Percutaneous dilatation tracheotomy in patients on extracorporeal membrane oxygenation after cardiac surgery

BACKGROUND

Current practices regarding percutaneous dilatational tracheostomy in adult patients treated with extracorporeal membrane oxygenation (ECMO) after cardiac surgery is not completely defined. This study aimed to evaluate the safety of the percutaneous dilatational tracheostomy in patients with ECMO after cardiac surgery.

METHODS

Between July 2017 and May 2021, 371 ECMO procedures were performed in more than 35,000 adult patients who underwent cardiac surgery in our hospital. Sixty-two patients underwent percutaneous dilatational tracheostomy (PDT) during or after ECMO. A retrospective analysis was performed comparing the incidence of complications and clinical outcomes of the two groups.

RESULTS

Of the 371 patients treated with ECMO after adult cardiac surgery during the enrollment period, 22 (7.1%) and 40 (12.8%) underwent PDT during or after ECMO, respectively. The platelet count (PLT) of the day was significantly lower in the PDT during ECMO group (54 (34, 68) vs. 108 (69, 162) (thousands), p < 0.001)). The prothrombin time (PT) and activated partial thromboplastin time (APTT) of the day were longer in the PDT during ECMO group (15.8 (14.6, 19.9) vs. 13.8 (13.2, 15.2) seconds, p = 0.001, 43.8 (38.0, 49.4) vs. 35.2 (28.2, 40.9) seconds, p < 0.001, respectively). There was no significant difference in tracheotomy-related complications between the two groups. Significantly decreased ventilator time was observed in the PDT during ECMO group.

CONCLUSIONS

Despite poor coagulation of the day, PDT during ECMO is safe and can appropriately reduce the duration of mechanical ventilation compared with PDT after ECMO weaning in adult patients who have undergone cardiac surgery.

The Importance of Early Percutaneous Dilatational Tracheostomy in Inhalation Injury: A Case Report

Maintaining a patent airway is critical for treating patients with severe inhalation injuries. Percutaneous Dilatational Tracheostomy (PDT) has been used effectively for many patients treated in the Intensive Care Unit (ICU). In addition to its safety for use at the bedside, according to Friedman et al. PDT has the same or even lower complication rate than surgical tracheostomy. PDT can be performed in a shorter time and is more cost-effective. Herein, we report a 44 year old obese woman who sustained an inhalation injury related to a burn. The patient fell headfirst into a pot of boiling water at the time of the burn. The patient showed signs of inhalation injury and suffered a second-to-third degree burn injury. She was treated in the ICU, and early PDT was performed. The procedure was performed by first locating the trachea, followed by a 1-cm incision made between the second and third tracheal ring. She was intubated successfully and treated in the ICU for 7 days. The anesthesiologist chose to perform an early PDT to prevent further complications. This procedure was done successfully despite many comorbidities from the patient, such as being an obese female and having a short neck, which makes finding the exact location for the incision challenging. In this case, the early decision to proceed with PDT showed promising results in decreasing the patient's mortality risk.

Fiberoptic Bronchoscope-guided vs Mini-surgical Technique of Percutaneous Dilatational Tracheostomy in Intensive Care Units: A Comment

How to cite this article: Bandyopadhyay A, Puri S, Ashok V. Fiberoptic Bronchoscope-guided vs Mini-surgical Technique of Percutaneous Dilatational Tracheostomy in Intensive Care Units: A Comment. Indian J Crit Care Med 2023;27(1):78.

Modified Technique of Percutaneous Tracheostomy Using Borescope Camera: A Case Series

Percutaneous dilatational tracheostomy (PDT) is a routinely performed procedure in the intensive care unit (ICU). Bronchoscopy guidance is recommended which requires expertise to use it, and also it is not readily available in all ICUs. Moreover, it can lead to carbondioxide (CO₂) retention and hypoxia during the procedure. To overcome these issues, we are using a waterproof 4 mm borescope examination camera in place of a bronchoscope which allows continuous ventilation, and real-time images of the tracheal lumen can be viewed on a smartphone or a tablet during the procedure. These real-time images can be transmitted wirelessly to a control room where experts can monitor and guide the junior staff performing the procedure. We are reporting successful use of the borescope camera during PDT.

How to cite this article

Mustahsin M, Srivastava A, Manchanda J, Kaushik R. Modified Technique of Percutaneous Tracheostomy Using Borescope Camera: A Case Series. Indian J Crit Care Med 2022;26(7):881-883.

Percutaneous dilatational tracheostomy: evaluation of YouTube videos

BACKGROUND AND OBJECTIVE

In today's rapidly changing world, the technology of social media is widely used for educational purposes. Our aim in this study was to investigate the accuracy and efficacy of video presentations of percutaneous dilatational tracheostomy procedures available on the international video sharing website YouTube.

METHODS

On 1 December 2020, the terms "percutaneous dilatational tracheostomy" and "percutaneous tracheostomy" were entered into the search feature of YouTube ( www.youtube.com ). The evaluation was made in three categories; general information about percutaneous tracheostomy, performing percutaneous tracheostomy steps and demographic features of videos.

