Tracheal stenosis after placement of percutaneous dilational tracheotomy

A novel case of tracheal deviation secondary to percutaneous tracheostomy

BACKGROUND

This is a novel case of iatrogenic airway stenosis and tracheal deviation in a patient with previous percutaneous dilational tracheostomy.

CASE PRESENTATION

This 65-year-old male presented with a short segment of combined flap-valve stenosis and tracheomalacia, with right tracheal deviation distal to the stenosis. Clinical staging of the stenosis corresponded to a Cotton-Meyer grade III and McCaffrey stage III. Tracheal resection and primary reconstruction was performed by thoracic surgery and otolaryngology.

CONCLUSION

No cases have reported both stenosis and tracheal deviation as a result of iatrogenic intervention. The nature of this injury highlights a need for rigour in approaching tracheostomy.

Short- and long-term complications of surgical and percutaneous dilatation tracheotomies: a large single-centre retrospective cohort study

Objectives

The aim of this study was to determine and compare the incidence of long- and short-term complications of percutaneous dilatation tracheotomies (PDT) and surgical tracheotomies (ST).

Design

A single-centre retrospective study.

Participants

305 patients undergoing a tracheotomy (PDT or ST) in the University Medical Center Groningen from 2003 to 2013 were included. Data were gathered from patient files.

Main outcome measures

Short-term and long-term complications including tracheal stenosis.

Results

The incidence of short- and long-term complications, including tracheal stenosis, was similar in both groups. Analysis of a small high-risk subgroup showed no difference in long-term complications.

Conclusions

The rate of short- and long-term complications, including tracheal stenosis, is equal in PDT and ST. PDT is a safe alternative for ST in selected patients.

Feasibility and safety of dilatational tracheotomy using the rigid endoscope: a multicenter study

Background

Fiberoptic tracheo-bronchoscopy is the most commonly used procedure for percutaneous dilational tracheotomy (PDT). However, PDT can be associated with major complications, including death. Furthermore it is unclear, whether the tracheal ring fractures may contribute to the development of tracheal stenosis after PDT nor whether tracheal ring fractures can be prevented by using a rigid endoscope for this procedure. The purpose of this study was to evaluate the feasibility of and the incidence of complications for PDT using the rigid tracheotomy endoscope (TED).

Methods

In a prospective multicenter observational study from 2006 to 2010, 180 adult patients in intensive care and those scheduled for ear, nose and throat surgery underwent PDT using TED. Data collection was performed using a structured protocol. The patients were observed according to PDT phase (phase 1: puncture, phase 2: dilatation and phase 3: cannula insertion). The descriptive data are given as the number (percent) of cases and the mean ± standard deviation (SD) where appropriate. The relationships between dichotomous and categorical parameters were analyzed using the chi-square test. P values ≤ 0.05 were considered significant.

Results

PDT was performed in 179 patients. The procedure time was 14.8 ± 6.2 (mean ± SD) minutes. Pneumothorax or procedure-related lethal complications did not occur. Other adverse events included tracheal ring fractures (17.1%), desaturations (6.8%), special incidents (6.2%), bleeding (5.5%), anesthesia complications (4.5%) and posterior tracheal wall injuries (1.1%).

Conclusion

The use of TED in PDT is feasible, and the incidence of complications and adverse events was comparable with that of PDT using the flexible endoscope. Tracheal ring fractures in PDT cannot be avoided by the use of a rigid endoscope. With TED, the airway always remains open thus the use of jet ventilation via the TED during PDT is possible.

Single dilator vs. guide wire dilating forceps tracheostomy: a meta-analysis of randomised trials

BACKGROUND

Single dilator technique (SDT) and guide wire dilating forceps (GWDF) are the two most commonly used techniques of percutaneous dilatational tracheostomy (PDT) in critically ill adult patients. We performed a meta-analysis of randomised, controlled trials comparing intraoperative, mid-term and late complications of these two techniques.

METHODS

Pertinent studies were searched in BioMedCentral, PubMed, Embase and the Cochrane Central Register of clinical trials. We selected all randomised studies comparing SDT and GWDF techniques in adult critically ill patients published in a peer-reviewed journal.

RESULTS

Among 1040 retrieved studies, five eligible studies randomising 363 patients (181 to GWDF, 182 to SDT) were identified. The incidence of the composite outcome difficult cannula insertion/difficult dilation or failure was higher with the GWDF technique (15.5% vs. 4.9 %, P = 0.02). Moreover, intraprocedural bleeding was more common in the GWDF group (19.3% vs. 7.6% in SDT group, P = 0.018). A trend towards an increased incidence of fracture of tracheal rings was noted in the SDT group (6.5% vs. 0.5% in the GWDF group, P = 0.13). No difference in mid-term or long-term complications was observed.

CONCLUSION

GWDF technique is associated with a higher incidence of intraprocedural bleeding and of technical difficulties in completing the procedure (difficult cannula insertions/difficult dilations or failures) compared with the SDT technique. No differences were identified in mid-term and long-term complications. Further studies comparing SDT and GWDF in the general population and in subgroups of high-risk patients (like obese or hypoxaemic patients) are warranted.

Issues of critical airway management (Which anesthesia; which surgical airway?)

Which anesthesia for patients with critical airway? Safe and effective analgesia and anesthesia in critical airway is a skilled task especially after severe maxillofacial injury combined with head injury and hemorrhagic shock. If on one side sedation is wanted, on the other hand it may worsen the airway and hemodynamic situation to a point where hypoventilation and decrease of blood pressure, common side-effect of many opioids, may prejudice the patient's level of consciousness and hemodynamic compensation, compounding an already critical situation. What to do when endotracheal intubation fails and blood is trickling down the airways in an unconscious patient or when a conscious patient has to sit up to breathe? Which surgical airway in critical airway? Comparative studies among the various methods of emergency surgical airway would be unethical; furthermore, operator's training and experience is relevant for indications and performance.

