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Keirns DL, Rajan AK, Wee SH, Govardhan IS, Eitan DN, Dilsaver DB, Ng I, Balters MW. Tracheal Stenosis in Open Versus Percutaneous Tracheostomy. Cureus 2024; 16:e57075. [PMID: 38681475 PMCID: PMC11052640 DOI: 10.7759/cureus.57075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2024] [Indexed: 05/01/2024] Open
Abstract
OBJECTIVE This study aims to investigate if there is an increased risk of developing tracheal stenosis after tracheostomy with an open versus percutaneous tracheostomy. METHODS The patient cohort included patients receiving open or percutaneous tracheostomies at Catholic Health Initiatives Midwest facilities from January 2017 to June 2023. The primary aim was to compare the differences in the risk of developing tracheal stenosis between open and percutaneous tracheostomy techniques. Between-technique differences in the risk of developing tracheal stenosis were assessed via a Cox proportional hazard model. To account for death precluding patients from developing tracheal stenosis, death was considered a competing risk. RESULTS A total of 828 patients met inclusion criteria (61.7% open, 38.3% percutaneous); 2.5% (N = 21) developed tracheal stenosis. The median number of days to develop tracheal stenosis was 84 (interquartile range: 60 to 243, range: 6 to 739). Tracheal stenosis was more frequent in patients who received a percutaneous tracheostomy (percutaneous: 3.5% vs. open: 2.0%); however, the risk of developing tracheal stenosis was statistically similar between open and percutaneous techniques (HR: 2.05, 95% CI: 0.86-4.94, p = 0.108). CONCLUSIONS This study demonstrates no significant difference in the development of tracheal stenosis when performing an open versus a percutaneous tracheostomy. Tracheal stenosis is a long-term complication of tracheostomy and should not influence the decision about the surgical technique used.
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Affiliation(s)
- Darby L Keirns
- Department of Surgery, Creighton University School of Medicine, Phoenix, USA
| | - Ajay K Rajan
- Department of Surgery, Creighton University School of Medicine, Phoenix, USA
| | - Shirline H Wee
- Department of Surgery, Creighton University School of Medicine, Phoenix, USA
| | - Isheeta S Govardhan
- Department of Surgery, Creighton University School of Medicine, Phoenix, USA
| | - Dana N Eitan
- Department of Surgery, Creighton University School of Medicine, Phoenix, USA
| | - Danielle B Dilsaver
- Department of Clinical Research and Public Health, Creighton University School of Medicine, Omaha, USA
| | - Ian Ng
- Department of Clinical Research and Public Health, Creighton University School of Medicine, Omaha, USA
| | - Marcus W Balters
- Department of Surgery, Creighton University School of Medicine, Omaha, USA
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Ghiani A, Tsitouras K, Paderewska J, Munker D, Walcher S, Neurohr C, Kneidinger N. Tracheal stenosis in prolonged mechanically ventilated patients: prevalence, risk factors, and bronchoscopic management. BMC Pulm Med 2022; 22:24. [PMID: 34991555 PMCID: PMC8740413 DOI: 10.1186/s12890-022-01821-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 12/31/2021] [Indexed: 11/14/2022] Open
Abstract
Background Various complications may arise from prolonged mechanical ventilation, but the risk of tracheal stenosis occurring late after translaryngeal intubation or tracheostomy is less common. This study aimed to determine the prevalence, type, risk factors, and management of tracheal stenoses in mechanically ventilated tracheotomized patients deemed ready for decannulation following prolonged weaning. Methods A retrospective observational study on 357 prolonged mechanically ventilated, tracheotomized patients admitted to a specialized weaning center over seven years. Flexible bronchoscopy was used to discern the type, level, and severity of tracheal stenosis in each case. We described the management of these stenoses and used a binary logistic regression analysis to determine independent risk factors for stenosis development. Results On admission, 272 patients (76%) had percutaneous tracheostomies, and 114 patients (32%) presented mild to moderate tracheal stenosis following weaning completion, with a median tracheal cross-section reduction of 40% (IQR 25–50). The majority of stenoses (88%) were located in the upper tracheal region, most commonly resulting from localized granulation tissue formation at the site of the internal stoma (96%). The logistic regression analysis determined that obesity (OR 2.16 [95%CI 1.29–3.63], P < 0.01), presence of a percutaneous tracheostomy (2.02 [1.12–3.66], P = 0.020), and cricothyrotomy status (5.35 [1.96–14.6], P < 0.01) were independently related to stenoses. Interventional bronchoscopy with Nd:YAG photocoagulation was a highly effective first-line treatment, with only three patients (2.6%) ultimately referred to tracheal surgery. Conclusions Tracheal stenosis is commonly observed among prolonged ventilated patients with tracheostomies, characterized by localized hypergranulation and mild to moderate airway obstruction, with interventional bronchoscopy providing satisfactory results. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-022-01821-6.
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Affiliation(s)
- Alessandro Ghiani
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart - Schillerhoehe Lung Clinic (Affiliated to the Robert-Bosch-Hospital GmbH, Stuttgart), Auerbachstrasse 110, 70376, Stuttgart, Germany.
| | - Konstantinos Tsitouras
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart - Schillerhoehe Lung Clinic (Affiliated to the Robert-Bosch-Hospital GmbH, Stuttgart), Auerbachstrasse 110, 70376, Stuttgart, Germany
| | - Joanna Paderewska
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart - Schillerhoehe Lung Clinic (Affiliated to the Robert-Bosch-Hospital GmbH, Stuttgart), Auerbachstrasse 110, 70376, Stuttgart, Germany
| | - Dieter Munker
- Department of Internal Medicine V, Ludwig-Maximilians-University (LMU) of Munich, Munich, Germany
| | - Swenja Walcher
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart - Schillerhoehe Lung Clinic (Affiliated to the Robert-Bosch-Hospital GmbH, Stuttgart), Auerbachstrasse 110, 70376, Stuttgart, Germany
| | - Claus Neurohr
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart - Schillerhoehe Lung Clinic (Affiliated to the Robert-Bosch-Hospital GmbH, Stuttgart), Auerbachstrasse 110, 70376, Stuttgart, Germany.,Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Nikolaus Kneidinger
- Department of Internal Medicine V, Ludwig-Maximilians-University (LMU) of Munich, Munich, Germany.,Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
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Nowak A, Klemm E, Michaelsen C, Usichenko TI, Koscielny S. Safety of percutaneous dilatational tracheotomy (PDT) with the rigid tracheotomy endoscope (TED): a 6-month follow-up multicenter investigation. BMC Anesthesiol 2021; 21:51. [PMID: 33588755 PMCID: PMC7883418 DOI: 10.1186/s12871-021-01264-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 01/07/2021] [Indexed: 11/30/2022] Open
Abstract
Background The rigid tracheotomy endoscope (TED) was recently introduced to improve the fiberoptic technique during percutaneous dilatational tracheotomy (PDT) in critically ill patients. The aim was to evaluate the long-term complications of PDT using TED equipment in a prospective multicenter investigation. Methods One hundred eighty adult patients underwent PDT using TED in four German hospitals. Patients who were alive or their guardians were contacted via telephone and interviewed using a structured questionnaire 6 months following the tracheostomy procedure. Patients with airway complaints were invited for outpatient clinical ENT examination. The incidence of adverse events related to PDT was registered. Results Of 180 patients who received tracheostomy, 137 (76.1%) were alive at the time of follow-up. None of the 43 lethal events was related to the PDT. Fifty-three (38.7%) patients were available for follow-up examination, whereas 14 (10.2%) were able to visit ENT physicians. Two (3.8%) out of 53 patients developed tracheocutaneous fistula with required surgical closure of tracheostoma. Dyspnea (7.5%), hoarseness (5.7%), stridor and swallowing difficulties (both with 3.8%) were the most common complaints. Tracheal stenosis was confirmed in 1 patient (1.88% [95% CI: 0.33; 9.93]). Conclusion The use of TED for PDT in the clinical setting is safe regarding adverse events at 6-month follow-up. The incidence of tracheal stenosis after PDT with TED is comparable with that of flexible bronchoscopy; however, its role for PDT at the intensive care unit should be clarified in further investigations. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-021-01264-2.
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Affiliation(s)
- Andreas Nowak
- Head of the Department of Anesthesiolgy & Intensive Care Medicine, Emergency Medicine & Pain Management, Dresden Municipal Hospital - Academic Teaching Hospital of the Dresden University of Technology, Friedrichstrasse 41, 01067, Dresden, Germany.
| | - Eckart Klemm
- Department of Otorhinolaryngology, Head and Neck Surgery, Plastic Surgery, Dresden Municipal Hospital - Academic Teaching Hospital of the Dresden University of Technology, Dresden, Germany
| | - Caroline Michaelsen
- Department of Otorhinolaryngology, Head and Neck Surgery, Plastic Surgery, Dresden Municipal Hospital - Academic Teaching Hospital of the Dresden University of Technology, Dresden, Germany
| | - Taras I Usichenko
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine, Pain Medicine, University Medicine of Greifswald, Greifswald, Germany.,Department of Anesthesia, McMaster University, Hamilton, Canada
| | - Sven Koscielny
- Department of Otolaryngology and Institute of Phoniatry and Pedaudiology, Jena University Hospital, Jena, Germany
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Ultrasound guided percutaneous dilatation tracheotomy (US-PDT) to prevent potentially life-threatening complications: A case report. Int J Surg Case Rep 2020; 77S:S125-S128. [PMID: 32972890 PMCID: PMC7876924 DOI: 10.1016/j.ijscr.2020.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 09/05/2020] [Indexed: 11/20/2022] Open
Abstract
Percutaneous dilatation tracheotomy enables non-surgeons to perform tracheotomies at patients bedside. Bleeding is a common complication of percutaneous dilatation tracheotomies. Performing a pre-operative neck ultrasound can help identifying aberrant vessels and reduce the risk of periprocedural bleeding.