RESULTS

The median number of viewings of the videos on the date our data were collected was 1342 (IQR, 237-8052), and the most watched video had been viewed 325,170 times. Surgical site cleaning was explained in 46 (65.7%) videos and incision site detection in 55 (78.6%) videos. Needle aspiration into the trachea, insertion of the Seldinger guidewire, dilatation, and tracheal tube placement were covered in all videos (70; 100%). Confirmation of the location of the tracheal tube with end tidal capnography, the last step of the procedure, is available in 34 videos (48.6%).

CONCLUSION

The use of inexpensive or freely available teaching materials is possible but should always be checked before use with respect to the completeness and correctness of the content conveyed. The unreflected adoption of such content can lead to serious treatment errors.

Application of Endotracheal Tube Cuff Pressure Monitoring during Percutaneous Dilatational Tracheostomy: A Novel Technique

Endotracheal tube (ETT) cuff pressure monitoring during percutaneous dilatational tracheostomy (PDT) procedure is an easy-to-use innovative addition to the standard blind technique in a resource-limited setting. This technique can be carried out without disconnecting the breathing circuit, resulting in a lower risk of infectious aerosol generation.

Fiber-optic Bronchoscope-guided vs Mini-surgical Technique of Percutaneous Dilatational Tracheostomy in Intensive Care Units

Background

Percutaneous dilatational tracheostomy (PCDT) using fiber-optic bronchoscope (FOB) is a widely practiced technique, but its availability and cost remain a concern in nations with limited resources. Mini-surgical technique of PCDT incorporating minimal blunt dissection has shown improved results even without the use of FOB. The study is primarily intended to compare these two techniques and establish a safer cost-effective alternative to FOB-guided PCDTs.

Patients and methods

This randomized comparative study [registered (CTRI/2018/04/013191)] was conducted on 120 mechanically ventilated patients. In 60 patients, mini-surgical PCDT (group-M) was performed with 2 cm longitudinal skin incision and blunt dissection till pretracheal fascia without FOB guidance using Portex-Ultraperc^™ sets. In remaining 60 patients, PCDT was performed under FOB vision with similar skin incision (without blunt dissection) using Portex-Ultraperc^™ sets (group-F). Two techniques were compared with regard to procedural time and percentage of complications occurred during or after the procedure.

Results

Procedure time [group-M: 6.30 ± 1.28 minutes; group-F: 14.43 ± 1.84 minutes (p <0.001)] and mean blood loss [group-M: 5.33 ± 1.69 mL; group-F: 6.87 ± 3.11 mL (p = 0.001)] was significantly less in group-M. Higher incidence of desaturation [group-M: 16.7%; group-F: 35% (p = 0.022)] was noted in group-F, whereas arrhythmias [group-M: 21.7%; group-F: 6.7% (p = 0.018)] were higher in group-M. There was no statistical difference in incidence of pneumothorax and subcutaneous emphysema. There was no incidence of posterior tracheal wall perforation in any of the patients.

Conclusion

Mini-surgical technique is a faster alternative of FOB-guided PCDT with comparable incidence of complications. It can safely be used in intensive care units (ICUs) where FOB is not available.

Clinical trial registration number

CTRI/2018/05/014307.

Name of registry

Clinical Trials Registry of India (CTRI), URL-http://ctri.nic.in.

How to cite this article

Kumar A, Kohli A, Kachru N, Bhadoria P, Wadhawan S, Kumar D. Fiber-optic Bronchoscope-guided vs Mini-surgical Technique of Percutaneous Dilatational Tracheostomy in Intensive Care Units. Indian J Crit Care Med 2021;25(11):1269-1274.

Percutaneous Tracheostomy in COVID Era: Time to Adapt and Improvise

Background

Percutaneous dilatation tracheostomy (PDT) is required in patients with novel coronavirus disease-2019 (COVID-19) with severe respiratory involvement, but the procedure needs modification to minimize the risk of aerosol exposure to caregivers.

Aim and objective

To share the experience of apnea approach of PDT in COVID patients. Also, to demonstrate the safety of the technique for healthcare workers (HCWs) and patients with respect to hemodynamic and oxygenation parameters. The incidence of adverse events and difficulties during the procedure were also recorded.

Materials and methods

According to this modified approach, percutaneous tracheostomy was performed with apnea technique during open tracheal steps (video attached) and the endotracheal tube was withdrawn to the level of cords under video-laryngoscopic guidance.

Study design

A retrospective data analysis of all the tracheostomy procedures (PDT) performed with the apnea technique during the COVID era (June–September) in non-COVID and COVID patients in intensive care units (ICUs).

Results

During these 4 months, 74 PDT procedures were performed in both COVID and non-COVID patients in the ICUs of our hospital. Out of these, PDT with apnea technique was performed in 45 patients (61%). This technique was successful in 44 patients (97.7%) with mean apnea time of 110 + 8.6 seconds. There was no significant (p < 0.05) change in mean arterial pressure and oxygen saturation of 15 COVID patients in pre-PDT and immediate post-PDT period. None of the six team members performing PDT had symptoms or tested positive for COVID-19.

