- Email: [email protected]
Minitracheotomy
Operative Techniques in Otolaryngology (2007) 18, 105-109
Minitracheotomy Alon Ben-Nun, MD, PhD, Michael Orlovsky, MD, Yakov Botvinkin, MD, Anson Best Lael, MD, FRCS From the Department of General Thoracic Surgery, Rambam Health Care Campus Center, Haifa, Israel. KEYWORDS Minitracheostomy; Sputum retention; Ventilatory support; Cricothyroidotomy; Minitracheotomy
The minitracheotomy tube is a useful tool in the prevention and management of sputum retention in postoperative and trauma patients. It may also be employed for short-term ventilatory support. The minitracheotomy tube is often inserted in conscious patients without secure airway, so even a minor complication might cause major respiratory deterioration. Thus, the surgical team should be experienced with the procedure and technical steps must be followed with caution. The tube has no cuff and its diameter is small. Therefore, it does not impair speech and cough. It is well tolerated by patients and care by nursing personnel is simple and effective. © 2007 Elsevier Inc. All rights reserved.
Cricothyroidotomy has been used for many years as an emergency lifesaving surgical airway when orotracheal intubation was unfeasible. Matthews and Hopkinson1 were the first to describe elective use of this procedure to insert a minitracheotomy tube (MTT) for the treatment of sputum retention. Later on, our group and others,2-4 reported encouraging results with MTT in the prevention and management of sputum retention in trauma and postoperative patients. Moreover, several authors described the use of MTT for ventilation in patients following thoracic surgery or thoracic trauma and for patients with neuromuscular diseases.5-7 Various modes of ventilation such as pressure control, pressure support, and oxygen flush are employed, with satisfactory results. Volume-controlled ventilation is less effective, primarily due to high airway resistance. MTT is usually inserted in conscious patients without secure airway. During the procedure, even a minor complication may cause respiratory deterioration, resulting in orotracheal intubation, ventilation, and further treatment. Mainly for this reason the surgical team should be experienced with the procedure, and technical steps must be followed judiciously. MTT has no cuff, and its diameter is small (10-F/4-mm internal diameter). Therefore, it does not impair speech and cough. We found that MTT is well tolerated by patients, and its management by the nursing staff is simple and effective.
Address reprint requests and correspondence: Alon Ben-Nun, MD, PhD, Department of General Thoracic Surgery, Rambam Health Care Campus Center, Halia 8 Street, Haifa, Israel. E-mail address: [email protected]. 1043-1810/$ -see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.otot.2007.05.008
Indications Minitracheotomy may be indicated for prevention or treatment of sputum retention in patients following major abdominal or thoracic surgery and thoracic and facial trauma. In exceptional cases, it may also be required for patients with pneumonia or pulmonary bronchiectasis. MTT provides an effective port for repeated evacuation of secretions. It may also be employed for short-term ventilatory support in patients who undergo major abdominal or thoracic surgery and require temporary ventilatory support. MTT is more effective when used early in the postoperative course before atelectasis or pneumonia has occurred. When used for ventilatory support, MTT is more effective in pressurecontrol mode.
Techniques Minitracheotomy is usually performed as a bedside procedure, with local anesthesia. There are 2 different techniques to install minitracheotomy, with similar excellent results, and several commercial kits are available (trocar-guided Minitrach Portex II, Minitrach Portex II-Seldinger kit [Smiths Medical Group, Carlsbad, CA]; Cook Minitracheostomy Seldinger kit [Cook Medical, Bloomington, IN]). With both methods, thorough knowledge of anatomy and careful adherence to the technical guidelines are essential to prevent unnecessary complications. The patient should be placed in a semisitting position, with the neck extended. Accurate identification of anatom-
106
Operative Techniques in Otolaryngology, Vol 18, No 2, June 2007
Figure 1 Local anesthesia is applied in the proper location. Special attention is paid to withdraw air from the trachea when the cricothyroid membrane is penetrated.
Figure 2
Horizontal skin incision followed by a blunt dissection of the soft tissues down to the cricothyroid membrane.
Ben-Nun et al
Minitracheotomy
Figure 3
107
Horizontal incision in the cricothyroid membrane is carefully performed.
ical landmarks (thyroid cartilage, cricoid cartilage, cricothyroid membrane, manubrium, and midline) is crucial. The surgical field is prepared with an alcoholic chlorhexidine solution and draped in a standard manner. Local anesthesia
Figure 4
is applied using a 5-mL syringe with a 25-gauge needle and 2% lidocaine solution (Figure 1). The skin, the subcutaneous soft tissue, and the cricothyroid membrane are systematically infiltrated with lidocaine. Special attention is paid to
MTT on a trocar, covered with a thin film of lidocaine gel, is inserted into the trachea.