Introduction Percutaneous dilatation tracheotomy (PDT) is a relatively recent technique that enables non surgeons to perform tracheotomies at bedside reducing operation rooms schedules. It is burdened by a moderate risk of postoperative bleeding. Presentation of case The patient was a 57 years old with a temporal intraparenchymal hematoma, submitted to percutaneous dilatation tracheotomy. Despite the favorable anatomical features, a pre-procedural US was performed, identifying a pulsating vessel with an arterial pattern, 2 cm above the hollow. The procedure was then considered at high risk, an operation room was required for the technique and an on-call surgeon was alerted. The procedure was ended safely and any bleeding was avoided because the technique was practiced with the best precautions. Discussion PDT strength is the possibility for non surgeons to perform tracheotomies in selected patients at bedside, reducing operation rooms congestion. Such technique though is a “blind” technique, and postoperative bleedings can occur and represent a feared complication. Conversely, the surgical tracheotomy permits a better control of hemorrhages, but needs the involvement of a surgeon and availability of an operation room. Performing a PDT guided by a neck ultrasound is useful to identify eventual aberrant vessel whose course could complicate the tracheotomy, it is part of PDT guidelines of some States. Conclusion US-PDT could help reducing procedure related complications selecting those high risk patients still in need of operating room and surgical assistance. US-PDT feasibility combined to its easy availability and low costs encourage its introduction into everyday practice.
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Nicosia D, Federico A, Vigna I, Iozzo P, Misseri G, Cortegiani A. Use of low dose of rFVIIa (recombinant Factor VII activated) to control late bleeding after percutaneous dilational tracheostomy. Clin Case Rep 2019; 7:665-667. [PMID: 30997059 PMCID: PMC6452479 DOI: 10.1002/ccr3.2061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 11/12/2018] [Accepted: 01/29/2019] [Indexed: 11/26/2022] Open
Abstract
In our case, the use of a low intravenous bolus dose of rFVIIa (recombinant factor VII activated; 15-20 mcg/kg) was effective and uneventful in controlling late postprocedural PDT bleeding associated with thrombocytopenia that cannot be corrected and after all other treatments failed.
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Affiliation(s)
- Dario Nicosia
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo GiacconeUniversity of PalermoPalermoItaly
| | - Antonino Federico
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo GiacconeUniversity of PalermoPalermoItaly
| | - Ivan Vigna
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo GiacconeUniversity of PalermoPalermoItaly
| | - Pasquale Iozzo
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo GiacconeUniversity of PalermoPalermoItaly
| | - Giovanni Misseri
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo GiacconeUniversity of PalermoPalermoItaly
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo GiacconeUniversity of PalermoPalermoItaly
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Araujo JB, Añón JM, García de Lorenzo A, García-Fernandez AM, Esparcia M, Adán J, Relanzon S, Quiles D, de Paz V, Molina A. Late complications of percutaneous tracheostomy using the balloon dilation technique. Med Intensiva 2017. [PMID: 28648671 DOI: 10.1016/j.medin.2017.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the late complications in critically ill patients requiring percutaneous tracheostomy (PT) using the balloon dilation technique. DESIGN A prospective, observational cohort study was carried out. SCOPE Two medical-surgical intensive care units (ICU). PATIENTS All mechanically ventilated adult patients consecutively admitted to the ICU with an indication of tracheostomy. INTERVENTIONS All patients underwent PT according to the Ciaglia Blue Dolphin® method, with endoscopic guidance. Survivors were interviewed and evaluated by fiberoptic laryngotracheoscopy and tracheal computed tomography at least 6 months after decannulation. VARIABLES Intraoperative, postoperative and long-term complications and mortality (in-ICU, in-hospital) were recorded. RESULTS A total of 114 patients were included. The most frequent perioperative complication was minor bleeding (n=20) and difficult cannula insertion (n=19). Two patients had severe perioperative complications (1.7%) (major bleeding and inability to complete de procedure in one case and false passage and desaturation in the other). All survivors (n=52) were evaluated 211±28 days after decannulation. None of the patients had symptoms. Fiberoptic laryngotracheoscopy and computed tomography showed severe tracheal stenosis (>50%) in 2patients (3.7%), both with a cannulation period of over 100 days. CONCLUSIONS Percutaneous tracheostomy using the Ciaglia Blue Dolphin® technique with an endoscopic guide is a safe procedure. Severe tracheal stenosis is a late complication which although infrequent, must be taken into account due to its lack of clinical expressiveness. Evaluation should be considered in those tracheostomized critical patients who have been cannulated for a long time.
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Affiliation(s)
- J B Araujo
- Servicio de Medicina Intensiva, Hospital Virgen de la Luz, Cuenca, España
| | - J M Añón
- Servicio de Medicina Intensiva, Hospital Universitario La Paz-Carlos III, IdiPAZ, Madrid, España.
| | - A García de Lorenzo
- Servicio de Medicina Intensiva, Hospital Universitario La Paz-Carlos III, IdiPAZ, Madrid, España
| | - A M García-Fernandez
- Servicio de Medicina Intensiva, Hospital Santa Bárbara, Puertollano (Ciudad Real), España
| | - M Esparcia
- Servicio de Otorrinolaringología, Hospital Virgen de la Luz, Cuenca, España
| | - J Adán
- Servicio de Otorrinolaringología, Hospital Santa Bárbara, Puertollano (Ciudad Real), España
| | - S Relanzon
- Servicio de Radiología, Hospital Virgen de la Luz, Cuenca, España
| | - D Quiles
- Servicio de Radiología, Hospital Santa Bárbara, Puerto Llano (Ciudad Real), España
| | - V de Paz
- Servicio de Medicina Intensiva, Hospital Virgen de la Luz, Cuenca, España
| | - A Molina
- Servicio de Medicina Interna, Hospital Virgen de la Luz, Cuenca, España
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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: 24] [Impact Index Per Article: 3.4] [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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Abstract
Tracheostomy is the most common surgical procedure performed on critically ill patients. For those who survive their critical illnesses but remain ventilator-dependent, tracheostomy provides patients with a secure airway that frees the mouth for oral nutrition, enhances verbalized speech, and promotes generalized comfort. Avoiding complications from tracheostomy requires a skilled multi-disciplinary approach to ensure that the benefits outweigh the risks of the procedure.
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Affiliation(s)
- J E Heffner
- Medical University of South Carolina, 169 Ashley Avenue, PO Box 250332, Charleston, South Carolina 29425, USA.
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A Novel, Adaptable Laryngeal Mask to Facilitate a Percutaneous Dilatational Tracheostomy: Proof-of-Concept Prototype Demonstration on a Mannequin Model and Cadaver. J Bronchology Interv Pulmonol 2016; 22:319-25. [PMID: 26492605 DOI: 10.1097/lbr.0000000000000216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Most percutaneous dilatational tracheostomy (PDT) mortalities result from airway-related complications. Improved airway pressure management and gas delivery are targets for innovation. This study describes an adaptable laryngeal mask (ALM) designed to remove the bronchoscope from the endotracheal tube (ETT) and place it in a separate lumen. Airflow and device efficacy were evaluated during PDTs with an ALM on mannequins and cadavers, respectively. METHODS Procedures were completed by a single physician using an 8.0 mm ETT and the Ciaglia Blue Rhino method on simulation mannequins (TruCorp AirSim Traci) and fresh-frozen cadavers. Mannequin simulation tested the respiratory capabilities of an ALM utilizing a BioPac spirometer and a Maquet Servo ventilator. Qualitative analysis on device efficacy was performed on 2 fresh-frozen cadavers (1 male, 1 female). RESULTS Preliminary ventilation testing on a PDT-able mannequin using the ALM showed an increase in airflow reaching the lungs compared with a deflated ETT. During mannequin and cadaver testing, the ALM was placed over the in situ ETT effectively, thereby removing the bronchoscope from the ETT while maintaining a continuous visual of the incision site. Both mannequin and cadaveric testing using an ALM enabled a single physician to safely perform the PDT procedure with minimal assistance. CONCLUSIONS Initial testing using an ALM during PDT on mannequins and cadavers showed an improvement in airflow and the removal of the bronchoscope from the ETT, respectively. Further studies using the ALM in a patient population compared with standard techniques would be useful.