Conclusion

PDT with apnea technique can be performed to minimize the risk of aerosol exposure and does not compromise the quality of care. It is safe both for the patient and HCWs.

How to cite this article

Paul G, Gautam PL, Sharma S, Sravani MV, Krishna MR. Percutaneous Tracheostomy in COVID Era: Time to Adapt and Improvise. Indian J Crit Care Med 2021;25(6):642–647.

Percutaneous Tracheostomy in COVID-19 Patients: A Four-step Safe Protocol

Background

Coronavirus disease-2019 (COVID-19) pandemic has inundated healthcare systems globally especially resources in intensive care units (ICUs). Tracheostomy may be required in critically ill COVID-19 patients to facilitate weaning and to optimize resources like ventilator and ICU beds. Percutaneous tracheostomy (PCT) has become the standard of care globally in ICUs; however, it is considered a high-risk procedure in COVID-19 patients because of the inherent risk of aerosol generation.

Materials and methods

Patients with severe COVID-19 who were on mechanical ventilation because of respiratory failure for ≥10 days were evaluated for PCT. We developed a four-step approach from patient selection and timing, preparation, performance, and postprocedure for PCT in these patients.

Results

We evaluated our four-step protocol in four patients. One of them was non-COVID patient and rest three were COVID patients. The procedure was uneventful in all of the patients with median time of procedure and apnea is 10 minutes 30 seconds and 2 minutes 20 seconds, respectively. The tracheostomy was decannulated in two of these patients and one patient is still on ventilator.

Conclusion

We believe our four-step protocol for PCT in critically ill COVID-19 patient is simple, safe, and easily adapted in any setting with limited training and available resources. We recommend further studies to evaluate this approach in selected critically ill COVID-19 patients who need tracheostomy.

How to cite this article

Nasa P, Singh A, Ali A, Patidar S, Georgian A. Percutaneous Tracheostomy in COVID-19 Patients: A Four-step Safe Protocol. Indian J Crit Care Med 2020;24(9):832-834.

Evaluation of regional ventilation by electric impedance tomography during percutaneous dilatational tracheostomy in neurocritical care: a pilot study

Background

Percutaneous dilatational tracheostomy (PDT) has become a widely performed technique in neurocritical care, which is however known to be accompanied by some risks to the patient. The aim of this pilot study was to assess the derecruitment effects of PDT with the electric impedance tomography (EIT) during the PDT procedure in neurocritical care.

Methods

The prospective observational pilot study investigated 11 adult, intubated, mechanically ventilated patients with acute brain disease. We recorded EIT data to determine regional ventilation delay standard deviation (RVD SD), compliance win (CW) and loss (CL), end-expiratory lung impedance (EELI), with the EIT belt placed at the level of Th 4 before, during and after the PDT, performed in the standard PDT position ensuring hyperextension of the neck.

Results

From 11 patients, we finally analyzed EIT data in 6 patients - EIT data of 5 patients have been excluded due to the insufficient EIT recordings. The mean RVD SD post-PDT decreased to 7.00 ± 1.29% from 7.33 ± 1.89%. The mean post-PDT CW was 27.33 ± 15.81 and PDT CL 6.33 ± 6.55. Only in one patient, where the trachea was open for 170 s, was a massive dorsal collapse (∆EELI − 25%) detected. In other patients, the trachea was open from 15 to 50 s.

Conclusions

This pilot study demonstrated the feasibility of EIT to detect early lung derecruitment occurring due to the PDT procedure. The ability to detect regional changes in ventilation could be helpful in predicting further progression of ventilation impairment and subsequent hypoxemia, to consider optimal ventilation regimes or time-schedule and type of recruitment maneuvres required after the PDT.

Per-cutaneous dilatation tracheostomy (PCTD) in COVID-19 patients and peri-tracheostomy care: A case series and guidelines

Background & Objective:

COVID 19 patients with severe respiratory failure may require prolonged mechanical ventilation. Placement of a tracheostomy tube often becomes necessary for such patients. The steps of tracheostomy procedure and post tracheostomy care of these patients can be classified as aerosol generating. We wish to highlight our modified technique to address these issues.

Methodology:

We performed percutaneous dilation tracheostomy in three clinically challenging COVID-19 patients in our ICU and developed guidelines aiming to minimise aerosolisation during and after the tracheostomy procedure to safeguard healthcare workers.

Results:

Percutaneous tracheostomy was performed by a team of three experienced anaesthetists and an ICU nurse.

Conclusion:

The decision of surgical or percutaneous tracheostomy should be dependent on the experience of the tracheostomy performer, health-care worker safety, resource availability, and patient-centred care. We believe our modified strategic approach of brief bronchoscopy, minimum PEEP and gas flows and step-wise planned approach for PCDT offers an extra level of safety to healthcare workers.

