Unit, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain.,Instituto de Investigación del Hospital Universitario La Paz (IdiPAZ), Madrid, Spain
| | | | - Belén Civantos
- Intensive Care Unit, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain.,Instituto de Investigación del Hospital Universitario La Paz (IdiPAZ), Madrid, Spain
| | - Alba López-Fernández
- Intensive Care Unit, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Irene Seises
- Intensive Care Unit, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Jorge García-Nerín
- Intensive Care Unit, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Juan C Figueira
- Intensive Care Unit, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Henar Casero
- Intensive Care Unit, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Javier Vejo
- Intensive Care Unit, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Alexander Agrifoglio
- Intensive Care Unit, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain.,Instituto de Investigación del Hospital Universitario La Paz (IdiPAZ), Madrid, Spain
| | - Lucía Cachafeiro
- Intensive Care Unit, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain.,Instituto de Investigación del Hospital Universitario La Paz (IdiPAZ), Madrid, Spain
| | | | - Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.,Research Unit, Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain.,Keenan Research Center for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
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6
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CIRIK MÖ, ERASLAN DOĞANAY G, ALAGÖZ A, SAZAK H. Can mini-tracheostomy needle be safer for residency training in percutaneous dilatation tracheostomy applications in intensive care unit? JOURNAL OF HEALTH SCIENCES AND MEDICINE 2021. [DOI: 10.32322/jhsm.894513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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7
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Abbott F, Ortega M, Bravo S, Basoalto R, Kattan E. Can we improve teaching and learning of percutaneous dilatational tracheostomy's bronchoscopic guidance? SAGE Open Med 2021; 9:20503121211002321. [PMID: 33796301 PMCID: PMC7983236 DOI: 10.1177/20503121211002321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 02/22/2021] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Francisco Abbott
- Departamento de Medicina Intensiva,
Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago,
Chile
- Departamento de Enfermedades
Respiratorias, Facultad de Medicina, Pontificia Universidad Católica de Chile,
Santiago, Chile
| | - Marcos Ortega
- Departamento de Medicina Intensiva,
Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago,
Chile
- Departamento de Enfermedades
Respiratorias, Facultad de Medicina, Pontificia Universidad Católica de Chile,
Santiago, Chile
| | - Sebastian Bravo
- Departamento de Medicina Intensiva,
Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago,
Chile
| | - Roque Basoalto
- Departamento de Medicina Intensiva,
Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago,
Chile
| | - Eduardo Kattan
- Departamento de Medicina Intensiva,
Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago,
Chile
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8
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Schönhofer B, Geiseler J, Dellweg D, Fuchs H, Moerer O, Weber-Carstens S, Westhoff M, Windisch W. Prolonged Weaning: S2k Guideline Published by the German Respiratory Society. Respiration 2020; 99:1-102. [PMID: 33302267 DOI: 10.1159/000510085] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 01/28/2023] Open
Abstract
Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by respiratory muscle insufficiency and/or lung parenchymal disease; that is, when other treatments such as medication, oxygen administration, secretion management, continuous positive airway pressure (CPAP), or nasal high-flow therapy have failed. MV is required for maintaining gas exchange and allows more time to curatively treat the underlying cause of respiratory failure. In the majority of ventilated patients, liberation or "weaning" from MV is routine, without the occurrence of any major problems. However, approximately 20% of patients require ongoing MV, despite amelioration of the conditions that precipitated the need for it in the first place. Approximately 40-50% of the time spent on MV is required to liberate the patient from the ventilator, a process called "weaning". In addition to acute respiratory failure, numerous factors can influence the duration and success rate of the weaning process; these include age, comorbidities, and conditions and complications acquired during the ICU stay. According to international consensus, "prolonged weaning" is defined as the weaning process in patients who have failed at least 3 weaning attempts, or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Given that prolonged weaning is a complex process, an interdisciplinary approach is essential for it to be successful. In specialised weaning centres, approximately 50% of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, the heterogeneity of patients undergoing prolonged weaning precludes the direct comparison of individual centres. Patients with persistent weaning failure either die during the weaning process, or are discharged back to their home or to a long-term care facility with ongoing MV. Urged by the growing importance of prolonged weaning, this Sk2 Guideline was first published in 2014 as an initiative of the German Respiratory Society (DGP), in conjunction with other scientific societies involved in prolonged weaning. The emergence of new research, clinical study findings and registry data, as well as the accumulation of experience in daily practice, have made the revision of this guideline necessary. The following topics are dealt with in the present guideline: Definitions, epidemiology, weaning categories, underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV, and recommendations for end-of-life decisions. Special emphasis was placed on the following themes: (1) A new classification of patient sub-groups in prolonged weaning. (2) Important aspects of pulmonary rehabilitation and neurorehabilitation in prolonged weaning. (3) Infrastructure and process organisation in the care of patients in prolonged weaning based on a continuous treatment concept. (4) Changes in therapeutic goals and communication with relatives. Aspects of paediatric weaning are addressed separately within individual chapters. The main aim of the revised guideline was to summarize both current evidence and expert-based knowledge on the topic of "prolonged weaning", and to use this information as a foundation for formulating recommendations related to "prolonged weaning", not only in acute medicine but also in the field of chronic intensive care medicine. The following professionals served as important addressees for this guideline: intensivists, pulmonary medicine specialists, anaesthesiologists, internists, cardiologists, surgeons, neurologists, paediatricians, geriatricians, palliative care clinicians, rehabilitation physicians, intensive/chronic care nurses, physiotherapists, respiratory therapists, speech therapists, medical service of health insurance, and associated ventilator manufacturers.
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Affiliation(s)
- Bernd Schönhofer
- Klinikum Agnes Karll Krankenhaus, Klinikum Region Hannover, Laatzen, Germany,
| | - Jens Geiseler
- Klinikum Vest, Medizinische Klinik IV: Pneumologie, Beatmungs- und Schlafmedizin, Marl, Germany
| | - Dominic Dellweg
- Fachkrankenhaus Kloster Grafschaft GmbH, Abteilung Pneumologie II, Schmallenberg, Germany
| | - Hans Fuchs
- Universitätsklinikum Freiburg, Zentrum für Kinder- und Jugendmedizin, Neonatologie und Pädiatrische Intensivmedizin, Freiburg, Germany
| | - Onnen Moerer
- Universitätsmedizin Göttingen, Klinik für Anästhesiologie, Göttingen, Germany
| | - Steffen Weber-Carstens
- Charité, Universitätsmedizin Berlin, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Virchow-Klinikum und Campus Mitte, Berlin, Germany
| | - Michael Westhoff
- Lungenklinik Hemer, Hemer, Germany
- Universität Witten/Herdecke, Herdecke, Germany
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Universität Witten/Herdecke, Herdecke, Germany
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9
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Simulation-Based Mastery Learning of Bronchoscopy-Guided Percutaneous Dilatational Tracheostomy. Simul Healthc 2020; 16:157-162. [DOI: 10.1097/sih.0000000000000491] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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10
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Chang J, Shin HJ, Kwon YS, Kim YI, Lim SC, Kim TO. Is percutaneous dilatational tracheostomy with bronchoscopic guidance better than without? Acute Crit Care 2020; 35:127-129. [PMID: 32506878 PMCID: PMC7280795 DOI: 10.4266/acc.2020.00101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 05/14/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
- Jinsun Chang
- Department of Pulmonology and Critical Care Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Hong-Joon Shin
- Department of Pulmonology and Critical Care Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Yong-Soo Kwon
- Department of Pulmonology and Critical Care Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Yu-Il Kim
- Department of Pulmonology and Critical Care Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Sung-Chul Lim
- Department of Pulmonology and Critical Care Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Tae-Ok Kim
- Department of Pulmonology and Critical Care Medicine, Chonnam National University Hospital, Gwangju, Korea
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11
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Design and Evaluation of a Low-Cost Bronchoscopy-Guided Percutaneous Dilatational Tracheostomy Simulator. Simul Healthc 2020; 14:415-419. [PMID: 31804426 PMCID: PMC6903325 DOI: 10.1097/sih.0000000000000399] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
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.