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Brass P, Hellmich M, Ladra A, Ladra J, Wrzosek A. Percutaneous techniques versus surgical techniques for tracheostomy. Cochrane Database Syst Rev 2016; 7:CD008045. [PMID: 27437615 PMCID: PMC6458036 DOI: 10.1002/14651858.cd008045.pub2] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Tracheostomy formation is one of the most commonly performed surgical procedures in critically ill intensive care participants requiring long-term mechanical ventilation. Both surgical tracheostomies (STs) and percutaneous tracheostomies (PTs) are used in current surgical practice; but until now, the optimal method of performing tracheostomies in critically ill participants remains unclear. OBJECTIVES We evaluated the effectiveness and safety of percutaneous techniques compared to surgical techniques commonly used for elective tracheostomy in critically ill participants (adults and children) to assess whether there was a difference in complication rates between the procedures. We also assessed whether the effect varied between different groups of participants or settings (intensive care unit (ICU), operating room), different levels of operator experience, different percutaneous techniques, or whether the percutaneous techniques were carried out with or without bronchoscopic guidance. SEARCH METHODS We searched the following electronic databases: CENTRAL, MEDLINE, EMBASE, and CINAHL to 28 May 2015. We also searched reference lists of articles, 'grey literature', and dissertations. We handsearched intensive care and anaesthesia journals, abstracts, and proceedings of scientific meetings. We attempted to identify unpublished or ongoing studies by contacting manufacturers and experts in the field, and searching in trial registers. SELECTION CRITERIA We included randomized and quasi-randomized controlled trials (quasi-RCTs) comparing percutaneous techniques (experimental intervention) with surgical techniques (control intervention) used for elective tracheostomy in critically ill participants (adults and children). DATA COLLECTION AND ANALYSIS Three authors independently checked eligibility and extracted data on methodological quality, participant characteristics, intervention details, settings, and outcomes of interest using a standardized form. We then entered data into Review Manager 5, with a double-entry procedure. MAIN RESULTS Of 785 identified citations, 20 trials from 1990 to 2011 enrolling 1652 participants fulfilled the inclusion criteria. We judged most of the trials to be at low or unclear risk of bias across the six domains, and we judged four studies to have elements of high risk of bias; we did not classify any studies at overall low risk of bias. The quality of evidence was low for five of the seven outcomes (very low N = 1, moderate N = 1) and there was heterogeneity among the studies. There was a variety of adult participants and the procedures were performed by a wide range of differently experienced operators in different situations.There was no evidence of a difference in the rate of the primary outcomes: mortality directly related to the procedure (Peto odds ratio (POR) 0.52, 95% confidence interval (CI) 0.10 to 2.60, I² = 44%, P = 0.42, 4 studies, 257 participants, low quality evidence); and serious, life-threatening adverse events - intraoperatively: risk ratio (RR) 0.93, 95% CI 0.57 to 1.53, I² = 27%, P = 0.78, 12 studies, 1211 participants, low quality evidence,and direct postoperatively: RR 0.72, 95% CI 0.41 to 1.25, I² = 24%, P = 0.24, 10 studies, 984 participants, low quality evidence.PTs significantly reduce the rate of the secondary outcome, wound infection/stomatitis by 76% (RR 0.24, 95% CI 0.15 to 0.37, I² = 0%, P < 0.00001, 12 studies, 936 participants, moderate quality evidence) and the rate of unfavourable scarring by 75% (RR 0.25, 95% CI 0.07 to 0.91, I² = 86%, P = 0.04, 6 studies, 789 participants, low quality evidence). There was no evidence of a difference in the rate of the secondary outcomes, major bleeding (RR 0.70, 95% CI 0.45 to 1.09, I² = 47%, P = 0.12, 10 studies, 984 participants, very low quality evidence) and tracheostomy tube occlusion/obstruction, accidental decannulation, difficult tube change (RR 1.36, 95% CI 0.65 to 2.82, I² = 22%, P = 0.42, 6 studies, 538 participants, low quality evidence). AUTHORS' CONCLUSIONS When compared to STs, PTs significantly reduce the rate of wound infection/stomatitis (moderate quality evidence) and the rate of unfavourable scarring (low quality evidence due to imprecision and heterogeneity). In terms of mortality and the rate of serious adverse events, there was low quality evidence that non-significant positive effects exist for PTs. In terms of the rate of major bleeding, there was very low quality evidence that non-significant positive effects exist for PTs.However, because several groups of participants were excluded from the included studies, the number of participants in the included studies was limited, long-term outcomes were not evaluated, and data on participant-relevant outcomes were either sparse or not available for each study, the results of this meta-analysis are limited and cannot be applied to all critically ill adults.
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Affiliation(s)
- Patrick Brass
- HELIOS Klinikum KrefeldDepartment of Anaesthesiology, Intensive Care Medicine, and Pain TherapyLutherplatz 40KrefeldGermany47805
- Witten/Herdecke UniversityIFOM ‐ The Institute for Research in Operative Medicine, Faculty of Health, Department of MedicineOstmerheimer Str. 200CologneGermany51109
| | - Martin Hellmich
- University of CologneInstitute of Medical Statistics, Informatics and EpidemiologyKerpener Str. 62CologneNRWGermany50937
| | - Angelika Ladra
- Marien‐Hospital ErftstadtDepartment of Anaesthesiology and Intensive CareMünchweg 3ErftstadtGermany
| | - Jürgen Ladra
- Operatives Zentrum MedicenterAbteilung für ChirurgieArnoldsweiler Str. 23DuerenGermany52351
| | - Anna Wrzosek
- Jagiellonian University, Medical CollegeDepartment of Interdisciplinary Intensive CareKrakowPoland
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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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Al-Qahtani K, Adamis J, Tse J, Harris J, Islam T, Seikaly H. Ultra percutaneous dilation tracheotomy vs mini open tracheotomy. A comparison of tracheal damage in fresh cadaver specimens. BMC Res Notes 2015; 8:237. [PMID: 26059328 PMCID: PMC4467670 DOI: 10.1186/s13104-015-1199-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 05/20/2015] [Indexed: 11/16/2022] Open
Abstract
Background To compare the ultra percutaneous dilation tracheostomy (PDT) and mini open techniques (MOT) in randomized fixed and fresh cadavers. Assess degrees of damage to tracheal cartilage and mucosa via tracheal lumen and external dissection. Method Comparative cadaver study was performed, tracheostomy was placed in 36 cadavers (16 fixed, 20 fresh) from July 2004 to December 2004, in University of Alberta, Canada. PDT (size 7) were placed by intensivist and MOT (size 7) otolaryngologist. Both fixed and fresh cadavers were randomized. Evaluation was done according to gender, ease of landmark, mucosal and cartilage injuries. Results Significant differences in mucosal injury (7 of 9 in UPDT VS 0 of 7 in MOT, p value 0.008), and cartilage injury (8 of 9 in UPDT VS 1 of 7 in MOT p value 0.012) were seen in fixed cadavers; and in fresh cadavers, mucosal injury (5 of 10 in UPDT VS 0 of 10 in MOT, p value 0.043), and cartilage injury (5 of 10 in UPDT VS 0 of 10 in MOT, p value 0.043). Conclusions PDT resulted in severe damage to mucosa and cartilage, that might contribute to subglottic stenosis preventing decannulation. Considering the injury, MOT has better outcome than UPDT.
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Affiliation(s)
- Khalid Al-Qahtani
- Division of Otolaryngology-Head and Neck Surgery, University of Alberta, Edmonton, Canada. .,Department of Otolaryngology-Head and Neck Surgery, College of Medicine, King Abdul Aziz University Hospital, King Saud University, PO Box no-245, Riyadh, 11411, Kingdom Saudi Arabia.
| | - Jon Adamis
- Division of Otolaryngology-Head and Neck Surgery, University of Alberta, Edmonton, Canada.
| | - Jennifer Tse
- Division of Otolaryngology-Head and Neck Surgery, University of Alberta, Edmonton, Canada.
| | - Jeffery Harris
- Division of Otolaryngology-Head and Neck Surgery, University of Alberta, Edmonton, Canada.
| | - Tahera Islam
- College of Medicine and Research Center, King Saud University, Riyadh, Kingdom Saudi Arabia.
| | - Hadi Seikaly
- Division of Otolaryngology-Head and Neck Surgery, University of Alberta, Edmonton, Canada.