Percutaneous Tracheostomy in COVID-19 Patients: A Four-step Safe Protocol

BACKGROUND

Coronavirus disease-2019 (COVID-19) pandemic has inundated healthcare systems globally especially resources in intensive care units (ICUs). Tracheostomy may be required in critically ill COVID-19 patients to facilitate weaning and to optimize resources like ventilator and ICU beds. Percutaneous tracheostomy (PCT) has become the standard of care globally in ICUs; however, it is considered a high-risk procedure in COVID-19 patients because of the inherent risk of aerosol generation.

MATERIALS AND METHODS

Patients with severe COVID-19 who were on mechanical ventilation because of respiratory failure for ≥10 days were evaluated for PCT. We developed a four-step approach from patient selection and timing, preparation, performance, and postprocedure for PCT in these patients.

RESULTS

We evaluated our four-step protocol in four patients. One of them was non-COVID patient and rest three were COVID patients. The procedure was uneventful in all of the patients with median time of procedure and apnea is 10 minutes 30 seconds and 2 minutes 20 seconds, respectively. The tracheostomy was decannulated in two of these patients and one patient is still on ventilator.

CONCLUSION

We believe our four-step protocol for PCT in critically ill COVID-19 patient is simple, safe, and easily adapted in any setting with limited training and available resources. We recommend further studies to evaluate this approach in selected critically ill COVID-19 patients who need tracheostomy.

HOW TO CITE THIS ARTICLE

Nasa P, Singh A, Ali A, Patidar S, Georgian A. Percutaneous Tracheostomy in COVID-19 Patients: A Four-step Safe Protocol. Indian J Crit Care Med 2020;24(9):832-834.

Percutaneous tracheostomy simulation training for ENT physicians in the treatment of COVID-19-positive patients

Tracheostomy in COVID-19-related severe acute respiratory syndrome is at high risk of viral dissemination. The percutaneous dilatation technique could reduce this risk, being performed at the bedside and minimising airway opening. In the COVID-19 context, however, with precarious respiratory status, it requires specific preparation. We designed a 3-hour training module, and here provide a step-by-step schedule, including video analysis, a demonstration of the kit, the recommended precautions related to COVID-19, and several simulation scenarios of increasing difficulty, using a high-tech mannequin. A low-tech procedural simulator was also developed for practicing the steps of the procedure. Our experience (3 sessions with 14 participants) highlighted the difficult points of the procedure in the COVID-19 context, and defined a checklist for clinical practice and an assessment grid. This type of simulation helps to prepare teams for a potentially delicate technical act.

Severe pain-related adverse events of percutaneous dilatational tracheostomy performed by a neurointensivist compared with conventional surgical tracheostomy in neurocritically ill patients

Background

We evaluated severe pain-related adverse events (SAE) during the percutaneous dilatational tracheostomy (PDT) procedure performed by a neurointensivist and compared the outcomes with that of conventional surgical tracheostomy in neurocritically ill patients.

Methods

This was a retrospective and observational study of adult patients who were admitted to the neurosurgical intensive care unit between January 2014 and March 2018 and underwent tracheostomy. In this study, primary endpoints were incidence of SAE: cardiac arrest, arrhythmias, hypertension, hypotension, desaturation, bradypnea, or ventilatory distress. The secondary endpoint was procedure-induced complications.

Results

A total of 156 patients underwent tracheostomy during the study. Elective surgery of brain tumors (34.0%) and intracranial hemorrhage (20.5%) were the most common reasons for admission. The most common reasons for tracheostomy were difficult ventilator weaning or prolonged intubation (42.9%) and sedative reduction (23.7%). Tachycardia (30.1%) and hypertension (30.1%) were the most common SAE. Incidence of SAE was more common in conventional tracheostomy compared to PDT (67.1% vs. 42.3%, P = 0.002). The total duration of SAE (19.8 ± 23.0 min vs. 3.4 ± 5.3 min, P < 0.001) and procedural time (42.2 ± 21.8 min vs. 17.7 ± 9.2 min, P < 0.001) were longer in conventional tracheostomy compared to PDT. Multivariable adjustment revealed that only PDT by a neurointensivist significantly reduced the incidence of SAE by one third (adjusted odds ratio [OR]: 0.36, 95% confidence interval [CI]: 0.187–0.691). In addition, PDT by a neurointensivist deceased the duration of SAE by 8.64 min (β: -8.64, 95% CI: − 15.070 – -2.205, P = 0.009) and prolonging the procedure time by every one minute significantly increased the duration of SAE by 6.38 min (β: 6.38, 95% CI: 0.166–0.470, P < 0.001). Procedure-induced complications were more common in conventional tracheostomy compared to PDT (23.5% vs. 11.3%, P = 0.047).

Conclusions

This retrospective and exploratory study of our single-center limited cohort of tracheostomy patients revealed that decreased SAE may be associated with short procedural time during the PDT procedure performed by a neurointensivist. It is proposed that PDT by a neurointensivist may be safe and feasible in neurocritically ill patients.