108
Operative Techniques in Otolaryngology, Vol 18, No 2, June 2007
Figure 5
Suction of pulmonary secretions confirms appropriate tube location.
withdraw air from the trachea when the cricothyroid membrane is penetrated by the needle. Failure to extract air is a sign of needle misplacement and the procedure should not be continued before reevaluation. Two milliliters of lidocaine is injected into the trachea once the needle penetrates the cricothyroid membrane and air is withdrawn. Horizontal skin incision, followed by a cautious blunt dissection of the soft tissues down to the cricothyroid membrane with a Péan clamp (Figure 2), is recommended to reduce the risk of bleeding.8 Horizontal puncture of the cricothyroid membrane is carefully performed with the appropriate scalpel (Figure 3). The MTT on a trocar, covered with a thin film of 2% lidocaine gel, is then inserted into the trachea (Figure 4). Suction of pulmonary secretions confirms successful tube location (Figure 5). The Seldinger technique is performed in a similar manner. The technical steps are almost identical to those described for percutaneous dilational tracheotomy.9,10 Following local anesthesia and skin incision, the cricothyroid membrane is punctured with an 18-gauge cannulated needle attached to a syringe with lidocaine. The intratracheal position of the needle is confirmed by the aspiration of air into the syringe. A J-tipped guidewire is placed inside the trachea. The dilator is then passed on the guidewire and into the tracheal lumen with gentle pressure, followed by the minitracheotomy cannula.
Complications The complication rate of MTT is very low. In experienced hands, it should not exceed 5% to 10%. The most common
complications are minor and include insignificant bleeding and local subcutaneous emphysema. In most cases, no further treatment is required. Pursestring suture may be used in cases with ongoing external bleeding. Major complications are uncommon. Approximately 100 MTT procedures were performed by our team from 1998 to 2006, with only 2 major complications. In both patients, there was significant intratracheal bleeding, necessitating endotracheal intubation. In 2 patients, MTT misplacement was diagnosed at the end of the procedure and the tube was removed without further damage. A search of the medical literature, using MEDLINE, came across the following documented complications: (1) minor complications: local hematoma, subcutaneous emphysema, hoarseness or voice changes, minor local infection, tube misplacement with no damage; (2) major complications: intratracheal bleeding necessitating endotracheal intubation, massive external bleeding requiring exploration, respiratory deterioration, severe local infection, descending mediastinitis, delayed subglottic stenosis. MTTrelated morbidity and mortality are minimal.2,3,11
Discussion Minitracheotomy gives permanent access to the trachea, without impairment of laryngeal function,12 and makes frequent aspiration of bronchial secretions possible. For this purpose, it is superior to both orotracheal intubation and full-sized tracheotomy. Orotracheal intubation is uncomfortable for the patient, often requires sedation, and makes eating, speaking, and coughing impossible. “Full-size” tracheotomy cannula with an outside diameter of 12 to 13 mm
Ben-Nun et al
Minitracheotomy
significantly impairs the ability to speak, eat, and generate a normal cough. Furthermore, tracheotomy carries the uncommon but important risk for devastating complications such as subglottic stenosis and tracheoesophageal fistula. In a computerized search of the literature and from our own experience, the risk for these severe complications following MTT is practically zero. MTT may also be employed for short-term ventilatory support.5-7 We find that for this purpose MTT is not the procedure of choice and better results are achieved with full-size percutaneous tracheotomy.9 The best position for the minitracheotomy cannula may be open to question.11 MTT is most commonly inserted through the cricothyroid membrane, although the subcricoid position has also been used. The most important advantages of cricothyroidotomy are relatively easy identification of anatomical landmarks (ie, thyroid and cricoid cartilages) and the protection of the esophagus by the posterior wall of the cricoid cartilage. Access to the trachea below the cricoid cartilage appears to be more difficult and may be associated with more operative complications. Subcricoid position may also carry a minimal but important risk for posterior tracheal wall damage during the procedure. Many clinicians are reluctant to use a cannula placed in the subcricoid position because of this risk. Although the rate of this complication is probably negligible, it remains a devastating complication. In conclusion, we believe that MTT inserted in the cricothyroid membrane is an easy procedure to perform and is very effective in the prevention and treatment of sputum retention.