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12
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Gupta S, Tomar DS, Dixit S, Zirpe K, Choudhry D, Govil D, Mohamed Z, Chakrabortty N, Gurav S, Wanchoo J, Gupta KV. Dilatational Percutaneous vs Surgical TracheoStomy in IntEnsive Care UniT: A Practice Pattern Observational Multicenter Study (DISSECT). Indian J Crit Care Med 2020; 24:514-526. [PMID: 32963433 PMCID: PMC7482354 DOI: 10.5005/jp-journals-10071-23441] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Tracheostomy is among the common procedures performed in the intensive care unit (ICU), with percutaneous dilatational tracheostomy (PDT) being the preferred technique. We sought to understand the current practice of tracheostomy in Indian ICUs. Materials and methods A pan-India multicenter prospective observational study, endorsed and peer-reviewed by the Indian Society of Critical Care Medicine (ISCCM), on various aspects of tracheostomy performed in critically ill patients was conducted between September 1, 2019 and December 31, 2019. The SPSS software was used for the statistical analysis. Cross tables were generated and the chi-square test was used for testing of association. The p value < 0.05 was considered statistically significant. Results Out of 67 ICUs that participated, 88.1% were from private sector hospitals. A total of 923 tracheostomies were performed during the study period; out of which, 666 were PDT and 257 were surgical tracheostomy (ST). Coagulopathic patients received more platelet transfusion [p = 0.037 with platelet count (PC) < 50 × 109, p = 0.021 with PC 50–100 × 109] and fresh frozen plasma transfusion in the ST group (p = 0.0001). The performance of PDT vs ST by day 7 of admission was 28.4% vs 21% (p = 0.023). The single dilator technique (60.4%) was the preferred technique for PDT followed by the Grigg's forceps and then the multiple dilator technique. Fiberoptic bronchoscope (FOB) and ultrasonography (USG) were used in 29.3% and 16.8%, respectively, for guidance during tracheostomy. Most of the PDTs were performed by a trained intensivist (74.2%), whereas ST was mostly done by an ENT surgeon (56.8%). Percutaneous dilatational tracheostomy resulted in less hemorrhagic (2.6% vs 7%, p = 0.002) and desaturation complications (2.3% vs 6.6%, p = 0.001) as compared to ST. The duration of procedure was shorter in the PDT group (average shortening by 9.2 minutes) and the ventilator-free days (VFD) were higher in the PDT group. The cost was less in PDT by approximately Rs. 13,104. Conclusion Percutaneous dilatational tracheostomy, especially the single dilator technique, is preferred by clinicians in Indian ICUs. The incidence of minor complications like hemorrhagic episodes is lower with PDT. Percutaneous dilatational tracheostomy was found to be cheaper on cost per patient basis as compared to ST (with or without complications). How to cite this article Gupta S, Tomar DS, Dixit S, Zirpe K, Choudhry D, Govil D, et al. Dilatational Percutaneous vs Surgical TracheoStomy in IntEnsive Care UniT: A Practice Pattern Observational Multicenter Study (DISSECT). Indian J Crit Care Med 2020;24(7):514–526.
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Affiliation(s)
- Sachin Gupta
- Department of Critical Care Medicine, Narayana Superspeciality Hospital, Gurugram, Haryana, India
| | - Deeksha S Tomar
- Department of Critical Care Medicine, Narayana Superspeciality Hospital, Gurugram, Haryana, India
| | - Subhal Dixit
- Department of Critical Care Medicine, Sanjeevan and MJM Hospital, Pune, Maharashtra, India
| | - Kapil Zirpe
- Department of Neurocritical Care, Ruby Hall Clinic, Grant Medical Foundation, Pune, Maharashtra, India
| | - Dhruva Choudhry
- Department of Pulmonary and Critical Care Medicine, University of Health Sciences, Rohtak, Haryana, India
| | - Deepak Govil
- Department of Critical Care, Institute of Critical Care and Anesthesiology, Medanta-The Medicity, Gurugram, Haryana, India
| | - Zubair Mohamed
- Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
| | - Nilanchal Chakrabortty
- Department of Neurointensive Care, Institute of Neurosciences, Kolkata, West Bengal, India
| | - Sushma Gurav
- Department of Neurocritical Care, Ruby Hall Clinic, Grant Medical Foundation, Pune, Maharashtra, India
| | - Jaya Wanchoo
- Department of Neuroanesthesia and Critical Care, Institute of Neurosciences, Medanta-The Medicity, Gurugram, Haryana, India
| | - Kanchi Vv Gupta
- Department of Critical Care Medicine, Manipal Hospitals, Bengaluru, Karnataka, India
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Gupta S, Dixit S, Choudhry D, Govil D, Mishra RC, Samavedam S, Zirpe K, Srinivasan S, Mohamed Z, Gupta KV, Wanchoo J, Chakrabortty N, Gurav S. Tracheostomy in Adult Intensive Care Unit: An ISCCM Expert Panel Practice Recommendations. Indian J Crit Care Med 2020; 24:S31-S42. [PMID: 32205955 PMCID: PMC7085814 DOI: 10.5005/jp-journals-10071-g23184] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Sachin Gupta
- Department of Critical Care Medicine, Narayana Superspeciality Hospital, Gurugram, Haryana, India, , e-mail:
| | - Subhal Dixit
- Department of Critical Care Medicine, Sanjeevan & MJM Hospital, Pune, Maharashtra, India, , e-mail:
| | - Dhruva Choudhry
- Department of Pulmonary & Critical Care Medicine, University of Health Sciences Rohtak, Haryana, India, , e-mail:
| | - Deepak Govil
- Department of Critical Care, Institute of Critical Care & Anesthesiology, Medanta The Medicity, Gurugram, Haryana, India, , e-mail:
| | | | - Srinivas Samavedam
- Department of Critical Care, Virinchi Hospital, Hyderabad, Telangana, India, , e-mail:
| | - Kapil Zirpe
- Department of Neurocritical Care, Ruby Hall Clinic, Grant Medical Foundation, Pune, Maharashtra, India, , e-mail:
| | - Shrikanth Srinivasan
- Department of Critical Care Medicine, Manipal Hospitals, New Delhi, India, , e-mail:
| | - Zubair Mohamed
- Department of Organ Transplant Anaesthesia and Critical Care, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India, , e-mail:
| | - Kv Venkatesha Gupta
- Department of Critical Care Medicine, Manipal Hospitals, Bengaluru, Karnataka, India, , e-mail:
| | - Jaya Wanchoo
- Department of Neuroanaesthesia and Critical Care, Institute of Neurosciences, Medanta The Medicity, Gurugram, Haryana, India, , e-mail:
| | - Nilanchal Chakrabortty
- Department of Neurointensive Care, Institute of Neurosciences, Kolkata, West Bengal, India, , e-mail:
| | - Sushma Gurav
- Department of Neurocritical Care, Ruby Hall Clinic, Grant Medical Foundation, Pune, Maharashtra, India, , e-mail:
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Karagiannidis C, Merten ML, Heunks L, Strassmann SE, Schäfer S, Magnet F, Windisch W. Respiratory acidosis during bronchoscopy-guided percutaneous dilatational tracheostomy: impact of ventilator settings and endotracheal tube size. BMC Anesthesiol 2019; 19:147. [PMID: 31399057 PMCID: PMC6689167 DOI: 10.1186/s12871-019-0824-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 08/06/2019] [Indexed: 11/10/2022] Open
Abstract
Background The current study investigates the effect of bronchoscopy-guided percutaneous dilatational tracheostomy (PDT) on the evolution of respiratory acidosis depending on endotracheal tube (ET) sizes. In addition, the impact of increasing tidal volumes during the intervention was investigated. Methods Two groups of ICU-patients undergoing bronchoscopy-guided PDT with varying tidal volumes and tube sizes were consecutively investigated: 6 ml/kg (N = 29, mean age 57.4 ± 14.5 years) and 12 ml/kg predicted body weight (N = 34, mean age 59.5 ± 12.8 years). Results The mean intervention time during all procedures was 10 ± 3 min. The combination of low tidal volumes and ETs of 7.5 mm internal diameter resulted in the most profound increase in PaCO2 (32.2 ± 11.6 mmHg) and decrease in pH-value (− 0.18 ± 0.05). In contrast, the combination of high tidal volumes and ETs of 8.5 mm internal diameter resulted in the least profound increase in PaCO2 (8.8 ± 9.0 mmHg) and decrease of pH (− 0.05 ± 0.04). The intervention-related increase in PaCO2 was significantly lower when using higher tidal volumes for larger ET: internal diameter 7.5, 8.0 and 8.5: P > 0.05, =0.006 and = 0.002, respectively. Transcutaneous PCO2 monitoring revealed steadily worsening hypercapnia during the intervention with a high correlation of 0.87 and a low bias of 0.7 ± 9.4 mmHg according to the Bland-Altman analysis when compared to PaCO2 measurements. Conclusions Profound respiratory acidosis following bronchoscopy-guided PDT evolves in a rapid and dynamic process. Increasing the tidal volume from 6 to 12 ml/kg PBW was capable of attenuating the evolution of respiratory acidosis, but this effect was only evident when using larger ETs. Trial registration DRKS00011004. Registered 20th September 2016. Electronic supplementary material The online version of this article (10.1186/s12871-019-0824-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, Kliniken der Stadt Köln GmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany.