Percutaneous Tracheostomy in Patients at High Risk of Bleeding Complications: A Retrospective Single-center Experience

Aims

To study the bleeding complications in patients undergoing percutaneous tracheostomy and who are at high risk of these complications (due to thrombocytopenia, use of anticoagulant or antiplatelet agents, and difficult anatomy).

Materials and methods

A retrospective study was undertaken, which included all patients undergoing percutaneous tracheostomy in the medical intensive care unit (MICU) of Rashid Hospital, Dubai, over a period of 15 months. Percutaneous tracheostomy was performed by senior medical intensivists using the single-tapered dilator technique under fiber optic bronchoscopic guidance. All patients underwent ultrasonographic evaluation of the neck to look for difficult anatomy and to determine the size of tracheostomy tube, etc. Patients were divided into two groups, those who were deemed to be at high risk of bleeding complications were compared with patients without any risk factors for bleeding complications. Other complications such as pneumothorax and tracheal leak were also looked for and were documented, if present. The data were summarized using descriptive statistics and the Fischer's exact test of significance was used for frequency distribution cross tables, at 5% level of significance (p value cutoff <0.05).

Results

One hundred and fifty-nine patients underwent percutaneous tracheostomy during the period of study. The age-group of patients ranged from 21 years to 104 years and males were predominant (65.41%). Of the 87 (54.71%) patients with one or more risk factors for bleeding, 53 (60.92%) patients had at least one risk factor for bleeding complications, while 34 (39.08%) had more than one risk factors. Bleeding was seen in total of two patients out of which one patient was in the group at risk of bleeding complications.

Conclusion

Percutaneous tracheostomy is a relatively safe procedure with very low rate of complications when performed with due precautions. Even in patients deemed to be at high risk of complications, the rate of complications is very low.

How to cite this article

Sasane SP, Telang MM, Alrais ZF, Alrahma AHNS, Khatib KI. Percutaneous Tracheostomy in Patients at High Risk of Bleeding Complications: A Retrospective Single-center Experience. Indian J Crit Care Med 2020;24(2):90–94.

Does Real Time Ultrasonography Confer Any Benefit During Bronchoscopy Guided Percutaneous Tracheostomy: A Preliminary, Randomized Controlled Trial

Background

There are studies comparing USG guided percutaneous dilatational tracheostomy (PDT) with bronchoscopy guided PDT. We have compared USG guided PDT to conventional landmark guided PDT using bronchoscopy in both the groups.

Objective

The primary outcome was the time of procedure and the secondary outcome was incidence of complications in USG guided PDT in comparision to the conventional PDT.

Materials and Methods

Seventy adult patients were randomly allocated in two groups, i.e., conventional landmark percutaneous dilatational tracheostomy (PDT) and ultrasonography (USG) guided PDT. Demographic data, injury severity score, time taken for the procedure, attempts of tracheal puncture, major and minor complications, and outcome were compared.

Results

The median time taken for the procedure was 12 minutes [min., max.; 8, 20] in conventional group 1 and 16 minutes [9, 24] in group 2 (USG guided) which was statistically significant. Minor bleeding was seen in 7 (20%) patients in group 1 and only in 4 patients (11.5%) in group 2. The rate of other complications and the long term outcome were similar in both the groups.

Conclusion

The use of real time USG during PDT may confer advantage over conventional PDT when using bronchoscopy in terms of decreasing the incidence of minor bleeding but duration of the procedure gets prolonged.

How to cite this article

Aggarwal R, Soni KD, Goyal K, Singh GP, Sokhal N, Trikha A. Does Real Time Ultrasonography Confer Any Benefit During Bronchoscopy Guided Percutaneous Tracheostomy: A Preliminary, Randomized Controlled Trial. Indian J Crit Care Med 2019;23(5):236–238.

Ultrasound-guided percutaneous dilatational tracheostomy using a saline-filled endotracheal tube cuff as an ultrasonographic puncture target: A feasibility study

PURPOSE

The saline-filled endotracheal tube (ETT) cuff can be easily identified under cervical ultrasound and can serve as an ideal puncture target during percutaneous dilatational tracheostomy (PDT). The authors present their initial experience with this novel technique.

MATERIALS AND METHODS

The records of 38 consecutive critically ill patients who underwent saline-filled cuff puncture PDT between October 2016 and December 2017 were retrospectively reviewed. The saline-filled ETT cuff was easily identified using ultrasound. Ultrasound-guided puncture into the cuff, followed by an inward-push of the ETT through the tube exchanger, facilitated accurate passage of the guidewire through the needle tip into the tracheal lumen.

RESULTS

Of 38 consecutive procedures, 37 (97.4%) were performed successfully, with only one converted to surgical tracheostomy due to guidewire displacement. The median procedure time was 8 min. There were no complications, such as accidental extubation, major bleeding, or posterior tracheal wall laceration or pneumothorax, and no procedure-related mortalities.

