Percutaneous Dilatational Tracheostomy for Emergent Airway Access

[Awake percutaneous tracheostomy in neurosurgical patients: clinical cases and literature review]

Transoral or combined transnasal-transoral approach is sometimes used for tumor resection in patients with skull base and vertebral neoplasms. In such cases, percutaneous tracheostomy before surgical intervention is advisable. Tracheostomy facilitates surgical access, eliminates intraoperative risk of endotracheal tube kinking and provides airway protection from aspiration in early postoperative period in case of bulbar disorders, hypopharynx and tongue edema. The authors present two patients with massive proliferation of pathological tissue in nasopharynx and oropharynx that excluded tracheal intubation before tracheostomy. These patients underwent awake percutaneous tracheostomy.

Percutaneous Dilational Tracheostomy

Tracheostomy tubes can be inserted surgically or percutaneously via percutaneous dilational tracheostomy (PDT). Tracheostomy is performed for upper airway obstruction, though more often to allow prolonged mechanical ventilation in place of endotracheal tubes. Preparation, performance, and postoperative management for PDT are best provided by a multidisciplinary team. Although PDT is a safe procedure in the hands of experienced operators, both early and late complications can arise. Caution must also be taken during early tracheostomy tube exchange given that immaturity of the stomal tract can risk loss of the airway.

Cricothyroid Membrane Puncture-Guided Tracheostomy: A New Technique for Emergency Airway Access

PURPOSE

We sought to compare cricothyroid membrane puncture-guided tracheostomy (CMPGT) with surgical cricothyroidotomy (SC) and percutaneous tracheostomy with Griggs' guidewire dilating forceps (GWDF) for establishing an emergency airway in a porcine model. We hypothesized that CMPGT would be associated with a shorter time to ventilation and more rapid restoration of oxygenation.

MATERIALS AND METHODS

We implemented a small pilot animal study. Eighteen miniature pigs were randomly assigned to undergo CMPGT, SC, or GWDF. The predictor variable was the technique used. The primary outcome variable was time to ventilation. Other outcome variables were efficiency of oxygenation restoration, procedure duration, and procedure-related complications. The data were assessed using 1-way analysis of variance and Bonferroni correction. The oxygen saturation (SpO2) changes over time were graphed using a time-series line plot. Statistical significance was set at P < .05.

RESULTS

Airways were successfully established in all 18 pigs. SC (68 ± 4 seconds) showed the shortest procedure duration compared with GWDF (95 ± 3 seconds) and CMPGT (96 ± 4 seconds); however, the time to ventilation using CMPGT (21 ± 2 seconds) was significantly shorter than that with SC (68 ± 4 seconds) and GWDF (95 ± 3 seconds) (P < .01). Spo2 in each group increased postoperatively, reaching 95% at 120 seconds, 131 seconds, and 144 seconds in the CMPGT, SC, and GWDF groups, respectively. The slope of the ascending phase of the Spo2 curve was 0.38 for CMPGT, 0.42 for SC, and 0.53 for GWDF (P < .05). Two pigs in each group had minor intraoperative bleeding, and 1 pig in the SC group had moderate bleeding.

CONCLUSIONS

The results of this animal study suggest that CMPGT is a time-efficient and safe technique for emergency airway access that allows for a more rapid return of ventilation and obviates conversion to definitive tracheostomy. Further cadaveric study is ongoing.

Management of the chronically ventilated patient with a tracheostomy

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.

Urgent Awake Tracheotomy for Impending Airway Obstruction

BACKGROUND/OBJECTIVE: Awake tracheotomy is performed for patients with impending airway obstruction. Few studies to date have addressed the issues surrounding awake tracheotomy. We sought to review the indications, complications, and outcome of awake tracheotomy for urgent airway control.

MATERIALS AND METHODS: We conducted a retrospective review of patients who underwent awake tracheotomy over a 4-year period from 2001 to 2004 at an urban tertiary medical center. Data were obtained from inpatient records and operative charts.

RESULTS: We obtained data on 54 men and 19 women, with a mean age of 61 years. The majority of patients presented with hoarseness, dyspnea, and stridor. Twenty patients had obstruction from head and neck cancers. Nonmalignant causes included deep neck infections (n = 18), bilateral vocal cord paralysis (n = 17), trauma (n = 9), and laryngeal edema (n = 6). Other causes include laryngeal cyst, subglottic stenosis, and vocal cord granuloma. Six (8.2%) patients experienced complications, including postoperative hemorrhage, pneumothorax, and chest and wound infections. There were no long-term complications or deaths.

CONCLUSION: Awake tracheotomy is efficacious and safe and has a low complication rate.

SIGNIFICANCE: Awake tracheotomy should be performed for impending airway obstruction and in a timely manner before complete obstruction occurs.

Emergency percutaneous tracheostomy in two cancer patients with difficult airway: An alternative to cricothyroidotomy?