| | - Michaela L Merten
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, Kliniken der Stadt Köln GmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Leo Heunks
- Dept of Intensive Care Medicine, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - Stephan E Strassmann
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, Kliniken der Stadt Köln GmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Simone Schäfer
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, Kliniken der Stadt Köln GmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Friederike Magnet
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, Kliniken der Stadt Köln GmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Wolfram Windisch
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, Kliniken der Stadt Köln GmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
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Haddad SH, Aldawood AS, Arabi YM. The Diagnostic Yield and Clinical Impact of a Chest X-Ray after Percutaneous Dilatational Tracheostomy: A Prospective Cohort Study. Anaesth Intensive Care 2019; 35:393-7. [PMID: 17591135 DOI: 10.1177/0310057x0703500313] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- S H Haddad
- Intensive Care Department, King Fahad National Guard Hospital, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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Shen G, Yin H, Cao Y, Zhang M, Wu J, Jiang X, Yu T, Lu W. Percutaneous dilatational tracheostomy versus fibre optic bronchoscopy-guided percutaneous dilatational tracheostomy in critically ill patients: a randomised controlled trial. Ir J Med Sci 2018; 188:675-681. [PMID: 30099716 DOI: 10.1007/s11845-018-1881-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 08/01/2018] [Indexed: 01/03/2023]
Abstract
BACKGROUND To determine whether fibre optic bronchoscopy-guided percutaneous dilatational tracheostomy (FOB-PDT) is a better option in critically ill patients, we compared the efficacy and incidence of procedure complications between PDT with and without FOB. METHODS We included 90 patients with oral intubation and mechanical ventilation who received PDT with (n = 45, FOB-PDT group) and without (n = 45, PDT group) FOB. For all patients, a simplification of the Griggs technique was used in this study with a central venous catheter set and dilating forceps. Demographic data, body mass index (BMI), Sequential Organ Failure Assessment (SOFA) score, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, rate of first-time success, complication rate and time of procedure were evaluated in both groups. PDT was performed guided by FOB only in the FOB-PDT group. RESULTS The rate of major complications, including minor or major haemorrhage requiring intervention and subcutaneous emphysema in the neck or pneumothorax, was significantly higher in the PDT group than in the PDT-FOB group (40% vs. 20%, P < 0.05). Significant differences were observed between the two groups with respect to the rate of first-time success (64.4% vs. 93.3%, P < 0.05); the rate of first-time success puncture with the puncture needle in the PDT-FOB group was higher than that in the PDT group (93.3% vs. 75.6%, P < 0.05). The mean procedure duration was significantly longer in the PDT group than in the PDT-FOB group (12.9 ± 1.1 vs. 9.8 ± 1.2 min, P < 0 .05). CONCLUSIONS PDT with FOB offers the advantages of a high rate of first-time success, a low complication rate and short-procedure duration. Thus, FOB-PDT is a better option in critically ill patients.
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Affiliation(s)
- Guanggui Shen
- Department of Critical Care Medicine, Research Center for Functional Maintenance and Reconstruction of Viscera, Wannan Medical College First Affiliated Hospital, Yijishan Hospital, Wuhu, China
| | - Hongzhen Yin
- Department of Critical Care Medicine, Research Center for Functional Maintenance and Reconstruction of Viscera, Wannan Medical College First Affiliated Hospital, Yijishan Hospital, Wuhu, China
| | - Yingya Cao
- Department of Critical Care Medicine, Research Center for Functional Maintenance and Reconstruction of Viscera, Wannan Medical College First Affiliated Hospital, Yijishan Hospital, Wuhu, China
| | - Meijun Zhang
- Department of Critical Care Medicine, Research Center for Functional Maintenance and Reconstruction of Viscera, Wannan Medical College First Affiliated Hospital, Yijishan Hospital, Wuhu, China
| | - Jingyi Wu
- Department of Critical Care Medicine, Research Center for Functional Maintenance and Reconstruction of Viscera, Wannan Medical College First Affiliated Hospital, Yijishan Hospital, Wuhu, China
| | - Xiaogan Jiang
- Department of Critical Care Medicine, Research Center for Functional Maintenance and Reconstruction of Viscera, Wannan Medical College First Affiliated Hospital, Yijishan Hospital, Wuhu, China
| | - Tao Yu
- Department of Critical Care Medicine, Research Center for Functional Maintenance and Reconstruction of Viscera, Wannan Medical College First Affiliated Hospital, Yijishan Hospital, Wuhu, China.
| | - Weihua Lu
- Department of Critical Care Medicine, Research Center for Functional Maintenance and Reconstruction of Viscera, Wannan Medical College First Affiliated Hospital, Yijishan Hospital, Wuhu, China
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Cohen O, Shnipper R, Yosef L, Stavi D, Shapira-Galitz Y, Hain M, Lahav Y, Shoffel-Havakuk H, Halperin D, Adi N. Bedside percutaneous dilatational tracheostomy in patients outside the ICU: a single-center experience. J Crit Care 2018; 47:127-132. [PMID: 29957510 DOI: 10.1016/j.jcrc.2018.06.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 06/19/2018] [Accepted: 06/20/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE To assess the safety of medical-ward bedside percutaneous dilatational tracheostomy (GWB-PDT). MATERIALS AND METHODS A retrospective study of all patients who underwent elective GWB-PDT between 2009 and 2015. A joint otolaryngology-ICU team performed all GWB-PDTs. The patients were followed until decannulation, discharge or death. Complications were divided into early (within 24 h) and late, and into minor and major. RESULTS Two hundred and fifty six patients were included in the study. The mean age was 77.7 ± 11.8 Medical history included cardiac comorbidities (42.6%) and cerebrovascular accidents (34.4%). Overall, 48 patients (18.9%) had 60 complications, of which 70% (42/60) were minor (13 early; 29 late complications). Fifteen patients (5.9%) had major complications. Eight patients had early major complications (loss of airway - two patients [0.8%], pneumothorax - two patients [0.8%], resuscitation - one patient [0.4%], and a single patient (0.4%) died within 24 h following PDT). Two additional patients (0.8%) underwent conversion to an open tracheostomy. Seven patients had late complications (airway complications in six patients [2.3%] and major bleeding in a single patient [0.4%]). Of the seven patients with late major complications, three had two major complications. Half of the complications occurred by POD 3. CONCLUSION GWB-PDT is a feasible and safe solution for tracheostomies in general-ward ventilated patients.
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Affiliation(s)
- Oded Cohen
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel; Hebrew University- Hadassah Medical School, Jerusalem, Israel.
| | - Ruth Shnipper
- Hebrew University- Hadassah Medical School, Jerusalem, Israel
| | - Liron Yosef
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel; Hebrew University- Hadassah Medical School, Jerusalem, Israel
| | - Dekel Stavi
- Intensive Care Unit, Kaplan Medical Center, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yael Shapira-Galitz
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel; Hebrew University- Hadassah Medical School, Jerusalem, Israel
| | - Moshe Hain
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yonatan Lahav
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel; Hebrew University- Hadassah Medical School, Jerusalem, Israel
| | - Hagit Shoffel-Havakuk
- Department of Otolaryngology, Head and Neck Surgery, Rabin Medical Center, Petach-Tikva, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Doron Halperin
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel; Hebrew University- Hadassah Medical School, Jerusalem, Israel
| | - Nimrod Adi
- Intensive Care Unit, Kaplan Medical Center, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Baek JK, Lee JS, Kang M, Choi NJ, Hong SK. Feasibility of Percutaneous Dilatational Tracheostomy with a Light Source in the Surgical Intensive Care Unit. Acute Crit Care 2018; 33:89-94. [PMID: 31723868 PMCID: PMC6849057 DOI: 10.4266/acc.2017.00563] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 02/07/2018] [Accepted: 02/19/2018] [Indexed: 11/30/2022] Open
Abstract
Background Although percutaneous dilatational tracheostomy (PDT) under bronchoscopic guidance is feasible in the intensive care unit (ICU), it requires extensive equipment and specialists. The present study evaluated the feasibility of performing PDT with a light source in the surgical ICU. Methods The study involved a retrospective review of the outcomes of patients who underwent PDT with a light source performed by a surgery resident under the supervision of a surgical intensivist in the surgical ICU from October 2015 through September 2016. During the procedure, a light wand was inserted into the endotracheal tube after skin incision. Then, the light wand and the endotracheal tube were pulled out slightly, the passage of light through the airway was confirmed, and the relevant point was punctured. Results Fifty patients underwent PDT with a light source. The average procedural duration was 14.0 ± 7.0 minutes. There were no procedure-associated deaths. Intraoperative complications included minor bleeding in three patients (6%) and paratracheal placement of the tracheostomy tube in one patient (2%); these were immediately resolved by the surgical intensivist. Two patients required conversion to surgical tracheostomy because of the difficulty in light wand insertion into the endotracheal tube and a very narrow trachea, respectively. Conclusions PDT with a light source can be performed without bronchoscopy and does not require expensive equipment and specialist intervention in the surgical ICU. It can be safely performed by a surgical intensivist with experience in surgical tracheostomy.
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Affiliation(s)
- Jong-Kwan Baek
- Division of Acute Care Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung-Sun Lee
- Division of Acute Care Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Minchang Kang
- Division of Acute Care Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Nak-Jun Choi
- Division of Acute Care Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Suk-Kyung Hong
- Division of Acute Care Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Gobatto ALN, Besen BAMP, Cestari M, Pelosi P, Malbouisson LMS. Ultrasound-Guided Percutaneous Dilational Tracheostomy: A Systematic Review of Randomized Controlled Trials and Meta-Analysis. J Intensive Care Med 2018; 35:445-452. [PMID: 29409380 DOI: 10.1177/0885066618755334] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Percutaneous dilational tracheostomy (PDT) is a common and increasingly used procedure in the intensive care unit (ICU). It is usually performed with bronchoscopy guidance. Ultrasound has emerged as a useful tool in order to assist PDT, potentially improving its success rate and reducing procedural-related complications. OBJECTIVE To investigate whether the ultrasound-guided PDT is equivalent or superior to the bronchoscopy-guided or anatomical landmarks-guided PDT with regard to procedural-related and clinical complications. METHODS A systematic review of randomized clinical trials was conducted comparing an ultrasound-guided PDT to the control groups (either a bronchoscopy-guided PDT or an anatomical landmark-guided PDT) in patients undergoing a PDT in the ICU. The primary outcome was the incidence of major procedural-related and clinical complication rates. The secondary outcome was the incidence of minor complication rates. Random-effect meta-analyzes were used to pool the results. RESULTS Four studies fulfilled the inclusion criteria and they were analyzed. The studies included 588 participants. There were no differences in the major complication rates between the patients who were assigned to the ultrasound-guided PDT when compared to the control groups (pooled risk ratio [RR]: 0.48; 95% confidence interval [CI]: 0.13-1.71, I2 = 0%). The minor complication rates were not different between the groups, but they had a high heterogeneity (pooled RR: 0.49; 95% CI 0.16-1.50; I2 = 85%). The sensitivity analyzes that only included the randomized controlled trials that used a landmark-guided PDT as the control group showed lower rates of minor complications in the ultrasound-guided PDT group (pooled RR: 0.55; 95% CI: 0.31-0.98, I2 = 0%). CONCLUSION The ultrasound-guided PDT seems to be safe and it is comparable to the bronchoscopy-guided PDT regarding the major and minor procedural-related or clinical complications. It also seems to reduce the minor complications when compared to the anatomical landmark-guided PDT.