CONCLUSIONS

PDT performed using a saline-filled cuff as the ultrasound-guided puncture target and an endotracheal tube exchanger is feasible, and appeared to be easier to perform than standard PDT. Larger studies are required to confirm the safety and benefits of this technique.

Iatrogenic Tracheal Posterior Wall Perforation Repaired with Bronchoscope-Guided Knotless Sutures Through Tracheostomy

A 68-year-old man presented with a posterior tracheal wall injury caused by percutaneous dilatational tracheostomy. The wound was immediately covered with an absorbable polyglycolic acid sheet. Ten days after the injury, the perforation was closed with knotless sutures using a Castroviejo needle-holder through the tracheostomy. The successful repair in this case indicates the feasibility of the knotless suture technique for perforations. The technique is described in detail in this report. The patient was weaned from the mechanical ventilator on postoperative day 25. In cases of posterior tracheal posterior wall perforation, every effort should be made to repair the perforation through an existing opening.

Bedside percutaneous dilatational tracheostomy in patients outside the ICU: a single-center experience

PURPOSE

To assess the safety of medical-ward bedside percutaneous dilatational tracheostomy (GWB-PDT).

MATERIALS AND METHODS

A retrospective study of all patients who underwent elective GWB-PDT between 2009 and 2015. A joint otolaryngology-ICU team performed all GWB-PDTs. The patients were followed until decannulation, discharge or death. Complications were divided into early (within 24 h) and late, and into minor and major.

RESULTS

Two hundred and fifty six patients were included in the study. The mean age was 77.7 ± 11.8 Medical history included cardiac comorbidities (42.6%) and cerebrovascular accidents (34.4%). Overall, 48 patients (18.9%) had 60 complications, of which 70% (42/60) were minor (13 early; 29 late complications). Fifteen patients (5.9%) had major complications. Eight patients had early major complications (loss of airway - two patients [0.8%], pneumothorax - two patients [0.8%], resuscitation - one patient [0.4%], and a single patient (0.4%) died within 24 h following PDT). Two additional patients (0.8%) underwent conversion to an open tracheostomy. Seven patients had late complications (airway complications in six patients [2.3%] and major bleeding in a single patient [0.4%]). Of the seven patients with late major complications, three had two major complications. Half of the complications occurred by POD 3.

CONCLUSION

GWB-PDT is a feasible and safe solution for tracheostomies in general-ward ventilated patients.

Percutaneous versus surgical strategy for tracheostomy: a systematic review and meta-analysis of perioperative and postoperative complications

PURPOSE

Tracheostomy is one of the most frequently performed procedures in intensive care medicine. The two main approaches are open surgical tracheostomy (ST) and percutaneous dilatational tracheostomy (PDT). This systematic review summarizes and analyzes the existing evidence regarding perioperative and postoperative parameters of safety.

METHODS

A systematic literature search was conducted in the Cochrane Library, EMBASE, LILACS, and MEDLINE to identify all randomized controlled trials (RCTs) comparing complications of ST and PDT and to define the strategy with the lower risk of potentially life-threatening events. Risk of bias was assessed using the criteria outlined in the Cochrane Handbook.

RESULTS

Twenty-four citations comprising 1795 procedures (PDT: n = 926; ST: n = 869) were found suitable for systematic review. No significant difference in the risk of a potentially life-threatening event (risk difference (RD) 0.01, 95% CI - 0.03 to 0.05, P = 0.62, I ² = 47%) was found between PDT and ST. There was no difference in mortality (RD - 0.00, 95% CI - 0.01 to 0.01, P = 0.88, I ² = 0%). An increased rate of technical difficulties was shown for PDT (RD 0.04, 95% CI 0.01, 0.08, P = 0.01, I ² = 60%). Stomal infection occurred more often with ST (RD - 0.05, 95% CI - 0.08 to - 0.02, P = 0.003, I ² = 60%). Both techniques can be safely performed on the ICU. Meta-analysis of the duration of procedure was not possible owing to high heterogeneity (I ² = 99%).

CONCLUSION

ST and PDT are safe techniques with low incidence of complications. Both techniques can be performed successfully in an ICU setting. ST can be performed on every patient whereas PDT is restricted by several contraindications like abnormal anatomy, previous surgery, coagulopathies, or difficult airway of the patient.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015021967.

Percutaneous dilatational tracheostomy using the ETView Tracheoscopic Ventilation Tube®: a teaching course in a pig model

OBJECTIVE

We planned a training course for trainees of different specialties with the aim of teaching the skills of a new procedure for performing percutaneous dilatational tracheostomy (PDT) with an ETView tracheoscopic ventilation tube instead of standard bronchoscopy in an ex vivo pig model.

METHODS

The endotracheal tube, with a camera-embedded tip, was used as an alternative to standard bronchoscopy for visualization of patient airways. The procedure was performed on a home-made animal model. The participants were asked to perform PDT in three different sessions to improve their dexterity. The primary endpoint was the reduction of complications seen during the different sessions of the training course. The secondary endpoint was the satisfaction of the participants as assessed by an anonymous survey.