Subacute airway obstruction caused by a suprastomal tracheal granuloma following tracheotomy in an adult

We report a case of a post-tracheotomy suprastomal granuloma in the early postoperative phase that caused subacute airway obstruction in a 28-year-old woman. The patient had undergone the tracheotomy during the surgical treatment of a submental abscess. During recovery, several capping trials had failed. Therefore, direct laryngoscopy was performed on postoperative day 11, and it revealed that the airway was being obstructed by a tracheal granuloma. The granuloma was managed with a partial resection and corticosteroids. The patient was successfully decannulated with no recurrence of the granuloma. To the best of our knowledge, airway obstruction secondary to a tracheal granuloma has not been previously reported as an early complication of a traditional surgical tracheotomy in an adult. In this report, we discuss the presenting features of this case and we propose several possible etiologies.

Early and late outcome after single step dilatational tracheostomy versus the guide wire dilating forceps technique: a prospective randomized clinical trial

Purpose

Percutaneous tracheostomy is frequently performed in long-term ventilated patients in the intensive care unit (ICU). Unfortunately, despite many years of experience, the optimal technique is still unknown, especially considering the occurrence of late complications. The purpose of this study was to determine which of the two most frequently used percutaneous tracheostomy techniques performs best with the emphasis on late complications.

Methods

This prospective randomized trial involved 120 patients, comparing two techniques of percutaneous tracheostomy, the guide wire dilating forceps (GWDF) and the single step dilatational tracheostomy (SSDT) technique.

Results

Sixty patients in each group underwent a percutaneous tracheostomy and were followed for up to 3 months after decannulation. The majority of complications in both groups were minor (58.3% in the GWDF group and 61.7% in the SSDT group). We found a trend towards more major perioperative complications in the GWDF group versus the SSDT group, 10.0 versus 1.7% (p = 0.06). One patient in the SSDT group developed a significant tracheal stenosis. However, this may also have been related to prolonged translaryngeal intubation. Results of magnetic resonance imaging (MRI) investigations showed only minor tracheal changes. Only 37.5% of patients in the GWDF group and 31.8% in the SSDT group had no complaints after their percutaneous tracheostomy.

Conclusion

Compared with the GWDF, the SSDT shows a trend toward less major perioperative complications with a comparable long-term outcome.

External light guidance for percutaneous dilatational tracheotomy

BACKGROUND

Percutaneous dilatational tracheotomy (PDT) is considered a safe technique; however, there is still room for improvement. We present our initial experience with an external white light guide to position the endotracheal tube and guide needle placement during PDT.

METHODS

This is a retrospective series of 15 consecutive patients undergoing external light-guided PDT. A white light source was placed on the anterior trachea wall externally and the transmitted light was identified in the tracheal lumen with a bronchoscopic to predict the needle entrance point.

RESULTS

The transmitted light was rapidly identified in all 15 patients, facilitated endotracheal tube tip placement in the subglottis in approximately 10 seconds in 13 of 15 patients, and predicted needle penetration into the trachea within 1 to 2 mm of the external light in all patients.

CONCLUSIONS

External light guidance facilitates rapid, accurate placement of the needle through the tracheal wall and can reduce surgeon anxiety, especially in teaching situations.

[Dilatation tracheotomy update : indications, limitations and management of complications]

Percutaneous dilatational tracheotomy is a standard procedure today for transient airway management in intensive care units. When correctly indicated and applied, preferably following interdisciplinary case discussion with the otolaryngologist, PDT seems to be as safe as classical surgical tracheotomy. The latter is the alternative when PDT is contraindicated. There is currently a trend towards one-step PDT procedures. In addition to the permanent necessity for an alternative airway, there is a series of clearly defined contraindications to PDT. In such cases, only surgical tracheotomy is viable. In contrast to surgical tracheotomy, PDT presents more challenges to the physicians and nursing staff in order to avoid specific complications such as re-cannulation into a via falsa followed by acute dyspnea. The otolaryngologist is an important partner in the management of PDT-related complications due to his discipline-specific experience. Further prospective trials, especially concerning long-term complications, are needed to answer the question of whether PDT or surgical tracheotomy is the best method in situations with overlapping indications.

[Preliminary results of percutaneous tracheotomies]

OBJECTIVES

Percutaneous tracheotomy (PT) is an alternative to surgical tracheotomy (ST). We describe our procedure and discuss the current status of PT through a retrospective study of our first 30 cases.

MATERIAL AND METHODS

Thirty patients had a PT between October 2006 and March 2008 in the intensive care units of Caen University Hospital (France). Twenty-eight were done with the Ciaglia Blue Rhino (CBR) and two with the Percutwist. Each PT was endoscopically guided. We retrospectively collected preoperative data and most of the intraoperative as well as early postoperative complications.

RESULTS

No death was reported with the PT application. Twenty-two (73.3%) PTs had neither preoperative nor early postoperative complications. Eight complications were observed, half preoperative and half early postoperative. The most frequent complication was minor bleeding in three cases (10%), the most important one was the intraoperative appearance of a tracheoesophageal fistula with the CBR.

DISCUSSION

The principal advantages of PT are safety attributable to simultaneous endoscopic guidance as well as shorter operative time and lower cost in comparison with the ST technique.

CONCLUSION

PT is a safe and valid alternative procedure to ST. Initially performed by intensivists, it should be part of the ENT/head and neck surgeon's repertory as the upper airway specialist.