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Affiliation(s)
- André L N Gobatto
- Department of Anesthesiology, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
- Internal Medicine, Hospital São Rafael, Salvador, Brazil
- Intensive Care Unit, Hospital da Cidade, Salvador, Brazil
- Department of Internal Medicine, Salvador University, Salvador, Brazil
| | - Bruno A M P Besen
- Medical Intensive Care Unit, Emergency Department, Hospital das Clínicas - University of Sao Paulo Medical School, São Paulo, Brazil
- Intensive Care Unit, Hospital da Luz - Vila Mariana, São Paulo, Brazil
| | - Mino Cestari
- Intensive Care Unit, Hospital AC Camargo - Cancer Center, São Paulo, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, IRCCS AOU San Martino IST, University of Genoa, Genoa, Italy
| | - Luiz M S Malbouisson
- Department of Anesthesiology, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
- Trauma Intensive Care Unit, Surgery Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
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Grensemann J, Eichler L, Kähler S, Jarczak D, Simon M, Pinnschmidt HO, Kluge S. Bronchoscopy versus an endotracheal tube mounted camera for the peri-interventional visualization of percutaneous dilatational tracheostomy - a prospective, randomized trial (VivaPDT). CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:330. [PMID: 29284503 PMCID: PMC5747130 DOI: 10.1186/s13054-017-1901-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 11/29/2017] [Indexed: 11/16/2022]
Abstract
Background Percutaneous dilatational tracheostomy (PDT) in critically ill patients often involves bronchoscopic optical guidance. However, this procedure is not without disadvantages. Therefore, we aimed to study a recently introduced endotracheal tube-mounted camera (VivaSightTM-SL tube [VST]; ETView, Misgav, Israel) for guiding PDT. Methods This was a randomized controlled trial involving 46 critically ill patients who received PDT using optical guidance with a VST or with bronchoscopy. The primary outcome measure was visualization of the tracheal structures (i.e., identification and monitoring of the thyroid, cricoid, and tracheal cartilage and the posterior wall) rated on 4-point Likert scales. Secondary measures were the quality of ventilation (before puncture and during the tracheostomy procedure rated on 4-point Likert scales) and blood gases sampled at standardized time points. Results The mean ratings for visualization (lower values better; values given for per-protocol analysis) were 5.4 (95% CI 4.5–6.3) for the VST group and 4.0 (95% CI 4.0–4.0) for the bronchoscopy group (p < 0.001). Mean ventilation ratings were 2.5 (95% CI 2.1–2.9) for VST and 5.0 (95% CI 4.4–5.7) for bronchoscopy (p < 0.001). Arterial carbon dioxide increased to 5.9 (95% CI 5.4–6.5) kPa in the VST group vs. 8.3 (95% CI 7.2–9.5) kPa in the bronchoscopy group (p < 0.001), and pH decreased to 7.40 (95% CI 7.36–7.43) in the VST group vs. 7.26 (95% CI 7.22–7.30) in the bronchoscopy group (p < 0.001), at the end of the intervention. Conclusions Visualization of PDT with the VST is not noninferior to guidance by bronchoscopy. Ventilation is superior with less hypercarbia with the VST. Because visualization is not a prerequisite for PDT, patients requiring stable ventilation with normocarbia may benefit from PDT with the VST. Trial registration ClinicalTrials.gov, NCT02861001. Registered on 13 June 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1901-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jörn Grensemann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Lars Eichler
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Sophie Kähler
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Dominik Jarczak
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Marcel Simon
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Hans O Pinnschmidt
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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Grensemann J, Eichler L, Hopf S, Jarczak D, Simon M, Kluge S. Feasibility of an endotracheal tube-mounted camera for percutaneous dilatational tracheostomy. Acta Anaesthesiol Scand 2017; 61:660-667. [PMID: 28493334 DOI: 10.1111/aas.12904] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 03/08/2017] [Accepted: 04/13/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Percutaneous dilatational tracheostomy (PDT) in critically ill patients is often led by optical guidance with a bronchoscope. This is not without its disadvantages. Therefore, we aimed to study the feasibility of a recently introduced endotracheal tube-mounted camera (VivaSight™-SL, ET View, Misgav, Israel) in the guidance of PDT. METHODS We studied 10 critically ill patients who received PDT with a VivaSight-SL tube that was inserted prior to tracheostomy for optical guidance. Visualization of the tracheal structures (i.e., identification and monitoring of the thyroid, cricoid, and tracheal cartilage and the posterior wall) and the quality of ventilation (before puncture and during the tracheostomy) were rated on four-point Likert scales. Respiratory variables were recorded, and blood gases were sampled before the interventions, before the puncture and before the insertion of the tracheal cannula. RESULTS Visualization of the tracheal landmarks was rated as 'very good' or 'good' in all but one case. Monitoring during the puncture and dilatation was also rated as 'very good' or 'good' in all but one. In the cases that were rated 'difficult', the visualization and monitoring of the posterior wall of the trachea were the main concerns. No changes in the respiratory variables or blood gases occurred between the puncture and the insertion of the tracheal cannula. CONCLUSION Percutaneous dilatational tracheostomy with optical guidance from a tube-mounted camera is feasible. Further studies comparing the camera tube with bronchoscopy as the standard approach should be performed.
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Affiliation(s)
- J. Grensemann
- Department of Intensive Care Medicine; University Medical Center Hamburg-Eppendorf; Hamburg Germany
| | - L. Eichler
- Department of Intensive Care Medicine; University Medical Center Hamburg-Eppendorf; Hamburg Germany
| | - S. Hopf
- Department of Intensive Care Medicine; University Medical Center Hamburg-Eppendorf; Hamburg Germany
| | - D. Jarczak
- Department of Intensive Care Medicine; University Medical Center Hamburg-Eppendorf; Hamburg Germany
| | - M. Simon
- Department of Respiratory Medicine; University Medical Center Hamburg-Eppendorf; Hamburg Germany
| | - S. Kluge
- Department of Intensive Care Medicine; University Medical Center Hamburg-Eppendorf; Hamburg Germany
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Klemm E, Karl Nowak A. Tracheotomy-Related Deaths. DEUTSCHES ARZTEBLATT INTERNATIONAL 2017; 114:273-279. [PMID: 28502311 PMCID: PMC5437259 DOI: 10.3238/arztebl.2017.0273] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 09/02/2016] [Accepted: 02/09/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Tracheotomies are frequently performed on ventilated patients in intensive care and sometimes lead to fatal complications. In this article, we discuss the causes and frequency of death associated with open surgical tracheotomy (OST) and percutaneous dilatational tracheotomy (PDT) on the basis of a review of the pertinent literature. METHODS We systematically searched the PubMed, EMBASE, and Cochrane Library databases and the Karlsruhe Virtual Catalog for publications (1990-2015) on tracheotomy-related deaths in adults, using the search terms "tracheotomy" and "tracheostomy." 39 relevant dissertations were included in the analysis as well. RESULTS 109 publications were included. Of the 25 056 tracheotomies described, there were 16 827 PDTs and 7934 OSTs; for 295 tracheotomies, the technique used was not stated. 352 deaths were reported, including 113 in patients treated with PDT, 49 in those treated with OST, and 190 deaths related to a tracheotomy without specification of the method used. The frequency of death among patients with OST and those treated with PDT was similar: 0.62% for OST (95% confidence interval [0.47; 0.82]) and 0.67% for PDT ([0.56; 0.81]). The most common causes of death and their frequencies, as a percentage of all tracheotomies, were hemorrhage (OST: 0.26% [0.17; 0.40], PDT: 0.26% [0.19; 0.35]), loss of airway (OST: 0.21% [0.13; 0.34], PDT: 0.20% [0.14; 0.28]), and false passage (OST: 0.11% [0.06; 0.22], PDT: 0.20% [KI 0.15; 0.29]). CONCLUSION Bias in the data cannot be excluded, as these were not epidemiologic data and the documentation was found to be incomplete. The likelihood of a fatal complication seems to be the same with both tracheotomy techniques as far as can be determined from the available evidence. Tracheotomy-related deaths can be avoided in several ways: by thorough training under the leadership of experienced physicians, by the use of the World Health Organization's Surgical Safety Checklist regardless of where the tracheotomy is performed, and by the continuous vigilance of nursing staff.