RESULTS

Thirty-seven residents in anesthesiology and 7 in thoracic surgery in the first 2 years of their training and without any confidence with percutaneous tracheostomy participated in the study. Tracheal cuff lesions and impalement of the tracheal tube were the most observed complications, and were concentrated in the early sessions. A significant reduction in complications and operative time was seen during the ongoing sessions of the course. No lesions of the posterior tracheal wall and only a ring fracture occurred during the last session of the course. All participants were satisfied with the course.

CONCLUSIONS

Our course seems to confer the technical skills to perform percutaneous tracheostomy to trainees and instill confidence with the procedure. However, the experience acquired on a training course should be evaluated in clinical practice.

Fatal air embolism as complication of percutaneous dilatational tracheostomy on venovenous extracorporeal membrane oxygenation, two case reports

BACKGROUND

Tracheostomy is recommended in case of prolonged mechanical ventilation. Therefore, most patients with an indication for venovenous extracorporeal membrane oxygenation (ECMO) will also have an indication for tracheostomy.

CASE PRESENTATION

We report 2 cases of fatal air embolism into the ECMO system as complication of percutaneous dilatational tracheostomy. Both patients had an AVALON ELITE® bi-caval cannula implanted draining blood from the vena cava superior and inferior.

CONCLUSION

Since there is limited safety data on this specific group of patients, a routine early dilatational tracheostomy might be associated with a significant risk.

Comparison of EtView™ tracheoscopic ventilation tube and video-assisted fiberoptic bronchoscopy during percutaneous dilatational tracheostomy

Fiberoptic bronchoscopy (FOB) via endotracheal tube (ETT) is the most frequent utilized technique for monitoring of percutaneous dilatational tracheostomy (PDT) procedure while maintaining mechanical ventilation. Endoscopic guidance has increased the safety of this procedure; nevertheless, the use of a bronchoscope via ETT potentially may deteriorate ventilation and lead to hypercarbia and/or hypoxia. EtView tracheoscopic ventilation tube (EtView TVT) is a standard endotracheal tube with a camera and light source embedded at the tip. The objectives of this study are to introduce EtView TVT as a monitoring tool during PDT and to compare it with video assisted FOB via ETT. We hypothesized that using EtView TVT during PDT may obtain similar visualization; also may have advantages regarding better mechanical ventilation conditions when compared with video-assisted FOB via ETT. Patients, 18-75 years of age requiring mechanical ventilation scheduled for PDT were randomly allocated into two groups for airway monitorization to guide PDT procedure either with FOB via ETT (Group FOB, n = 12) or EtView TVT (Group EtView, n = 12). After standard anesthesia protocol, alveolar recruitment maneuver was applied and all patients were mechanically ventilated at pressure-controlled ventilation mode with same pressure levels. The primary outcome variable was the reduction in arterial oxygen partial pressure (PaO₂) values during the procedure. Other respiratory variables and the effectiveness (the visualization and identification of relevant airway structures) of two techniques were the secondary outcome variables. Patients in both groups were comparable with respect to demographic characteristics and initial respiratory variables. Visualization and identification of relevant airway structures in any steps of the PDT procedure were also comparable. The decrease in minute ventilation in Group FOB was higher when compared with Group EtView (51 ± 4 % vs. 12 ± 7.3 %, p < 0.05). The decrease in PaO₂ from initial levels during (34 ± 21 % vs. 5 ± 7 % decrease) and after (26 ± 27 % vs. 2.8 ± 16 % decrease) the procedure was higher in Group FOB when compared with Group EtView (p < 0.05). Considering comparable features in monitorization and advantageous features over mechanical ventilation when compared with video bronchoscopy; EtView TVT would be a good alternative for airway monitorization during PDT especially for patients with poor pulmonary reserve.

Technical Improvements of Difficult Tracheotomy

The aim of this study was to explore the application value of technical improvements of difficult tracheotomy. Percutaneous dilatational tracheotomy kit combined with traditional surgical tracheotomy was performed on seven patients with various types of difficult tracheotomy surgery from Jan. 2011 to Mar. 2013 in our hospital. The indicators, such as difficulty degree and intraoperative peripheral oxygen saturation changes of each patient, were assessed and analyzed. The average operating time was 20 min (from the beginning of skin incision to the implantation of the tracheal tube), and the time from cutting out tracheal cartilage rings to completely implanting tracheal tube was with 2 min; the intraoperative oxygen saturation degrees were all above 92 %. There were no serious complications, such as intraoperative hemorrhea, asphyxia, cardiac arrest, or others, and no complications, such as postoperative bleeding, pneumothorax, cervical spinal cord injury, tracheal stenosis, tracheoesophageal fistula, or others, appeared. The technical improvements used in difficult tracheotomy could reduce the risk of surgery, difficulties of the surgical operation and postoperative complications and make the operation much more easy and more suitable for the clinical application.