Inability to intubate and/or ventilate either due to distorted neck anatomy or restricted mouth opening is uncommon but potentially hazardous clinical scenario in head and neck cancer patients. Emergency cricothyroidotomy in such patients may provide a means of oxygenating the patient, but in practice has limitations and does not establish a definitive airway. We report 2 cases who had distorted face and neck anatomy in which percutaneous tracheostomy was done as an emergency life-saving procedure when other measures to obtain a definitive airway failed.

Emergency percutaneous tracheostomy in two cancer patients with difficult airway: An alternative to cricothyroidotomy?

Inability to intubate and/or ventilate either due to distorted neck anatomy or restricted mouth opening is uncommon but potentially hazardous clinical scenario in head and neck cancer patients. Emergency cricothyroidotomy in such patients may provide a means of oxygenating the patient, but in practice has limitations and does not establish a definitive airway. We report 2 cases who had distorted face and neck anatomy in which percutaneous tracheostomy was done as an emergency life-saving procedure when other measures to obtain a definitive airway failed.

[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.

Percutaneous tracheotomy

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.

Airway Management in Critical Illness

Airway management in the ICU can be complicated due to many factors including the limited physiologic reserve of the patient. As a consequence, the likelihood of difficult mask ventilation and intubation increases. The incidence of failed airways and of cardiac arrest related to airway instrumentation in the ICU is much higher than that of elective intubations performed in the operating room. A thorough working knowledge of the devices available for the management of the difficult airway and recommended rescue strategies is paramount in avoiding bad patient outcomes. In this review, we will provide a conceptual framework for airway assessment, with an emphasis on assessment of the patient with limited cervical spine movement or injury and of morbidly obese patients. Furthermore, we will review the devices that are available for airway management in the ICU, and discuss controversies surrounding interventions like cricoid pressure and the use of muscle relaxants in the critically ill patient. Finally, strategies for the safe extubation of patients with known difficult airways will be provided.

Clinical review: percutaneous dilatational tracheostomy

As the number of critically ill patients requiring tracheotomy for prolonged ventilation has increased, the demand for a procedural alternative to the surgical tracheostomy (ST) has also emerged. Since its introduction, percutaneous dilatational tracheostomies (PDT) have gained increasing popularity. The most commonly cited advantages are the ease of the familiar technique and the ability to perform the procedure at the bedside. It is now considered a viable alternative to (ST) in the intensive care unit. Evaluation of PDT procedural modifications will require evaluation in randomized clinical trials. Regardless of the PDT technique, meticulous preoperative and postoperative management are necessary to maintain the excellent safety record of PDT.

A comparison of two single dilator percutaneous tracheostomy sets: the Blue Rhino and the Ultraperc

The single tapered dilator kit is the most commonly used percutaneous tracheostomy set in the UK. The Cook Blue Rhino and the Portex Ultraperc were compared in the laboratory on mannequin and porcine airway models. The following data were collected: the subjective ease of dilating the trachea and inserting the tracheostomy tube; the time taken and the anterior-posterior compression during dilatation and tube insertion; the incidence and extent of posterior tracheal wall damage. During dilatation, the Blue Rhino caused less mean percentage anterior-posterior compression (34.8% vs. 51.5%, p = 0.0014). There was no difference in subjective ease or time for dilatation in either mannequin or porcine airway models. During insertion of the tracheostomy tube, the Ultraperc was subjectively easier in the porcine airway model (p = 0.001); had a shorter median insertion time in both the mannequin (3 s vs. 7.2 s, p = 0.0006) and the porcine airway model (4.3 s vs. 8.5 s, p = 0.0005); the mean percentage anterior-posterior compression caused was less in the mannequin (51.5% vs. 76%, p = 0.0008). The overall incidence of posterior wall damage was 65% with 25% having deep lacerations. There was no difference in the incidence of damage between the two sets. The Ultraperc therefore has advantages during tracheostomy tube insertion that are statistically and clinically significant. The advantages are probably due to the presence of the tracheostomy tube introducer.

Recent trends in tracheal intubation: emphasis on the difficult airway

PURPOSE OF REVIEW

Difficult airways can lead to critical incidents during anaesthesia, and death. Although many cases can be anticipated, some still go undiscovered before induction, thereby exposing the patient to unexpected risks and the anaesthesiologist to unexpected challenges. In addition to improving prediction of difficult airways, education for skill acquisition and management planning, and a quest for superior management techniques and airway tools are of the utmost importance in preventing airway catastrophes.

RECENT FINDINGS

We review recent advances in predicting difficult airways in special population groups that are known to have a higher incidence of difficult airway. Education, exercising airway skills, management planning with both predicted and unpredicted difficult airways, and the need for adherence to algorithms for management of difficult airway are emphasized as key to successful management. Finally, recent developments in airway management techniques and new airway devices are summarized.

SUMMARY

Improving reproducibility and reliability in predicting a difficult airway may limit the number of unpredicted difficult intubations. A safer approach to management of the difficult airway can be achieved by improving airway management skills and adhering to universally accepted and proven airway algorithms, including developing approaches to management of predicted and unpredicted difficult airways. Improving on existing airway techniques and tools (of which there are many), rather than creating new devices, is a desirable trend that may contribute to safer airway management in the future.