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Affiliation(s)
- Eckart Klemm
- Department of Otorhinolaryngology, Head and Neck Surgery, Plastic Surgery, Muncipial Hospital Dresden, Academic Teaching Hospital of the Technical University of Dresden
| | - Andreas Karl Nowak
- Department of Anesthesiology and Intensive Care Medicine, Emergency Medicine and Pain Therapy, Muncipial Hospital Dresden, Academic Teaching Hospital of the Technical University of Dresden
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23
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Sarıtaş A, Kurnaz MM. Comparison of Bronchoscopy-Guided and Real-Time Ultrasound-Guided Percutaneous Dilatational Tracheostomy: Safety, Complications, and Effectiveness in Critically Ill Patients. J Intensive Care Med 2017; 34:191-196. [PMID: 28446075 DOI: 10.1177/0885066617705641] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To compare the efficacy, safety, and incidence of complications between fiber-optic bronchoscopy-guided percutaneous dilatational tracheostomy (FOB-PDT) and ultrasound-guided percutaneous dilatational tracheostomy (US-PDT) and to determine whether US-PDT is a viable alternative to FOB-PDT. METHODS This randomized prospective study was carried out in 80 patients who were randomly divided into US-PDT and FOB-PDT groups. Demographic data and Acute Physiology and Chronic Health Evaluation II (APACHE II), procedure duration, hemorrhage status, complications, procedure difficulty, displacement of entry location after US, and hemodynamic data were evaluated in both groups. Tracheal incision was performed with real-time US and a transverse probe position in the out-of-plane mode. RESULTS No significant differences were observed between the 2 groups in terms of demographic data, oral intubation time, APACHE II values, difficulty of the procedure, or the number of needle interventions ( P > .05). The mean hemorrhage ratio of the FOB-PDT group was significantly higher than that of the US-PDT group ( P < .05). The entry location was changed in 6 patients in the US-PDT group following neck examination with US. The mean duration of the procedure for the FOB-PDT group was significantly longer than that for the US-PDT group ( P < .05). CONCLUSION Ultrasound-guided percutaneous dilatational tracheostomy is a safe procedure for critically ill patients and has the advantages of a low complication rate, short duration of procedure, being informative with regard to neck anatomy, and facilitating prevention of vascular puncture. Thus, US-PDT can be used as an alternative to FOB-PDT.
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Affiliation(s)
- Aykut Sarıtaş
- 1 Department of Anesthesiology and Reanimation İzmir, Tepecik Training and Research Hospital, Konak, İzmir, Republic of Turkey
| | - Muhammed M Kurnaz
- 2 Department of Anesthesiology, Prof. Dr A.İlhan Özdemir State Hospital, Anesthesiology and Reanimation, Giresun, Republic of Turkey
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Ullman J, Karling J, Margolin G. A new safe and cost-effective percutaneous dilatational tracheotomy: SafeTrach. Acta Otolaryngol 2016; 136:598-605. [PMID: 26902954 DOI: 10.3109/00016489.2016.1139746] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
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).
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Affiliation(s)
- Johan Ullman
- Department of Anesthesiology and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Jonas Karling
- ENT Department, Karolinska University Hospital, Stockholm, Sweden
| | - Gregori Margolin
- Department of Otolaryngology and Head & Neck Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology, Karolinska University Hospital, Stockholm, Sweden
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25
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Ultrasound-guided percutaneous dilational tracheostomy versus bronchoscopy-guided percutaneous dilational tracheostomy in critically ill patients (TRACHUS): a randomized noninferiority controlled trial. Intensive Care Med 2016; 42:342-351. [DOI: 10.1007/s00134-016-4218-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 01/09/2016] [Indexed: 10/22/2022]
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26
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Dizdarevic A, Pagano P, Desai S. Anesthetic Implications for Tracheal Injury During Bronchoscopy-Guided Percutaneous Dilational Tracheostomy. ACTA ACUST UNITED AC 2016; 6:90-4. [PMID: 26859284 DOI: 10.1213/xaa.0000000000000291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Bronchoscopic-guided percutaneous dilational tracheostomy has become one of the most common elective tracheostomy methods for patients requiring prolonged ventilatory support. The safety profile, patient selection, and risks as well as complication management, when compared with an open surgical technique, remain somewhat controversial with no clear recommendations. We present a case of a critically ill patient undergoing percutaneous dilation tracheostomy complicated by tracheal wall injury and airway loss. The airway was successfully conservatively managed as well as the tracheal injury. Anesthetic implications, safety, and management options as well as recommendations are reviewed.
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Affiliation(s)
- Anis Dizdarevic
- From the Department of Anesthesiology and Pain Management, Columbia University Medical Center, New York, New York
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Stahl DL, Richard KM, Papadimos TJ. Complications of bronchoscopy: A concise synopsis. Int J Crit Illn Inj Sci 2015; 5:189-95. [PMID: 26557489 PMCID: PMC4613418 DOI: 10.4103/2229-5151.164995] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Flexible and rigid bronchoscopes are used in diagnosis, therapeutics, and palliation. While their use is widespread, effective, and generally safe; there are numerous potential complications that can occur. Mechanical complications of bronchoscopy are primarily related to airway manipulations or bleeding. Systemic complications arise from the procedure itself, medication administration (primarily sedation), or patient comorbidities. Attributable mortality rates remain low at < 0.1% for fiberoptic and rigid bronchoscopy. Here we review the complications (classified as mechanical or systemic) of both rigid and flexible bronchoscopy in hope of making practitioners who are operators of these tools, and those who consult others for interventions, aware of potential problems, and pitfalls in order to enhance patient safety and comfort.
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Affiliation(s)
- David L Stahl
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Kathleen M Richard
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Thomas J Papadimos
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, Ohio, USA
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28
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Gobatto ALN, Besen BAMP, Tierno PFGMM, Mendes PV, Cadamuro F, Joelsons D, Melro L, Park M, Malbouisson LMS. Comparison between ultrasound- and bronchoscopy-guided percutaneous dilational tracheostomy in critically ill patients: a retrospective cohort study. J Crit Care 2014; 30:220.e13-7. [PMID: 25306240 DOI: 10.1016/j.jcrc.2014.09.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 09/13/2014] [Accepted: 09/14/2014] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Percutaneous dilational tracheostomy (PDT) is routinely performed in the intensive care unit with bronchoscopic guidance. Recently, ultrasound (US) has emerged as a new safety adjunct tool to increase the efficacy of PDT. However, the available data are limited to case series without any control group. Hence, a retrospective cohort study was designed to evaluate the efficacy of US-guided PDT compared with bronchoscopy-guided PDT. METHODS All patients who were submitted to PDT after the standardization of US-guided PDT technique in our institution were analyzed. Demographic and procedure-related variables, complications, and clinical outcomes were collected and compared in patients undergoing US- or bronchoscopy-guided PDT. RESULTS Sixty patients who had been submitted to PDT were studied, including 11 under bronchoscopy guidance and 49 under US guidance. No surgical conversion was necessary in any of the procedures, and bronchoscopy assistance was only required in 1 case in the US group. The procedure length was shorter in the US group than in the bronchoscopy group (12 vs 15 minutes, P = .028). None of the patients had any major complications. The minor complication rates were not significantly different between the groups, nor was the probability of breathing without assistance within 28 days, intensive care unit length of stay, or hospital mortality. CONCLUSION Ultrasound-guided PDT is effective, safe, and associated with similar complication rates and clinical outcomes compared with bronchoscopy-guided PDT.
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Affiliation(s)
- André Luiz Nunes Gobatto
- Medical Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil; Surgical Intensive Care Unit, Anesthesiology Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil.
| | | | | | - Pedro Vitale Mendes
- Medical Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Filipe Cadamuro
- Trauma Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Daniel Joelsons
- Intensive Care Unit, Infectious Disease Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Livia Melro
- Medical Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Marcelo Park
- Medical Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Luiz Marcelo Sá Malbouisson
- Trauma Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil; Surgical Intensive Care Unit, Anesthesiology Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
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Álvarez-Maldonado P, Núñez-Pérez Redondo C, Casillas-Enríquez JD, Navarro-Reynoso F, Cicero-Sabido R. Indications and Efficacy of Fiberoptic Bronchoscopy in the ICU: Have They Changed Since Its Introduction in Clinical Practice? ACTA ACUST UNITED AC 2013. [DOI: 10.5402/2013/217505] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Purpose. We describe characteristics, utility, and safety of fiberoptic bronchoscopy (FOB) in an intensive care unit (ICU). Methods. Prospective and descriptive cohort of patients admitted to a respiratory ICU from March 2010 to June 2012. Results. A total of 102 FOBs were performed in 84 patients among 580 patients that were admitted to the ICU. Mean age was 48±17 years. FOB was useful in 65% of diagnostic procedures and 83% of therapeutic procedures, with an overall utility of 75%. Indications and utility according to indication were pneumonia in 31 cases, utility of 52%; percutaneous tracheostomy guidance in 26 cases, utility of 100%; atelectasis in 25 cases, utility of 76%; airway exploration in 16 cases, utility of 75%; hemoptysis in two cases, utility of 100%; and difficult airway intubation in two cases, utility of 100%. A decrease in oxygen saturation (SpO2) of >5% during FOB was present in 65% of cases, and other minor complications were present in 3.9% of cases. Conclusions. Reasons for performing FOB in the ICU have remained relatively stable over time with the exception of the addition of percutaneous tracheostomy guidance. Our series documents current indications and also the utility and safety of this procedure.