A modified technique for percutaneous dilatational tracheostomy: A retrospective review of 60 cases

BACKGROUND

We describe a modified technique for percutaneous dilatational tracheostomy (PDT) using intermittent bronchoscopy and ultrasound (US). This method requires 1 single physician operator and no special airway adjuncts. Our aim is to reduce the complications associated with the current popular PDT technique, that is, accidental intraprocedural airway loss, intraprocedural bleeding, and hypoventilation associated with use of continuous bronchoscopy.

STUDY DESIGN

This is a retrospective review of all PDTs performed on intensive care unit patients at a single nonacademic hospital by a pulmonologist using the modified PDT technique.

RESULTS

Sixty consecutive PDT procedures were performed using the modified technique. Forty-five percent of the patients were considered high-risk individuals for PDT. There were no deaths from the modified PDT procedure. There were no major complications including accidental extubation, major bleeding, posterior tracheal wall laceration, pneumothorax, hemodynamic instability, severe hypoxemia, or infection. The failure rate of PDT was 1.6%. There was no puncture of the bronchoscope, endotracheal tube, or endotracheal tube balloon. All procedures were performed by 1 single physician operator.

CONCLUSION

Our modified technique demonstrates a potential to reduce accidental intraprocedural airway loss and intraoperative bleeding associated with PDT while possibly improving gas exchange and saving procedural costs. This technique needs to be comparatively studied with current popular PDT technique in a prospective trial to firmly establish associated risks and benefits.

A home-made animal model in comparison with a standard manikin for teaching percutaneous dilatational tracheostomy

OBJECTIVES

As airway management specialists, thoracic surgeons should be familiar with percutaneous dilatational tracheostomy. To optimize the learning curve, we propose a home-made pig model obtained from a slaughterhouse for training residents in the technical aspects of performing percutaneous dilatational tracheostomy. The satisfaction of the residents' training experience using this model was compared with that using a standard manikin model.

METHODS

Fifty residents participated in the present study. At the end of the session, each participant completed a questionnaire assessing the pig model and the manikin by assigning a score (ranging from 1 to 4) to five specific characteristics including (i) reality of skin turgor; (ii) landmark recognition; (iii) feasibility of the procedure; (iv) reality of the model and (v) preference of each model. The differences between models were statistically analysed.

RESULTS

Forty-five participants completed the study. The pig model, compared with the manikin model, presented a higher value regarding the reality of skin turgor (1.7 ± 0.5 vs 0.4 ± 0.8; respectively, P < 0.0001); landmark recognition (3.8 ± 0.5 vs 2.0 ± 0.5; respectively; P < 0.0001) and reality of the model (3.0 ± 0.8 vs 1.3 ± 1.0; respectively; P < 0.0001). No difference was found regarding the feasibility of the procedure (3.7 ± 0.6 vs 3.5 ± 0.5; respectively, P = 0.1). The pig model was preferred to the manikin (3.2 ± 0.7 vs 1.6 ± 1.0; respectively, P < 0.0001).

CONCLUSIONS

Our pig model allowed residents to develop the skills required for successful percutaneous dilatational tracheostomy. In particular, they developed confidence with certain manoeuvres such as needle and guide-wire placement, dilatation of the trachea and insertion of a cannula, before attempting the procedure on a live patient.

[Percutaneous tracheostomy through dilatation with the Ciaglia Blue Dolphin(®) method]

OBJECTIVE

To describe the perioperative and postoperative complications in critically ill patients requiring percutaneous tracheostomy using the Ciaglia Blue Dolphin(®) technique.

DESIGN

A prospective, observational, cohort study was carried out.

SCOPE

Two medical-surgical Intensive Care Units.

PATIENTS

Adult patients subjected to prolonged mechanical ventilation.

INTERVENTION

Percutaneous tracheostomy using Ciaglia Blue Dolphin(®) with an endoscopic guide.

VARIABLES

Demographic variables, intraoperative and postoperative complications, and Intensive Care Unit and ward mortality were recorded.

RESULTS

Seventy patients were included. Age: 68.6 ± 12 years (68.6% males). APACHE II score: 23.5±8.7. Duration of mechanical ventilation prior to percutaneous tracheostomy: 14.3 ± 5.5 days. Perioperative complications were recorded in 25 patients. In 23 of them the complications were mild: difficulty inserting the tracheostomy cannula (n=10), mild bleeding (n=7), partial atelectasis (n=3), cuff leak (n=2), and technical inability to complete the procedure (switch to Ciaglia Blue Rhino(®)) (n=1). Severe complications were recorded in 2 patients: severe bleeding that forced completion of the procedure via surgical tracheostomy (n=1), and false passage with desaturation (n=1). None of the complications proved life-threatening. Eleven complications occurred in the learning curve. As postoperative complications, mild peri-cannula bleeding was seen in 2 patients.

CONCLUSIONS

Percutaneous tracheostomy using the Ciaglia Blue Dolphin(®) technique with an endoscopic guide is a safe procedure. As with other procedures, the learning curve contributes to increase the incidence of complications. Potential benefits versus other percutaneous tracheostomy techniques should be explored by randomized trials.