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Unusual airway complication after percutaneous tracheotomy: Case report and literature review. Laryngoscope 2015; 125:1883-5. [DOI: 10.1002/lary.25286] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 02/18/2015] [Accepted: 03/02/2015] [Indexed: 11/07/2022]
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Yavuz A, Yılmaz M, Göya C, Alimoglu E, Kabaalioglu A. Advantages of US in Percutaneous Dilatational Tracheostomy: Randomized Controlled Trial and Review of the Literature. Radiology 2014; 273:927-36. [DOI: 10.1148/radiol.14140088] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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15
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Dinh VA, Farshidpanah S, Lu S, Stokes P, Chrissian A, Shah H, Giri P, Hecht D, Nguyen HB. Real-time sonographically guided percutaneous dilatational tracheostomy using a long-axis approach compared to the landmark technique. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2014; 33:1407-1415. [PMID: 25063406 DOI: 10.7863/ultra.33.8.1407] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVES Sonographic evaluation of neck anatomy before performing percutaneous dilatational tracheostomy (PDT) has been shown to predict PDT success. In this study, we compared the real-time, long-axis, in-plane approach to the traditional bronchoscopically guided landmark technique. METHODS Data were analyzed from a prospectively maintained PDT database at a university tertiary care medical intensive care unit. A convenience sample of adult patients requiring PDT for prolonged mechanical ventilation dependence was enrolled. Critical care fellows, under direct supervision of an attending intensivist, performed all PDTs. Tracheostomy performance from the sonographically guided and landmark techniques was compared. RESULTS Twenty-three patients were enrolled: 11 in the sonography group and 12 in the landmark group. Initial midline introducer needle puncture was achieved in 72.7% in the sonography group compared to 8.3% in the landmark group (P< .001). The mean number of introducer needle punctures ± SD was significantly lower in the sonography group compared to the landmark group (1.4 ± 0.7 versus 2.6 ± 0.9; P < .001). The total tracheostomy time was 11.4 ± 4.2 minutes in the sonography group versus 15.3 ± 6.8 minutes in the landmark group (P = .12). Sonography accurately predicted tracheal ring space insertion in 90.9% of patients. Procedural complications did not differ significantly between the groups. CONCLUSIONS Percutaneous dilatational tracheostomy under real-time sonographic guidance using a long-axis approach may increase the rate of midline punctures and decrease the number of needle punctures when compared to the landmark technique. Sonographic guidance can also help guide accurate and efficient placement of a tracheostomy tube into the desired tracheal ring space.
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Affiliation(s)
- Vi Am Dinh
- Department of Emergency Medicine (V.A.D., D.H., H.B.N.), Department of Medicine, Division of Pulmonary and Critical Care (V.A.D., S.F., A.C., H.S., P.G., D.H., H.B.N.), and School of Medicine (S.L., P.S.), Loma Linda University, Loma Linda, California USA.
| | - Siavash Farshidpanah
- Department of Emergency Medicine (V.A.D., D.H., H.B.N.), Department of Medicine, Division of Pulmonary and Critical Care (V.A.D., S.F., A.C., H.S., P.G., D.H., H.B.N.), and School of Medicine (S.L., P.S.), Loma Linda University, Loma Linda, California USA
| | - Samantha Lu
- Department of Emergency Medicine (V.A.D., D.H., H.B.N.), Department of Medicine, Division of Pulmonary and Critical Care (V.A.D., S.F., A.C., H.S., P.G., D.H., H.B.N.), and School of Medicine (S.L., P.S.), Loma Linda University, Loma Linda, California USA
| | - Phillip Stokes
- Department of Emergency Medicine (V.A.D., D.H., H.B.N.), Department of Medicine, Division of Pulmonary and Critical Care (V.A.D., S.F., A.C., H.S., P.G., D.H., H.B.N.), and School of Medicine (S.L., P.S.), Loma Linda University, Loma Linda, California USA
| | - Ara Chrissian
- Department of Emergency Medicine (V.A.D., D.H., H.B.N.), Department of Medicine, Division of Pulmonary and Critical Care (V.A.D., S.F., A.C., H.S., P.G., D.H., H.B.N.), and School of Medicine (S.L., P.S.), Loma Linda University, Loma Linda, California USA
| | - Harsh Shah
- Department of Emergency Medicine (V.A.D., D.H., H.B.N.), Department of Medicine, Division of Pulmonary and Critical Care (V.A.D., S.F., A.C., H.S., P.G., D.H., H.B.N.), and School of Medicine (S.L., P.S.), Loma Linda University, Loma Linda, California USA
| | - Paresh Giri
- Department of Emergency Medicine (V.A.D., D.H., H.B.N.), Department of Medicine, Division of Pulmonary and Critical Care (V.A.D., S.F., A.C., H.S., P.G., D.H., H.B.N.), and School of Medicine (S.L., P.S.), Loma Linda University, Loma Linda, California USA
| | - David Hecht
- Department of Emergency Medicine (V.A.D., D.H., H.B.N.), Department of Medicine, Division of Pulmonary and Critical Care (V.A.D., S.F., A.C., H.S., P.G., D.H., H.B.N.), and School of Medicine (S.L., P.S.), Loma Linda University, Loma Linda, California USA
| | - H Bryant Nguyen
- Department of Emergency Medicine (V.A.D., D.H., H.B.N.), Department of Medicine, Division of Pulmonary and Critical Care (V.A.D., S.F., A.C., H.S., P.G., D.H., H.B.N.), and School of Medicine (S.L., P.S.), Loma Linda University, Loma Linda, California USA
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Simon M, Metschke M, Braune SA, Püschel K, Kluge S. Death after percutaneous dilatational tracheostomy: a systematic review and analysis of risk factors. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R258. [PMID: 24168826 PMCID: PMC4056379 DOI: 10.1186/cc13085] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 10/07/2013] [Indexed: 11/24/2022]
Abstract
Introduction Since the introduction and widespread acceptance of percutaneous techniques in the intensive care unit (ICU) setting, the number of critically ill patients undergoing tracheostomy has steadily increased. However, this procedure can be associated with major complications, including death. The purpose of this study is to estimate the incidence and analyze the causes of lethal complications due to percutaneous dilatational tracheostomy (PDT). Methods We analyzed cases of lethal outcome due to complications from PDT including cases published between 1985 and April 2013. A systematic literature search was performed and unpublished cases from our own departmental records were retrospectively analyzed. Results A total of 71 cases of lethal outcome following PDT were identified including 68 published cases and 3 of our own patients. The incidence of lethal complications was calculated to be 0.17%. Of the fatal complications, 31.0% occurred during the procedure and 49.3% within seven days of the procedure. The main causes of death were: hemorrhage (38.0%), airway complications (29.6%), tracheal perforation (15.5%), and pneumothorax (5.6%). We found specific risk factors for complications in 73.2% of patients, 25.4% of patients had more than one risk factor. Bronchoscopic guidance was used in only 46.5% of cases. Conclusions According to this analysis, PDT-related death occurs in 1 out of 600 patients receiving a PDT. Careful patient selection, bronchoscopic guidance, and securing the tracheal cannula with sutures are likely to reduce complication rates.
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Parchani A, Peralta R, El-Menyar A, Tuma M, Zarour A, Kumar S, Abdulrahman H, AbdulRahman Y, Al-Thani H, Latifi R. Percutaneous dilatational tracheostomies in a newly established trauma center: a report from Qatar. Eur J Trauma Emerg Surg 2013; 39:507-10. [PMID: 26815448 DOI: 10.1007/s00068-013-0299-x] [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: 03/07/2013] [Accepted: 05/19/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Percutaneous dilatational tracheostomy (PDT) is a routine surgical procedure for critically ill patients who require prolonged ventilatory support. METHODS We conducted a retrospective cohort study of all PDTs performed at the adult Trauma Intensive Care Unit (TICU) of Hamad Medical Corporation in Doha, Qatar, from January 2009 through September 2012. For all adult patients, we analyzed the demographic characteristics, mean ventilator time before the procedure, injury severity score (ISS), complications, and outcomes. RESULTS Of the 1,442 trauma patients admitted to the adult TICU during our study period, 124 (8.5 %) underwent PDT using the Ciaglia Blue Rhino technique. The vast majority were male (94.3 %). The mean age was 35 ± 15.6 years; mean ventilator time before the procedure, 12 ± 3 days; and mean ISS, 24.2 ± 9.3. More than half of patients had head injury (56 %), followed by chest and abdomen (26 %) and cervical spine injuries (18 %). Early complications included difficult tube placement (0.8 %), hypoxemia (0.8 %), minor bleeding (1.6 %), and hypotension (0.8 %), but the vast majority (93 %) of patients had no complications. The procedure-related mortality rate was 0 %. CONCLUSION PDT is safe and can be performed with minimal complications even in a newly established trauma center.
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Affiliation(s)
- A Parchani
- Section of Trauma Surgery, Department of Surgery, Hamad General Hospital, Doha, Qatar
| | - R Peralta
- Section of Trauma Surgery, Department of Surgery, Hamad General Hospital, Doha, Qatar
| | - A El-Menyar
- Weill Cornell Medical College, Doha, Qatar.,Clinical Research, Section of Trauma Surgery, Hamad General Hospital, Doha, Qatar
| | - M Tuma
- Section of Trauma Surgery, Department of Surgery, Hamad General Hospital, Doha, Qatar
| | - A Zarour
- Section of Trauma Surgery, Department of Surgery, Hamad General Hospital, Doha, Qatar
| | - S Kumar
- Section of Trauma Surgery, Department of Surgery, Hamad General Hospital, Doha, Qatar
| | - H Abdulrahman
- Section of Trauma Surgery, Department of Surgery, Hamad General Hospital, Doha, Qatar
| | - Y AbdulRahman
- Section of Trauma Surgery, Department of Surgery, Hamad General Hospital, Doha, Qatar
| | - H Al-Thani
- Section of Trauma Surgery, Department of Surgery, Hamad General Hospital, Doha, Qatar
| | - R Latifi
- Section of Trauma Surgery, Department of Surgery, Hamad General Hospital, Doha, Qatar. .,Weill Cornell Medical College, Doha, Qatar. .,Department of Surgery, University of Arizona, Tucson, AZ, USA.