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Affiliation(s)
- Pablo Álvarez-Maldonado
- Servicio de Neumología y Cirugía de Tórax, Hospital General de México O.D. “Dr. Eduardo Liceaga”, HGM, Balmis 148, 06726 México, DF, Mexico
| | - Carlos Núñez-Pérez Redondo
- Servicio de Neumología y Cirugía de Tórax, Hospital General de México O.D. “Dr. Eduardo Liceaga”, HGM, Balmis 148, 06726 México, DF, Mexico
| | - José D. Casillas-Enríquez
- Servicio de Neumología y Cirugía de Tórax, Hospital General de México O.D. “Dr. Eduardo Liceaga”, HGM, Balmis 148, 06726 México, DF, Mexico
| | - Francisco Navarro-Reynoso
- Servicio de Neumología y Cirugía de Tórax, Hospital General de México O.D. “Dr. Eduardo Liceaga”, HGM, Balmis 148, 06726 México, DF, Mexico
| | - Raúl Cicero-Sabido
- Servicio de Neumología y Cirugía de Tórax, Hospital General de México O.D. “Dr. Eduardo Liceaga”, HGM, Balmis 148, 06726 México, DF, Mexico
- Facultad de Medicina, UNAM, México, DF, Mexico
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Abstract
BACKGROUND Percutaneous tracheostomy is a routine procedure in the intensive care unit (ICU). Some surgeons perform percutaneous tracheostomies using bronchoscopy believing that it increases safety. The purpose of this study was to evaluate percutaneous tracheostomy in the trauma population and to determine whether the use of a bronchoscope decreases the complication rate and improves safety. METHODS A retrospective review was completed from January 2007 to November 2010. Inclusion criteria were trauma patients undergoing percutaneous tracheostomy. Data collected included age, Abbreviated Injury Score by region, Injury Severity Score, ventilator days, and outcomes. Complications were classified as early (occurring within <24 hours) or late (>24 hours after the procedure). RESULTS During the study period, 9,663 trauma patients were admitted, with 1,587 undergoing intubation and admission to the ICU. Tracheostomies were performed in 266 patients and 243 of these were percutaneous; 78 (32%) were performed with the bronchoscope (Bronch) and 168 (68%) without bronchoscope (No Bronch). There were no differences between the groups in Abbreviated Injury Score by region, Injury Severity Score, probability of survival, ventilator days, and length of ICU or overall hospital stay. There were 16 complications, 5 (Bronch) and 11 (No Bronch). Early complications were primarily bleeding (Bronch 3% vs. No Bronch 4%, not statistically significant). Late complications included tracheomalacia, tracheal granulation tissue, bleeding, and stenosis; Bronch 4% versus No Bronch 3%, (not statistically significant). One major complication occurred, with loss of airway and cardiac arrest, in the bronchoscopy group. CONCLUSION Percutaneous tracheostomy was safely and effectively performed by an experienced surgical team both with and without bronchoscopic guidance with no difference in the complication rates. This study suggests that the use of bronchoscopic guidance during tracheostomy is not routinely required but may be used as an important adjunct in selected patients, such as those with HALO cervical fixation, obesity, or difficult anatomy.
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Rezende-Neto JB, Oliveira AJ, Neto MP, Botoni FA, Rizoli SB. A technical modification for percutaneous tracheostomy: prospective case series study on one hundred patients. World J Emerg Surg 2011; 6:35. [PMID: 22047013 PMCID: PMC3216842 DOI: 10.1186/1749-7922-6-35] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Accepted: 11/02/2011] [Indexed: 12/03/2022] Open
Abstract
The purpose of this study is to describe a technical modification of percutaneous tracheostomy that combines principles of the Percu Twist™ and the Griggs-Portex® methods in a reusable kit. One hundred patients underwent the procedure. There were no false passage, tube misplacement, or deaths related to the procedure. There were two minor bleedings managed conservatively. The technical modification described in this study is safe and simple to execute.
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Affiliation(s)
- Joao B Rezende-Neto
- Universidade Federal de Minas Gerais and Risoleta Tolentino Neves Hospital, Brazil
| | | | | | - Fernando A Botoni
- Universidade Federal de Minas Gerais and Risoleta Tolentino Neves Hospital, Brazil
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32
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Abstract
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.
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Straetmans J, Schlöndorff G, Herzhoff G, Windfuhr JP, Kremer B. Complications of midline-open tracheotomy in adults. Laryngoscope 2010; 120:84-92. [PMID: 19795468 DOI: 10.1002/lary.20703] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS Percutaneous tracheotomy is progressively replacing open tracheotomy as a consequence of promising results of comparative studies. However, this comparison has four considerable weaknesses: 1) selected indications (high-risk patients excluded for percutaneous tracheotomy); 2) varying spectra of complications included in different studies; 3) varying operative settings (experienced surgeons exclusively, surgeons in training, or both); and 4) missing differentiation between different surgical techniques. Our study was performed to collect complete datasets of unselected patients who all underwent a tracheotomy in a uniform technique in an academic teaching hospital setting. METHODS Retrospective evaluation of all complications following 303 consecutive surgical tracheotomies (midline-open technique) performed by different surgeons and surgeons in training at one academic institution. Complications were classified and compared to results in the literature. RESULTS Rates of 21.5% minor and 1.0% major complications and 0% tracheotomy-related mortality were registered. The most prevalent complications were local wound infections (10.9%), intra- and postoperative hemorrhages (4.2%), and cartilage damage (1.7%). No significant difference was found for high-risk patients and emergency tracheotomies. CONCLUSIONS Our study demonstrates that open tracheotomy is a safe procedure, particularly if performed in high-risk patients even by inexperienced surgeons. Therefore, we emphasize the advantages of the midline-open tracheotomy in an academic teaching hospital setting.
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Affiliation(s)
- Jos Straetmans
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Maastricht, Maastricht, The Netherlands.
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Divisi D, Altamura G, Di Tommaso S, Di Leonardo G, Rosa E, De Sanctis C, Crisci R. Fantoni translaryngeal tracheostomy versus ciaglia blue rhino percutaneous tracheostomy: A retrospective comparison. Surg Today 2009; 39:387-92. [DOI: 10.1007/s00595-008-3899-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2007] [Accepted: 07/28/2008] [Indexed: 11/24/2022]
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35
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Sarkar SN, Kelly A, Townsend R. Survey of Percutaneous Tracheostomy Practice in UK Intensive Care Units. J Intensive Care Soc 2009. [DOI: 10.1177/175114370901000219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
In order to assess current practice of percutaneous tracheostomy (PT) in UK intensive care units (ICUs), we created a web-based survey by e-mail invitation to the clinical directors of 184 ICUs taking part in the ICNARC case-mix programme. The response rate was 46% (n=85). Most units performed 100 or fewer PTs each year. Just over half, 55.3%, had access to resident on-site surgical backup with ENT being the most common specialty providing this. Nearly one third, 30.6%, performed PTs out of routine hours; 30.6% used ultrasound to visualise potential problematic vessels. Bronchoscopy was used by 81.7% of units for all PTs performed, and conical dilation was the most popular technique. Fifteen units, 8.2%, did not routinely perform chest X-ray after PT insertion, but 49.4% of respondents did not feel that chest X-ray was mandatory after routine uncomplicated PT insertion. Despite certain trends in practice, there is still disparity in the practice of PT among ICUs in the UK. Ultrasound examination for problematic blood vessels prior to PT should be considered, bronchoscopy should be readily available and the use of routine chest X-ray after uncomplicated PT insertion should be questioned.
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Affiliation(s)
- Som Nath Sarkar
- Advanced Trainee in Intensive Care Medicine. University Hospitals Birmingham NHS Foundation Trust
| | - Andrew Kelly
- Specialist Registrar in Anaesthesia, University Hospitals Coventry and Warwickshire NHS Trust
| | - Roger Townsend
- Consultant in Intensive Care Medicine and Anaesthesia, University Hospitals Coventry and Warwickshire NHS Trust
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Waller EA, Aduen JF, Kramer DJ, Alvarez F, Heckman MG, Crook JE, Pajaro OE, McBride LR, Keller CA. Safety of percutaneous dilatational tracheostomy with direct bronchoscopic guidance for solid organ allograft recipients. Mayo Clin Proc 2007; 82:1502-8. [PMID: 18053458 DOI: 10.1016/s0025-6196(11)61094-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To determine the safety of percutaneous dilatational tracheostomy (PDT) for solid organ allograft recipients, who have increased risks of bleeding and infection. PARTICIPANTS AND METHODS We reviewed the records of patients who underwent solid organ transplant between January 1, 2001, and September 30, 2005, followed by PDT (using the Ciaglia technique) with direct bronchoscopic guidance. We recorded comorbid conditions, number of days from intubation and transplant, positive end-expiratory pressures, ratios of PaO2 to fraction of inspired oxygen, coagulation study findings, complications, and procedure-related mortality rates. RESULTS Of the 51 patients in our study, 17 had undergone lung transplant; 32, liver transplant; and 2, kidney transplant. The median age was 55 years (range, 27-73), and 53% of patients were men. The median time from intubation to PDT was 10 days and from transplant to PDT, 22 days. The median ratio of PaO2 to fraction of inspired oxygen was 293, and the median positive end-expiratory pressure was 5 cm H2O. Twenty-one patients were receiving dialysis, and 11 were recovering from sepsis (of these, 8 were receiving vasopressors). Ten had coagulopathies (none of which were associated with bleeding complications). Complications were infrequent (7 periprocedural, 4 postprocedural) and included bleeding, bradycardia, hypotension, tracheal ring fracture, and cannula malfunction. Of the bleeding complications, only 2 were clinically remarkable and required removal of the tracheostomy or surgical revision. No infectious complications or procedure-related deaths were noted. CONCLUSION Percutaneous dilatational tracheostomy was tolerated well in recipients of solid organ allografts and had a relatively low risk of major complications and a low procedure-related mortality rate. This method should be considered an acceptable alternative to surgical tracheostomy.
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Affiliation(s)
- E Andrew Waller
- Division of Pulmonary Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
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Sheu CC, Tsai JR, Hung JY, Cheng MH, Chong IW, Hwang JJ, Huang MS. A simple modification of Ciaglia Blue Rhino technique for tracheostomy: using a guidewire dilating forceps for initial dilation. Eur J Cardiothorac Surg 2006; 31:114-9. [PMID: 17067807 DOI: 10.1016/j.ejcts.2006.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2006] [Revised: 10/01/2006] [Accepted: 10/09/2006] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE The potential difficulty in doing initial dilation in the percutaneous dilational tracheostomy (PDT) with the Ciaglia Blue Rhino (CBR) technique has been reported by others and encountered in our clinical practice. To resolve this problem, we developed a modified CBR technique by using a guidewire dilating forceps (GWDF) to facilitate initial dilation. The present before-and-after comparison study aimed to evaluate the clinical benefits of this modified CBR technique. METHODS Consecutive 120 patients undergoing CBR technique in the pre-conversion year and 114 patients undergoing GWDF-CBR technique in the post-conversion year were enrolled for analysis. The procedure time and procedure-related complications were compared between these two groups. RESULTS The mean procedure time with GWDF-CBR technique was 4.5+/-1.6min, significantly shorter than 5.7+/-3.0min with CBR technique (p<0.001). Only two patients in the GWDF-CBR group required prolonged procedure time (>8min), compared with 14 patients in the CBR group. Thirty three (27.5%) of 120 patients undergoing CBR technique and 15 (13.1%) of 114 patients undergoing GWDF-CBR technique had PDT-related complications (p=0.006). Most of the complications were minor and transient. Only 13 patients in the CBR group and 3 patients in the GWDF-CBR group encountered major complications (10.8% vs 2.6%, p=0.012). Regarding the high-risk patients, 21 (36.2%) of 58 patients in the CBR group and 9 (15.8%) of 57 patients in the GWDF-CBR group had PDT-related complications (p=0.011). CONCLUSIONS Pre-dilation with a GWDF in the CBR technique helped to prevent prolonged procedure time and procedure-related complications. We suggest that the bronchoscopy-guided GWDF-CBR serves an easy-to-operate and relatively safe PDT technique for critically ill patients.
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Affiliation(s)
- Chau-Chyun Sheu
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan.
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Buehner U, Oram J, Elliot S, Mallick A, Bodenham A. Bonfils semirigid endoscope for guidance during percutaneous tracheostomy. Anaesthesia 2006; 61:665-70. [PMID: 16792612 DOI: 10.1111/j.1365-2044.2006.04651.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We report on the use of the Bonfils semirigid scope for endoscopic guidance during percutaneous dilational tracheostomy. Forty patients requiring percutaneous dilational tracheostomy on the General or Neurosurgical Intensive Care Unit were enrolled in this study. We used the '45 degree curved distal tip' scope in the first 15 patients, evaluating its ease of use, optical quality of focus and image resolution as well as light intensity on a 10-point scale. We evaluated straight and curved versions of it in another 15 and 10 patients, respectively. We examined the impact on ventilation and cardiovascular parameters. In all patients (n = 40) visualisation of the procedure was satisfactory. There were no clinically significant changes in ventilatory or cardiovascular parameters. The image quality for most patients received a score of 7-10. The Bonfils scope provides a practical alternative to flexible bronchoscopes in this setting.
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See JJ, Wong DT. Unilateral subcutaneous emphysema after percutaneous tracheostomy. Can J Anaesth 2006; 52:1099-102. [PMID: 16326683 DOI: 10.1007/bf03021612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE Percutaneous tracheostomy techniques are widely used in intensive care units. Subcutaneous emphysema is a rare but well recognized complication associated with this procedure. We report an unusual presentation of sc emphysema after percutaneous tracheostomy. The clinical features, diagnosis and postulated mechanism are discussed. CLINICAL FEATURES A 39-yr-old man had percutaneous tracheostomy done after prolonged intubation in the intensive care unit. Subcutaneous emphysema developed over the right neck fever mimicking deep sc infection resulted in neck exploration. No obvious lesion was found in the tracheobronchial tree. CONCLUSION Subcutaneous emphysema occurring after percutaneous tracheostomy could occur without significant injury to the tracheobronchial tree. We postulate that air leaking from the tracheostomy site might have been prevented by the snug fit between the tracheostomy tube and the skin, resulting in accumulation in the neck. Asymmetric dilatation of the trachea may explain the unilateral localization of the sc emphysema.
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Affiliation(s)
- Jee Jian See
- Department of Anesthesiology, Toronto Western Hospital, Ontario M5T 2S8, Canada
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Brander L, Takala J. Tracheal tear and tension pneumothorax complicating bronchoscopy-guided percutaneous tracheostomy. Heart Lung 2006; 35:144-5. [PMID: 16543045 DOI: 10.1016/j.hrtlng.2005.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2005] [Accepted: 09/26/2005] [Indexed: 11/16/2022]
Abstract
Percutaneous dilatational tracheostomy (PDT) is a frequently conducted procedure in critically ill patients. Bronchoscopic guidance of PDT is generally recommended to minimize the risk of unintentional tracheal injury. We present a case of tracheal tear and tension pneumothorax, a rare but potentially life-threatening complication, during continuously bronchoscopy-guided PDT. Sealing the large tracheal air fistula with the cuff of an endotracheal tube helped bridge time to definitive surgical repair in our patient. Bronchoscopic guidance may minimize, but cannot completely eliminate, the risk of tracheal injury during PDT.
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Affiliation(s)
- Lukas Brander
- Clinic of Intensive Care Medicine, University Hospital Bern, Inselspital, Switzerland
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Patel PB, Ferguson C, Patel A. A comparison of two single dilator percutaneous tracheostomy sets: the Blue Rhino and the Ultraperc. Anaesthesia 2006; 61:182-6. [PMID: 16430571 DOI: 10.1111/j.1365-2044.2005.04468.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The single tapered dilator kit is the most commonly used percutaneous tracheostomy set in the UK. The Cook Blue Rhino and the Portex Ultraperc were compared in the laboratory on mannequin and porcine airway models. The following data were collected: the subjective ease of dilating the trachea and inserting the tracheostomy tube; the time taken and the anterior-posterior compression during dilatation and tube insertion; the incidence and extent of posterior tracheal wall damage. During dilatation, the Blue Rhino caused less mean percentage anterior-posterior compression (34.8% vs. 51.5%, p = 0.0014). There was no difference in subjective ease or time for dilatation in either mannequin or porcine airway models. During insertion of the tracheostomy tube, the Ultraperc was subjectively easier in the porcine airway model (p = 0.001); had a shorter median insertion time in both the mannequin (3 s vs. 7.2 s, p = 0.0006) and the porcine airway model (4.3 s vs. 8.5 s, p = 0.0005); the mean percentage anterior-posterior compression caused was less in the mannequin (51.5% vs. 76%, p = 0.0008). The overall incidence of posterior wall damage was 65% with 25% having deep lacerations. There was no difference in the incidence of damage between the two sets. The Ultraperc therefore has advantages during tracheostomy tube insertion that are statistically and clinically significant. The advantages are probably due to the presence of the tracheostomy tube introducer.
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Affiliation(s)
- P B Patel
- Intensive Care Medicine, The Hammersmith Hospital, Du Cane Road, London, UK.
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Schlossmacher P, Martinet O, Testud R, Agesilas F, Benhamou L, Gauzëre BA. Emergency percutaneous tracheostomy in a severely burned patient with upper airway obstruction and circulatory arrest. Resuscitation 2006; 68:301-5. [PMID: 16325326 DOI: 10.1016/j.resuscitation.2005.06.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2005] [Revised: 06/15/2005] [Accepted: 06/30/2005] [Indexed: 11/17/2022]
Abstract
We report the life-saving use of Griggs percutaneous tracheostomy in an arrested patient with complex upper airway obstruction, as a result of burns, smoke injuries and iterative tracheal intubation attempts. The technique was performed blindly at bedside to treat an acute episode of failed ventilation and intubation and cardiac arrest in a patient with altered neck anatomy. The intervention salvaged the situation, leaving a definitive airway. The feasibility of using an emergency Griggs percutaneous tracheostomy versus cricothyroidotomy is suggested in selected cases.
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Affiliation(s)
- Pascal Schlossmacher
- Intensive Care Unit, Centre Hospitalier Départemental Félix Guyon, Allée des Topazes, 97400 Saint Denis, Reunion Island, France.