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Traqueostomía percutánea por dilatación sin fibrobroncoscopio. Evaluación de 80 casos en cuidados intensivos. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.rca.2012.05.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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19
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Calvache JA, Molina García RA, Trochez AL, Benitez F, Arroyo Flga L. Percutaneous dilatational tracheostomy without fiber optic bronchoscopy—Evaluation of 80 intensive care units cases. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2013. [DOI: 10.1016/j.rcae.2012.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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20
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Improvements in pulmonary and general critical care reduces mortality following ventilator-associated pneumonia. J Trauma Acute Care Surg 2013; 74:568-74. [PMID: 23354252 DOI: 10.1097/ta.0b013e3182789312] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is the most common hospital-acquired infection in the intensive care unit, with substantial subsequent mortality. The mortality following VAP declined in the 1980s and 1990s. Experts suggest that little progress has been made in the outcomes from VAP since several novel interventions have failed. We nonetheless hypothesized that mortality following VAP has continued to decrease owing to advances in pulmonary critical care. METHODS We identified all adult patients with Centers for Disease Control and Prevention-defined, intensive care unit-acquired VAP between January 1, 1997, and December 31, 2008, from a prospectively collected database. RESULTS A total of 793 cases of VAP occurred in the study period. Cases were divided into four periods (1997-1999, 2000-2002, 2003-2005, or 2006-2008) to compare outcomes over time. Acute Physiology and Chronic Health Evaluation II scores were stable, while mortality was significantly lower in Period 4 when compared with Periods 1 and 2 (p = 0.004 and 0.009, respectively). A logistic regression model predicting death (c statistic = 0.871) revealed age (odds ratio, 1.03; 95% confidence interval, 1.02-1.05), Acute Physiology and Chronic Health Evaluation II score (1.09, 1.05-1.14), white blood cell count (1.03, 1.00-1.06), transplant recipient (3.45, 1.40-8.53), transfusions (3.25, 1.37-7.68), and pulmonary disease (3.01, 1.67-5.45) were independent predictors of death, as was the presence of trauma (0.10, 0.06-0.18), chronic steroid therapy (0.39, 0.17-0.91), and patient length of stay (0.99, 0.98-0.99), with odds ratios less than 1.0. In addition, those patients treated in Period 1 (2.23, 1.16-4.29) or Period 2 (2.13, 1.12-4.06) had twice the risk of death following an episode of VAP when compared with those treated in the most recent period. CONCLUSION We have shown that mortality following an episode of VAP continues to decrease over time and attribute this to advancements in pulmonary and general critical care rather than any specific interventions. LEVEL OF EVIDENCE Prognostic study, level II.
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Añón JM, Araujo JB, Escuela MP, González-Higueras E. [Percutaneous tracheostomy in the ventilated patient]. Med Intensiva 2013; 38:181-93. [PMID: 23347906 DOI: 10.1016/j.medin.2012.11.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 11/21/2012] [Accepted: 11/22/2012] [Indexed: 11/25/2022]
Abstract
The medical indications of tracheostomy comprise the alleviation of upper airway obstruction; the prevention of laryngeal and upper airway damage due to prolonged translaryngeal intubation in patients subjected to prolonged mechanical ventilation; and the facilitation of airway access for the removal of secretions. Since 1985, percutaneous tracheostomy (PT) has gained widespread acceptance as a method for creating a surgical airway in patients requiring long-term mechanical ventilation. Since then, several comparative trials of PT and surgical tracheostomy have been conducted, and new techniques for PT have been developed. The use of percutaneous dilatation techniques under bronchoscopic control are now increasingly popular throughout the world. Tracheostomy should be performed as soon as the need for prolonged intubation is identified. However a validated model for the prediction of prolonged mechanical ventilation is not available, and the timing of tracheostomy should be individualized. The present review analyzes the state of the art of PT in mechanically ventilated patients--this being regarded by many as the technique of choice in performing tracheostomy in critically ill patients.
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Affiliation(s)
- J M Añón
- Servicio de Medicina Intensiva, Hospital Virgen de la Luz, Cuenca, España.
| | - J B Araujo
- Servicio de Medicina Intensiva, Hospital Virgen de la Luz, Cuenca, España
| | - M P Escuela
- Servicio de Medicina Intensiva, Hospital Virgen de la Luz, Cuenca, España
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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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Hameed AA, Mohamed H, Al-Ansari M. Experience with 224 percutaneous dilatational tracheostomies at an adult intensive care unit in Bahrain: a descriptive study. Ann Thorac Med 2010; 3:18-22. [PMID: 19561878 PMCID: PMC2700427 DOI: 10.4103/1817-1737.37949] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2007] [Accepted: 12/02/2007] [Indexed: 11/09/2022] Open
Abstract
Tracheostomy is one of the most commonly performed procedures in critically ill patients. Over the past 15 years, many large university hospitals have reported their experience with percutaneous dilatational tracheostomy (PDT). We have described and compared our experience with 224 PDTs that we performed in the last four and a half years. We have also compared PDT performed with and without bronchoscopic guidance at our setting and PDT verses surgical tracheostomy.
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Affiliation(s)
- Akmal A Hameed
- Department of ICU, Salmaniya Medical Complex, Manama, Kingdom of Bahrain.
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Patil VP, Singhal A, Pramesh CS. Airway bleed after percutaneous tracheostomy is not always procedure-related. Indian J Crit Care Med 2010; 13:96-8. [PMID: 19881192 PMCID: PMC2772246 DOI: 10.4103/0972-5229.56057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Tracheotomies are the most frequent surgical procedures performed in the intensive care unit. We present a case of major hemorrhage that occurred in the intensive care unit during an elective percutaneous dilational tracheostomy in a 46-year-old female diagnosed with multiple myeloma. The patient was later taken to the operation theatre and procedure-related cause of bleeding was ruled out. It was subsequently realized that the cause of bleeding was intrapulmonary and occurred coincidently with the tracheostomy.
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Affiliation(s)
- Vijaya P Patil
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Parel, Mumbai 400 012, India.
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Abstract
Tracheotomy is one of the most commonly performed procedures in critically ill patients. This article describes in particular the use of percutaneous dilatational tracheotomy. A brief history is included.
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Affiliation(s)
- Kia Sheykholeslami
- Department of Otolaryngology-Head and Neck Surgery, Case Western Reserve University School of Medicine, University Hospitals/Case Medical Center/Ireland Cancer Center, Cleveland, OH 44106, USA
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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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Kahveci SF, Acar HV, Özcan B, Kutlay O. The use of a laryngeal mask airway during percutaneous tracheostomy. MINIM INVASIV THER 2009. [DOI: 10.3109/13645709909153160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Goldenberg D, Park SS, Carr M. Percutaneous tracheotomy in otolaryngology-head and neck surgery residency training programs. Laryngoscope 2009; 119:289-92. [DOI: 10.1002/lary.20080] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Rogers SA, Mills KG, Tufail Z. Airway fire due to diathermy during tracheostomy in an intensive care patient. Anaesthesia 2008. [DOI: 10.1046/j.1365-2044.2001.1317.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Adam H, Hemprich A, Koch C, Oeken J, Schmidt H, Schramek J, Frerich B. Safety and practicability of percutaneous translaryngeal tracheotomy (Fantoni technique) in surgery of maxillofacial and oropharyngeal tumours--own results and review of the literature. J Craniomaxillofac Surg 2008; 36:38-46. [PMID: 18312790 DOI: 10.1016/j.jcms.2007.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2007] [Accepted: 08/21/2007] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The study examines the suitability of the Fantoni method of translaryngeal tracheotomy (TLT) for airway management after surgery due to oropharyngeal and maxillofacial tumours. PATIENTS AND METHODS During a 4-year period, 156 translaryngeal pull-through tracheotomies were performed in 145 patients. This method is the only puncture tracheotomy technique that involves a dilatation process from inside the trachea to the outside through the skin and differs from other established puncture methods regarding practicability and frequency of complications. RESULTS The mean puncture time (from puncture of the trachea to correct tube placement) was 10.1+/-4.8 min. With an oxygen supply of FiO(2)=1.0 the oxygen saturation prior to TLT was 98.4+/-1.29%, and the lowest median saturation value during the TLT procedure was 96.7+/-3.9%. No serious complications such as bleeding, loss of airway, pneumothorax or death were observed. Complications occurring during the TLT procedure were exclusively technical and at no time were they life-threatening. CONCLUSIONS TLT is a technique with few complications and a straightforward procedure for those familiar with the method. It has some advantages compared with other puncture techniques which appear to commend TLT in terms of safety for the patient.
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Affiliation(s)
- Horst Adam
- Department of Anaesthesiology and Intensive Care, University of Leipzig, Leipzig, Germany.