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Agrò F, Carassiti M, Magnani C, Alfery D. Airway control via the Cobrapla™ during percutaneous dilatational tracheotomy in five patients. Can J Anaesth 2005; 52:418-20. [PMID: 15814759 DOI: 10.1007/bf03016287] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To evaluate the use of the new supraglottic airway device CobraPLA (CPLA) for performing percutaneous dilatational tracheotomy (PDT) utilizing continuous fibreoptic visualization of the larynx and trachea and uninterrupted airway control. CLINICAL FEATURES The percutaneous tracheotomies were carried out in five patients (four males and one female; mean age 72 yr, mean height 164.6 cm, mean weight 74 kg) following the Griggs technique under continuous fibreoptic vision and airway control provided by the CPLA. The mean time required for removal of the ETT, positioning of the CPLA, and confirmation of adequate ventilation and cuff seal was 78 sec. The mean time for the entire PDT procedure was six minutes and 57 sec. In one patient a 7-mm tracheostomy cannula was used, and in the other four patients an 8-mm cannula was used. The hemodynamic and respiratory variables remained stable during the entire procedure; there were no adverse events. At no point was there any significant difficulty in placing the CPLA or in providing ventilation or oxygenation. Each procedure could be observed easily in its entirety through the FOB. CONCLUSIONS This technique can be considered simple and safe because it is video-assisted and ensures a continuous airway control. The CPLA offers several advantages over some other supraglottic devices when performing this surgical procedure.
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Affiliation(s)
- Felice Agrò
- Department of Anesthesia, University School of Medicine Campus Bio-Medico, Via E. Longoni 83 00155 Rome, Italy.
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Abstract
Percutaneous tracheostomy (PT) is an increasingly common procedure in the management of critically ill patients. Current practice for both open and percutaneous tracheostomies is a post-procedure chest X-ray to rule out potentially life-threatening complications such as a pneumothorax or tube malposition. Our study evaluated the utility of chest X-ray after PT. A retrospective chart review was conducted for patients undergoing PT at Kern Medical Center between January 1999 and December 2003. Charts were reviewed for age, sex, and clinical outcome as well as the radiologist's interpretation of the postprocedure chest X-ray. A total of 73 procedures were completed in 47 men and 26 women. The majority of the tracheostomies were in trauma patients who needed prolonged ventilatory support. There were no complications identified on postprocedure chest X-ray. A single patient was converted to an open procedure secondary to bleeding. We conclude that routine chest X-ray after PT is unnecessary.
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Oberwalder M, Weis H, Nehoda H, Kafka-Ritsch R, Bonatti H, Prommegger R, Aigner F, Profanter C. Videobronchoscopic guidance makes percutaneous dilational tracheostomy safer. Surg Endosc 2004; 18:839-42. [PMID: 15216870 DOI: 10.1007/s00464-003-9082-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Percutaneous dilational tracheostomy (PDT) can be performed under either conventional bronchoscopic or videobronchoscopic guidance. Only the latter procedure provides the surgeon with direct visual information. This study prospectively assessed procedural parameters and complications of PDT guided by conventional bronchoscopy (CB) or videobronchoscopy (VB). METHODS Consecutive intensive care unit (ICU) patients who underwent PDT were enrolled in this study. Videobronchoscopy was available in two ICUs, whereas CB was available in three ICUs. Demographic data, procedural variables, and complications were recorded. RESULTS In this study, 36 patients underwent PDT guided by VB (group V), and 38 patients underwent PDT guided by CB (group C). The two groups were well matched in terms of gender, anatomic aspects, and positioning of the patient. Operating time, procedural difficulty, and extent of tracheal bleeding were not different between the two groups. Group V showed a tendency to younger age (p = 0.055). Surgeons significantly more often considered PTD to be "completely safe" in group V (92% vs 61% in group C). The skin incisions were smaller (p = 0.003), and the extent of stomal bleeding was less (p = 0.001). Complications were tendentiously less frequent in group V (5.5%) than in group C (23.7%; p = 0.062). CONCLUSIONS The surgeon performing PDT guided by VB has a higher degree of safety, resulting in less bleeding than with PDT guided by CB.
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Affiliation(s)
- M Oberwalder
- Department of General and Transplant Surgery, University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria.
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Fritz GA, Buerschaper G, Wolf S. Novel approach to management of a posterior tracheal tear complicating percutaneous tracheostomy. Br J Anaesth 2004; 93:598; author reply 598. [PMID: 15361479 DOI: 10.1093/bja/aeh611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Sengupta N, Ang KL, Prakash D, Ng V, George SJ. Twenty Months’ Routine Use of a New Percutaneous Tracheostomy Set Using Controlled Rotating Dilation. Anesth Analg 2004; 99:188-192. [PMID: 15281528 DOI: 10.1213/01.ane.0000116925.11961.56] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
After a favorable trial period, we introduced the new percutaneous tracheostomy set, PercuTwist, in February of 2002 for our routine procedures. Over the next 20 mo, 90 procedures were performed with minimal complications. To prospectively evaluate this experience, we collected information on reasons for unit admission, operators' previous experience, the duration of prior tracheal intubation, the time needed for the procedure, the grading of the difficulty, the amount of bleeding, and the complications of the procedure. Twenty-two of 90 (24.4%) procedures were performed by senior consultants with experience; 68 of 90 (75.6%) were safely performed by intensive care residents under close bedside supervision. The mean time needed for the procedure was 13 min 7 s. In only one procedure during the entire study was any difficulty observed during the insertion process. This occurred because the initial skin incision was too small. However, no major bleeding or complications were encountered.
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Affiliation(s)
- Neel Sengupta
- Intensive Care Unit, Harefield Hospital, Royal Brompton & Harefield Hospitals NHS Trust, Middlesex, UK
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Fikkers BG, van Veen JA, Kooloos JG, Pickkers P, van den Hoogen FJA, Hillen B, van der Hoeven JG. Emphysema and Pneumothorax After Percutaneous Tracheostomy. Chest 2004; 125:1805-14. [PMID: 15136394 DOI: 10.1378/chest.125.5.1805] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
STUDY OBJECTIVE Part 1: To describe cases of emphysema (subcutaneous and/or mediastinal) and pneumothorax after percutaneous dilational tracheostomy (PDT) in a series of 326 patients, and to review the existing literature describing the incidence and possible mechanisms. Part 2: To analyze the potential mechanisms for the development of emphysema and pneumothorax in human cadaver models. DESIGN A retrospective analysis of PDTs, in combination with an anatomic study in human cadavers. MATERIALS AND METHODS Part 1: All ICU patients who underwent PDT between 1997 and 2002 were enrolled in the study. We analyzed the cases of emphysema and pneumothorax. Similar cases were retrieved from the literature and underwent a systematic review. Part 2: The relevant anatomic structures were studied. We simulated the clinical situation after PDT in a human pathologic study in order to induce subcutaneous emphysema and pneumothorax. MEASUREMENTS AND RESULTS Part 1: Five cases of subcutaneous emphysema (1.5%) and two cases of pneumothorax (0.6%) are described. In the literature search, we found 41 cases of emphysema (1.4%) and 25 cases of pneumothorax (0.8%) in a total of 3,012 patients. Part 2: Subcutaneous emphysema could easily be induced in a human cadaver model by inflating air in the pretracheal tissues and after posterior tracheal wall laceration. Air leakage was also possible through a fenestrated cannula via the space between the inner nonfenestrated cannula and outer cannula and then through the fenestration. CONCLUSIONS We conclude that one mechanism for the development of emphysema is an imperfect positioning of the fenestrated cannula, whereby the fenestration is extraluminal. For this reason, fenestrated cannulas should not be used immediately after placement of a PDT. Posterior tracheal wall laceration is another mechanism responsible for emphysema after PDT. After perforation of the posterior tracheal wall, the pleural space can be reached easily. This may result in a pneumothorax.
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Affiliation(s)
- Bernard G Fikkers
- Department of Intensive Care, University Medical Centre Nijmegen, Nijmegen, The Netherlands.
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Madden BP, Sheth A, Ho TBL, McAnulty G. Novel approach to management of a posterior tracheal tear complicating percutaneous tracheostomy. Br J Anaesth 2004; 92:437-9. [PMID: 14742343 DOI: 10.1093/bja/aeh061] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
We treated a patient who developed a posterior tracheal wall perforation and severe respiratory compromise following percutaneous tracheostomy, using a covered expandable metallic stent. The stent was deployed under direct vision using rigid and fibreoptic bronchoscopy. The defect was sealed and the right lung, which had been collapsed, was re-expanded. The patient was subsequently weaned from mechanical ventilation. Late complications included halitosis, which was treated with nebulized colistin sulphate, and the development of intratracheal granulation tissue, which was cleared using low power (10 W) Nd:YAG laser.
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Affiliation(s)
- B P Madden
- Department of Cardiothoracic Surgery, St George's Hospital, Blackshaw Road, London SW17 0QT, UK.
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Abstract
Care of the long-term tracheostomy patient is changing. By moving the initiation of tracheostomy out of the operating room and shifting responsibility for the procedure to the medical specialist, more patients are undergoing tracheostomy for a wider spectrum of diagnoses. With much of the aftercare now directed by the medical specialist, successful reintegration of the long-term tracheostomy patient into a productive life is dependent upon the collaborative care of several disciplines directed by the specialist. To effectively care for these challenging patients, it is critical for the physician who performs tracheostomy to be aware of the new caregiving role that is now theirs.
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Affiliation(s)
- Shawn E Wright
- Division of Pulmonary and Critical Care Medicine, St. Joseph's Hospital and Medical Center, 350 West Thomas Road, Phoenix, AZ 85013, USA.
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