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Tracheostomy. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50017-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Karvandian K, Mahmoodpoo A, Beigmohamm M, Arab S. Emergent Tracheostomy in Two Patients with Acute Leukemia: Comparing Surgical and Percutaneous Methods. JOURNAL OF MEDICAL SCIENCES 2007. [DOI: 10.3923/jms.2008.81.84] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Henderson W. Percutaneous Dilational Tracheostomy in a Community Intensive Care Unit. Eur J Trauma Emerg Surg 2007; 34:294-8. [PMID: 26815752 DOI: 10.1007/s00068-007-6126-5] [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: 06/21/2006] [Accepted: 10/22/2006] [Indexed: 11/26/2022]
Abstract
PURPOSE Percutaneous dilational tracheostomy (PDT) is increasingly being used to replace traditional surgical tracheostomy (ST) in the management of critically ill patients. There is considerable controversy regarding the safety of this procedure in the hands of non-surgeons, and most data so far have come from large tertiary care centres. We report our experience and safety data in the implementation of a PDT program for critically ill patients in a teaching community hospital in an attempt to demonstrate that this procedure can be performed safely outside of an academic ICU. METHODS Prospective observational study in a large community teaching hospital. All patients without contraindications were considered for enrollment. Contraindications to PDT included evidence of infection at the surgical site, the presence of a coagulopathy not correctable to an international normalized ratio of less than 1.5, or unstable cervical spine injuries. A total of 42 patients were included in the study and all received PDT using the Ciaglia Blue Rhino single dilator introducer set (Cook Critical Care, Bloomington, IN, USA). Data collected included patient age, sex, reason for intubation, and complications. RESULTS Of 42 patients, 25 were males, and 17 were females. The average age was 47.6 years (range 16-87 years). The commonest admitting diagnosis was traumatic brain injury, followed by sepsis and cardiac arrest. Our total recorded complication rate was 7.1%, with no deaths. There were two episodes of transient hypotension (4.8%). CONCLUSION Percutaneous dilational tracheostomy appears to be at least as safe as traditional ST, and may have advantages with respect to timeliness and minimization of patient transport. The complication rate seen in our program is similar to that seen in other PDT series.
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Affiliation(s)
- William Henderson
- UBC Program of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada.
- Departments of Critical Care Medicine and Emergency Medicine, Royal Columbian Hospital, New Westminster, BC, Canada.
- Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.
- Departments of Critical Care Medicine and Emergency Medicine, Royal Columbian Hospital, New Westminster, BC, Canada.
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Shen LY, Helmer SD, Tran MT, Nold RJ, Thomas BW, Vasquez DG. Percutaneous tracheostomy placement with external laser light transillumination identifies proper tracheal orientation and improves surgeon insertion confidence. Am J Surg 2007; 194:409-12. [PMID: 17693293 DOI: 10.1016/j.amjsurg.2006.10.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2006] [Revised: 10/11/2006] [Accepted: 10/11/2006] [Indexed: 10/23/2022]
Abstract
Complications of percutaneous tracheostomy include bleeding, loss of airway control, inadvertent injury to surrounding structures, and equipment damage, all of which can be attributed to poor visualization and inaccurate orientation. Initially, we performed percutaneous tracheostomy in the intensive care unit setting using the single-dilator technique with video bronchoscopy without external transillumination. During our first 30 procedures, the video bronchoscope was damaged in four instances, requiring costly repairs each time. To decrease the potential for uncertainty, loss of airway control, and equipment damage, the investigators developed a technique incorporating an external laser light source to transilluminate the trachea to accurately identify the correct and appropriate orientation. Since integration of the external transillumination technique, no additional video bronchoscopes have been damaged in 100 subsequent procedures. We conclude transillumination using an external laser light source is useful in identifying the tracheostomy insertion site. This tool decreases instrument damage and improves surgeon confidence during percutaneous tracheostomy placement.
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Affiliation(s)
- Luke Y Shen
- Department of Surgery, The University of Kansas School of Medicine-Wichita, Room 3082, 929 N. Saint Francis St, Wichita, KS 67214, USA
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Abstract
Percutaneous tracheostomy is an effective method of airway management in the critically ill patient, avoiding an open exposure of the trachea. This method is time and cost-efficient and is used in many intensive care units. However, we would like to draw attention to one serious potential complication of this technique. This case report describes a case of complete tracheal stenosis above the level of tracheostoma as a direct result of the procedure. The aetiology of the stenosis as well as the surgical and postoperative managements is discussed.
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Affiliation(s)
- Hou-Kiat Lim
- Department of Otolaryngology, Head and Neck Surgery, Alfred Hospital, Prahran, Victoria, Australia.
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Koitschev A, Simon C, Blumenstock G, Mach H, Graumueller S. Surgical technique affects the risk for tracheostoma-related complications in post-ICU patients. Acta Otolaryngol 2006; 126:1303-8. [PMID: 17101592 DOI: 10.1080/00016480600702134] [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: 10/24/2022]
Abstract
CONCLUSIONS This study provides evidence that the surgical technique used for tracheotomy influences the risk of tracheostomy-related complications. techniques resulting in an epithelialized tracheostoma seem to minimize the risk. OBJECTIVE Tracheotomies are frequently performed procedures in critically ill patients requiring long-term ventilation. Hence, we undertook a study to evaluate factors for tracheostomy-related complications among patients with a persisting stoma after critical care. PATIENTS AND METHODS The patients underwent endoscopic examination of the tracheostoma, larynx, and trachea. The intensive care units (ICUs) were contacted with a questionnaire about the patient's diagnosis, the indication for the tracheotomy, the date of the tracheotomy, and the method of the tracheotomy procedure. RESULTS A total of 170 patients were included in this study. In all, 57.6% of the patients had unstable tracheostomas, a stenosis of the tracheal lumen above the stoma was encountered in 48.2% (G I, <50% of the lumen = 27.6% and G II, >50% of the lumen = 20.6%), and below the stoma in 3.5% of the patients. A significant association was found between severe suprastomal stenosis, tracheostoma instability and the use of dilatational tracheotomy (DT) (p<0.001). A malacia of the trachea was significantly more common among female patients (p < 0.010).
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Affiliation(s)
- Assen Koitschev
- Department of Otorhinolaryngology and Head and Neck Surgery, University of Tuebingen, Tuebingen, Germany.
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Koitschev A, Simon C, Blumenstock G, Mach H, Graumüller S. Suprastomal tracheal stenosis after dilational and surgical tracheostomy in critically ill patients. Anaesthesia 2006; 61:832-7. [PMID: 16922748 DOI: 10.1111/j.1365-2044.2006.04748.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
We have previously reported cases of severe suprastomal stenosis after tracheostomy. In this observational study we investigated the occurrence of suprastomal stenosis as a late complication. Patients with persistent tracheostomy after intensive care underwent an endoscopic examination of tracheostoma, larynx and trachea. A percutaneous dilational tracheostomy was employed in 105 (71.9%) and surgical tracheostomy in 41 (28.1%) of the cases (n = 146). The incidence of severe suprastomal stenosis (grade II > 50% of the lumen) was 23.8% (25 of 105) after dilational tracheostomy and 7.3% (3 of 41) after surgical tracheostomy (p = 0.033). Age, gender, underlying disease, ventilation time, and swallowing ability were not significantly associated with the tracheal pathology. This study suggests that dilational tracheostomy is associated with an increased risk of severe suprastomal tracheal stenosis compared to the surgical technique.
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Affiliation(s)
- A Koitschev
- Department of Otorhinolaryngology--Head and Neck Surgery, University of Tuebingen Medical Center, Elfriede-Aulhorn-Str. 5, D-72076, Germany.
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Heyrosa MG, Melniczek DM, Rovito P, Nicholas GG. Percutaneous Tracheostomy: A Safe Procedure in the Morbidly Obese. J Am Coll Surg 2006; 202:618-22. [PMID: 16571432 DOI: 10.1016/j.jamcollsurg.2005.12.009] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2005] [Revised: 12/07/2005] [Accepted: 12/12/2005] [Indexed: 11/30/2022]
Abstract
BACKGROUND Percutaneous dilational tracheostomy (PDT) is becoming a widely accepted technique that has replaced open tracheostomy (OT) in many hospitals. One of the remaining relative contraindications is morbid obesity. There are no published case series of its use in this patient population. We reviewed our experience with PDT in the morbidly obese and compared it to OT in this patient population. Our hypothesis is that PDT and OT have a similar frequency of adverse events. STUDY DESIGN We reviewed charts of all morbidly obese patients (body mass index [BMI]>or=35, calculated as kg/m2) undergoing either PDT or OT at our institution during a 58-month period. Variables examined included age, gender, BMI, diagnosis, bedside or operating room, and bronchoscopy-assisted. We recorded all procedural complications and all tracheostomy-related complications that occurred for 30 days postprocedure or death. Primary adverse end points were defined as procedures that started percutaneous and converted to open; any reoperation related to the initial tracheostomy; malpositioning of tracheostomy resulting in patient morbidity, loss of airway control, and bleeding requiring surgical intervention. Secondary adverse end points occurred when a tracheostomy tube was dislodged or malfunctioned, as in the case of a cuff leak, and any bleeding that occurred more than 24 hours after insertion. RESULTS From January 1, 2000, until September 30, 2004, our institution performed 1,062 tracheostomies. One hundred forty-three patients had a BMI>or=35. Eighty-nine patients underwent PDT and 53 patients underwent OT. Sixty-seven of the PDTs were performed at the bedside and 22 were performed in the operating room. All OTs were performed in the operating room. Five (6.5%) primary end points were recorded for PDTs (4 conversions to open, 1 malpositioning). Three (6.5%) primary end points were reported for OTs (malpositioning resulting in hypoxia, bleeding requiring surgical intervention, aborted attempt at open). CONCLUSIONS PDT is a safe procedure to perform on morbidly obese patients.
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Kost KM. Endoscopic percutaneous dilatational tracheotomy: a prospective evaluation of 500 consecutive cases. Laryngoscope 2006; 115:1-30. [PMID: 16227862 DOI: 10.1097/01.mlg.0000163744.89688.e8] [Citation(s) in RCA: 150] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES/HYPOTHESIS An evaluation of 500 adult, intubated, intensive care unit patients undergoing endoscopic percutaneous tracheotomy using the multiple and single dilator techniques was conducted to assess the feasibility and safety of the procedure as it compares with surgical tracheotomy. Endoscopy was used in all cases and evaluated as an added safety measure in reducing complications. STUDY DESIGN A prospective evaluation of endoscopic percutaneous dilatational tracheotomy in 500 consecutive adult, intubated intensive care unit patients. METHODS Between 1990 and 2003, endoscopically guided percutaneous dilatational tracheotomy (PDT) was performed in 500 consecutive adult, intubated patients in the intensive care units (ICU) of three tertiary care adult hospitals. The first 191 patients underwent PDT using the Ciaglia Percutaneous Tracheostomy Introducer Kit (Cook Critical Care Inc., Bloomington, Indiana) and in the remaining 309 patients the Ciaglia Blue Rhino Single Dilator Kit (Cook Critical Care Inc., Bloomington, Indiana) was used. The procedure was contraindicated in the following situations: 1) children, 2) unprotected airway, 3) emergencies, 4) presence of a midline neck mass, 5) inability to palpate the cricoid cartilage, and 6) uncorrectable coagulopathy. The following parameters were recorded preoperatively: age, sex, diagnosis, American Society of Anesthesia (ASA) class, body mass index (BMI), and number of days intubated. Recorded hematologic parameters included hemoglobin (Hgb), platelets, prothrombin time (PT), partial thromboplastin time (PTT), and the international normalized ratio (INR) since it became available in 1998. All patients were ventilated on 100% oxygen and vital signs were continuously monitored. Tracheotomy was carried out under continuous endoscopic guidance using a series of graduated dilators in the first 191 cases, and a single, tapered dilator in the remaining 309 patients. The preoperative data on each patient, along with the type of dilator used, the size of the tube, the intraoperative and postoperative complications, and blood loss information were recorded prospectively and maintained in a computer spreadsheet. Univariate analyses were used in each group separately for each type of dilator to assess the risks of a complication within subgroups defined by each parameter/characteristic, and the statistical significance assessed with a chi test, or Fisher exact test. RESULTS The total complication rate was 9.2% (13.6% in the multiple dilator group, and 6.5% in the single dilator group), with more than half of these considered minor. Overall, the two most common complications were oxygen desaturation in 14 cases and bleeding in 12 cases. The absence of serious complications such as pneumothorax and pneumomediastinum are attributable to the use of bronchoscopy. There was no significant association between the rate of complications and age, gender, ASA, weeks intubated, tracheostomy tube size, Hgb levels, platelets, PT, PTT, or INR. There was a statistically significant relationship between experience and the likelihood of complications in the multiple dilator group (P < .0001), with a higher rate of complications in the first 30 patients (40%) compared with 8.7% in the remaining 161 patients. This relationship did not exist for the first 30 patients in the single dilator group. Patients with a BMI of 30 or higher experienced a significantly greater (P < .05) number of complications (15%), compared with an 8% complication rate in patients with a BMI of less than 30. This risk was even more significant for patients with a BMI of 30 or greater who were also in ASA class 4 (11/56 or 20%) (P < .02). CONCLUSIONS Endoscopic PDT is associated with a low complication rate and is at least as safe as surgical tracheotomy in the ICU setting. Bronchoscopy significantly decreases the incidence of complications and should be used routinely. While embraced by critical care physicians, endoscopic PDT has been infrequently performed by otolaryngologists. As the airway experts, otolaryngologists are in the best position to learn and teach the procedure as it should be done.
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Affiliation(s)
- Karen M Kost
- Department of Otolaryngology, McGill University, Montreal, Quebec, Canada.
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Liao L, Myers J, Johnston J, Corneille M, Danielson D, Dent D, Stewart R, Pruitt B, Root HD, Cohn S. Percutaneous tracheostomy: one center’s experience with a new modality. Am J Surg 2005; 190:923-6. [PMID: 16307947 DOI: 10.1016/j.amjsurg.2005.08.021] [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] [Received: 04/08/2005] [Revised: 08/08/2005] [Accepted: 08/08/2005] [Indexed: 12/01/2022]
Abstract
BACKGROUND A retrospective review of our experience with percutaneous tracheostomy was performed to determine our complication rate and pattern of use since this modality was introduced at our institution. METHODS A retrospective chart review captured all patients in whom tracheostomy was performed or supervised by a trauma/critical care faculty member. Dates of hospital admission, ICU admission, intubation, discontinuation of mechanical ventilation, type and location of procedure, procedural complications, Injury Severity Score, charges, and patient demographics were collected. Percutaneous tracheostomy (PT) and open tracheostomy (OT) experiences were compared. RESULTS Three hundred sixty-eight tracheostomies were performed (190 OT and 178 PT). The average time to tracheostomy (TTT) for PT patients decreased from 12.7 to 7.4 days. The average TTT for OT patients remained stable at 14.0 days. The complication rate was 3.5%, with 4 complications (1.5%) associated with OT and 9 complications (5.1%) associated with PT. All complications in the PT group occurred before using a single dilator system. The 9 complications in the PT group occurred among 5 surgeons, all before their 11th attempt. PT saves 444 dollars in charges per procedure. CONCLUSION OT continues to be a safe method of performing tracheostomies. PT has a steep learning curve but can be mastered quickly. Benefits include a shorter time to tracheostomy, elimination of patient transport, and saving in charges. Initial PT attempts should be supervised by an experienced surgeon.
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Affiliation(s)
- Lillian Liao
- Department of Surgery, Division of Trauma and Emergency Surgery, University of Texas Health Science Center, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
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Ferraro F. In reply: A New Tracheostomy Procedure. Chest 2005. [DOI: 10.1016/s0012-3692(15)52744-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Raghuraman G, Rajan S, Marzouk JK, Mullhi D, Smith FG. Is tracheal stenosis caused by percutaneous tracheostomy different from that by surgical tracheostomy? Chest 2005; 127:879-85. [PMID: 15764771 DOI: 10.1378/chest.127.3.879] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVE To compare the surgical findings of tracheal stenosis caused by percutaneous tracheostomy (PCT) and surgical tracheostomy (SGT). DESIGN AND SETTING A combined prospective (from 2001 to 2003) and retrospective (from 1993 to 2001) observational study of the patients undergoing tracheal resection and reconstruction for treatment of tracheal stenosis following PCT or SGT in a national referral center for thoracic surgery in the United Kingdom. PATIENTS AND MEASUREMENTS We studied 29 patients presenting with symptomatic tracheal stenosis requiring tracheal reconstruction. We recorded the demographic data, duration of mechanical ventilation, onset of tracheal stenosis after decannulation, and type of tracheostomy (PCT or SGT) from referral notes. Tracheal reconstruction was preceded by rigid bronchoscopy, through which the distance of the superior level of stenosis to the vocal cords, and the length and the diameter of stenosis were measured. The type of surgical technique for tracheal resection was also recorded. We then compared the stenosis caused by PCT (n = 15) and SGT (n = 14) using an unpaired t test, Mann-Whitney U test, or Fisher exact test as appropriate for statistical analysis. RESULTS The mean distance from the superior level of stenosis in the PCT group was significantly closer to the vocal cords compared with the mean distance in the SGT group: 1.6 cm (95% confidence interval [CI], 1.1 to 2.1) vs 3.4 cm (95% CI, 2.3 to 4.5), respectively (p = 0.04). The mean onset of stenosis was significantly earlier in the PCT group compared to the SGT group: 5.0 weeks (95% CI, 5.0 to 6.0) vs 28.5 weeks (95% CI, 12 to 84), respectively (p = 0.009). Seven of 15 patients in the PCT group required partial cricoid resection and a mucosal flap, compared with 1 of 14 patients in the SGT group, although the difference did not reach statistic significance (p = 0.23). CONCLUSION Stenosis caused by PCT occurred earlier and was subglottic in nature compared to that by SGT. Surgical correction of stenosis was more difficult in the PCT group due to its presentation in the subglottic area.
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Affiliation(s)
- Govindan Raghuraman
- Anaesthesia and Intensive Care Medicine, Department of Anaesthesia and Thoracic Surgery, Birmingham Heartlands Hospital, Birmingham Heartlands and Solihull NHS Trust (Teaching), Bordesley Green East, Birmingham, B9 5SS, UK
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O'Keeffe T, Goldman RK, Mayberry JC, Rehm CG, Hart RA. Tracheostomy after anterior cervical spine fixation. ACTA ACUST UNITED AC 2005; 57:855-60. [PMID: 15514542 DOI: 10.1097/01.ta.0000083006.48501.b2] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with cervical spine injury may require both anterior cervical spine fusion and tracheostomy, particularly in the setting of associated cervical spinal cord injury (SCI). Despite the close proximity of the two surgical incisions, we postulated that tracheostomy could be safely performed after anterior spine fixation. In addition, we postulated that the severity of motor deficits in patients with cervical spine injury would correlate with the need for tracheostomy. METHODS A retrospective review was undertaken of all adult trauma patients diagnosed with cervical spine fractures or cervical SCI admitted between June 1996 and June 2001 at our university Level I trauma center. Demographic data, severity of neurologic injury based on the classification of the American Spinal Injury Association (ASIA), complications, and use and type of tracheostomy were collected. In the subgroup of patients with unstable cervical spine injury that underwent anterior stabilization and tracheostomy, data regarding timing and technique of these procedures and wound outcomes were also collected. Categorical data were analyzed using chi analysis using Yates correction when appropriate, with p <0.05 considered significant. RESULTS During this time period, 275 adult survivors were diagnosed with cervical spinal cord or bony injury. Forty-five percent of patients with SCI (27 of 60) and 14% of patients without SCI (30 of 215) underwent tracheostomy (p <0.001). Moreover, on the basis of the ASIA classification system, 76% of ASIA A and B patients, 38% of ASIA C patients, 23% of ASIA D patients, and 14% of ASIA E patients were treated with tracheostomy (p <0.001). In the subgroup that underwent both anterior spine fixation and tracheostomy (n=17), the median time interval from spine fixation to airway placement was 7 days (interquartile range, 6-10 days), with 71% of these tracheostomies performed percutaneously. No patient developed a wound infection or nonunion as a consequence of tracheostomy placement, and there were no deaths because of complications of either procedure. CONCLUSION These data support the safety of tracheostomy insertion 6 to 10 days after anterior cervical spine fixation, particularly in the presence of cervical SCI. The presence of severe motor neurologic deficits was strongly associated with the use of tracheostomy in patients with cervical spine injury. Percutaneous tracheostomy, which is our technique of choice, may be advantageous in this setting by virtue of creating only a small wound. The optimal timing and use of tracheostomy in patients with cervical spine injury requires further study.
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Affiliation(s)
- Terence O'Keeffe
- Department of Surgery, Oregon Health & Science University, Portland, Oregon 97239, USA
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Norwood MGA, Spiers P, Bailiss J, Sayers RD. Evaluation of the role of a specialist tracheostomy service. From critical care to outreach and beyond. Postgrad Med J 2004; 80:478-80. [PMID: 15299159 PMCID: PMC1743081 DOI: 10.1136/pgmj.2003.016956] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The impact that a new specialist tracheostomy service, designed specifically for the care of patients with tracheostomies, was assessed in terms of type of tracheostomy tube used, time to first tube change, time to decannulation, and incidence of tracheostomy related complications in a teaching hospital with no on-site ear, nose, and throat facility. A total of 170 patients were studied. After service implementation, fewer patients (17.6%, n = 21) were discharged from the intensive treatment unit to the wards with tracheostomy tubes compared with the first group (39%, n = 20) (p = 0.006), and the number of tracheostomy related complications on the wards were significantly reduced (p = 0.031).
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Affiliation(s)
- M G A Norwood
- Department of Surgery, Leicester General Hospital, Leicester LE5 4PW, UK.
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Fikkers BG, Staatsen M, Lardenoije SGGF, van den Hoogen FJA, van der Hoeven JG. Comparison of two percutaneous tracheostomy techniques, guide wire dilating forceps and Ciaglia Blue Rhino: a sequential cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2004; 8:R299-305. [PMID: 15469572 PMCID: PMC1065019 DOI: 10.1186/cc2907] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/21/2004] [Revised: 05/07/2004] [Accepted: 06/11/2004] [Indexed: 01/28/2023]
Abstract
Introduction To evaluate and compare the peri-operative and postoperative complications of the two most frequently used percutaneous tracheostomy techniques, namely guide wire dilating forceps (GWDF) and Ciaglia Blue Rhino (CBR). Methods A sequential cohort study with comparison of short-term and long-term peri-operative and postoperative complications was performed in the intensive care unit of the University Medical Centre in Nijmegen, The Netherlands. In the period 1997–2000, 171 patients underwent a tracheostomy with the GWDF technique and, in the period 2000–2003, a further 171 patients with the CBR technique. All complications were prospectively registered on a standard form. Results There was no significant difference in major complications, either peri-operative or postoperative. We found a significant difference in minor peri-operative complications (P < 0.01) and minor late complications (P < 0.05). Conclusion Despite a difference in minor complications between GWDF and CBR, both techniques seem equally reliable.
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Affiliation(s)
- Bernard G Fikkers
- Department of Intensive Care, University Medical Centre Nijmegen, The Netherlands.
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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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Añón JM, Escuela MP, Gómez V, García de Lorenzo A, Montejo JC, López J. Use of percutaneous tracheostomy in intensive care units in Spain. Results of a national survey. Intensive Care Med 2004; 30:1212-5. [PMID: 15118816 DOI: 10.1007/s00134-004-2276-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2003] [Accepted: 03/09/2004] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To assess the use of percutaneous tracheostomy in Intensive Care Units (ICU) in Spain, its practice, and current opinions on the technique. DESIGN AND SETTING An e-mail or post survey was sent to 239 Spanish ICU directors. Pediatric ICUs and coronary units were excluded. MEASUREMENTS AND MAIN RESULTS One hundred ICUs (41.8%) replied. The 44% ( n=44) of the ICUs that answered belonged to university hospitals and 53% ( n=53) had postgraduate teaching. Eighty-two percent ( n=82) used percutaneous tracheostomy. Griggs' Guide Wire Dilating Forceps and Ciaglia Blue Rhino were the most frequent techniques employed. In 30.5% of ICUs ( n=25) endoscopic guidance was used, in 15.7% ( n= 13) it was routine. In 24.4% ( n=20) some kind of long-term follow-up was carried out, but only in 12.2% ( n=10) was follow-up done routinely. In 58.5% of ICUs ( n=48) in which percutaneous tracheostomy is performed is this technique considered safer than surgical tracheostomy and in 86.4% ( n=70) percutaneous tracheostomy is the first choice for tracheostomy in the critically ill patient. CONCLUSIONS Percutaneous tracheostomy is a well-established technique in ICUs in Spain, and is considered the technique of choice for tracheostomy in critically ill patients. It is mainly performed without endoscopic guidance and follow-up is not usually carried out.
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Affiliation(s)
- José M Añón
- Servicio de Medicina Intensiva, Hospital Virgen de la Luz, Hermandad Donantes de Sangre No.1, 16002 Cuenca, Spain.
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Abstract
PURPOSE OF REVIEW Until the past 40 years, the timing of tracheotomy was of little concern. It was an emergency procedure developed for the relief of airway obstruction. Following the development of positive pressure ventilation, tracheotomy became an elective procedure. Today, the optimal time for tracheotomy is a subject of dispute and continued investigation. As this operation has become one of the most commonly performed procedures in the intensive care unit, nonoperative dilational methods have gained acceptability. The purpose of this review is to analyze the recent literature and draw insight into the timing and technique of the current state of tracheotomy. RECENT FINDINGS Individualized assessment of patients should guide the timing of tracheotomy, with a preference toward early tracheotomy. Percutaneous dilational tracheotomy (PDT) can be performed with equivalent safety to open tracheotomy. Bedside open tracheotomy negates the cost-saving benefits of PDT. Endoscopic guidance in PDT decreases complications with needle placement and posterior tracheal wall injury. Major complications of PDT usually are associated with displacement of the tracheotomy tube. SUMMARY Tracheotomy indications have remained unchanged, but the timing of the procedure has advanced to individualized assessment with a predilection for earlier tracheotomy. The traditional operative technique is a much safer procedure today. Percutaneous dilational tracheotomy has become an acceptable alternative with proper patient selection. A multidisciplinary team with a surgeon provides the best care for the patient undergoing percutaneous tracheotomy.
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Affiliation(s)
- Andrew J McWhorter
- Department of Otolaryngology--Head and Neck Surgery, LSU Health Sciences Center, New Orleans, Louisiana 70112, USA.
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Abstract
When significant clinical end points are considered, PDT is a cost-effective and safe alternative to ST in critically ill patients in the ICU when performed by skilled and experienced practitioners [1, 40]. There are insufficient data to establish clear superiority of either technique. Important advantages of PDT may include eliminating the need for operating room facilities and personnel by the performance of the procedure at the bedside and significantly decreasing the time interval between the decision to perform tracheostomy and the actual procedure [1, 2, 20].
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Affiliation(s)
- Luis F Angel
- Division of Pulmonary and Critical Care, Division of Cardiothoracic Surgery, University of Texas Health Science Center, 7703 Floyd Curl Drive, San Antonio, TX 78230, USA.
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