109
References 1. Matthews HR, Hopkinson RB: Treatment of sputum retention by minitracheostomy. Br J Surg 71:147-150, 1984 2. Ben-Nun A, Altman E, Best LA: Treatment of sputum retention by minitracheostomy. Harefuah 139:195-198, 2000 3. Wain JC, Wilson DJ, Mathieson DJ: Clinical experience with minitracheostomy. Ann Thorac Surg 49:881-886, 1990 4. Issa MM, Healy DM, Maghur HA, et al: Prophylactic minitracheotomy in lung resections: A randomized controlled study. J Thorac Cardiovasc Surg 101:895-900, 1991 5. Matthews HR, Fischer BJ, Smith BE, et al: Minitracheostomy: A new delivery system for jet ventilation. J Thorac Cardiovasc Surg 92:673675, 1986 6. Nomori H, Horio H, Suemasu K: Assisted pressure control ventilation via a mini-tracheostomy tube for postoperative respiratory management of lung cancer patients. Respir Med 94:214-220, 2000 7. Nomori H, Ishihara T: Pressure-controlled ventilation via a minitracheostomy tube for patients with neuromuscular disease. Neurology 55:698-702, 2000 8. Parry GW, Batrick NC, Lau OJ, et al: Modification of minitracheostomy technique to limit bleeding complications. Eur J Cardiothorac Surg 9:659-660, 1995 9. Ben-nun A, Altman E, Best LA: Extended indications for percutaneous tracheostomy. Ann Thorac Surg 80:1276-1279, 2005 10. Ben-Nun A, Orlovsky M, Best LA: Percutaneous tracheostomy in patients with cervical spine fracture. ICVTS 2007 (in press) 11. van Heurn LW, van Geffen GJ, Brink PR: Percutaneous subcricoid minitracheostomy: Report of 50 procedures. Ann Thorac Surg 59:707709, 1995 12. Campbell JB, Watson MG, Povery L, et al: Minitracheostomy and laryngeal function. J Laryngol Otolaryngol 1102:49-52, 1988
Minitracheotomy Alon Ben-Nun, MD, PhD, Michael Orlovsky, MD, Yakov Botvinkin, MD, Anson Best Lael, MD, FRCS From the Department of General Thoracic Surgery, Rambam Health Care Campus Center, Haifa, Israel. KEYWORDS Minitracheostomy; Sputum retention; Ventilatory support; Cricothyroidotomy; Minitracheotomy
The minitracheotomy tube is a useful tool in the prevention and management of sputum retention in postoperative and trauma patients. It may also be employed for short-term ventilatory support. The minitracheotomy tube is often inserted in conscious patients without secure airway, so even a minor complication might cause major respiratory deterioration. Thus, the surgical team should be experienced with the procedure and technical steps must be followed with caution. The tube has no cuff and its diameter is small. Therefore, it does not impair speech and cough. It is well tolerated by patients and care by nursing personnel is simple and effective. © 2007 Elsevier Inc. All rights reserved.
Cricothyroidotomy has been used for many years as an emergency lifesaving surgical airway when orotracheal intubation was unfeasible. Matthews and Hopkinson1 were the first to describe elective use of this procedure to insert a minitracheotomy tube (MTT) for the treatment of sputum retention. Later on, our group and others,2-4 reported encouraging results with MTT in the prevention and management of sputum retention in trauma and postoperative patients. Moreover, several authors described the use of MTT for ventilation in patients following thoracic surgery or thoracic trauma and for patients with neuromuscular diseases.5-7 Various modes of ventilation such as pressure control, pressure support, and oxygen flush are employed, with satisfactory results. Volume-controlled ventilation is less effective, primarily due to high airway resistance. MTT is usually inserted in conscious patients without secure airway. During the procedure, even a minor complication may cause respiratory deterioration, resulting in orotracheal intubation, ventilation, and further treatment. Mainly for this reason the surgical team should be experienced with the procedure, and technical steps must be followed judiciously. MTT has no cuff, and its diameter is small (10-F/4-mm internal diameter). Therefore, it does not impair speech and cough. We found that MTT is well tolerated by patients, and its management by the nursing staff is simple and effective.
Address reprint requests and correspondence: Alon Ben-Nun, MD, PhD, Department of General Thoracic Surgery, Rambam Health Care Campus Center, Halia 8 Street, Haifa, Israel. E-mail address: [email protected]. 1043-1810/$ -see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.otot.2007.05.008
Indications Minitracheotomy may be indicated for prevention or treatment of sputum retention in patients following major abdominal or thoracic surgery and thoracic and facial trauma. In exceptional cases, it may also be required for patients with pneumonia or pulmonary bronchiectasis. MTT provides an effective port for repeated evacuation of secretions. It may also be employed for short-term ventilatory support in patients who undergo major abdominal or thoracic surgery and require temporary ventilatory support. MTT is more effective when used early in the postoperative course before atelectasis or pneumonia has occurred. When used for ventilatory support, MTT is more effective in pressurecontrol mode.
Techniques Minitracheotomy is usually performed as a bedside procedure, with local anesthesia. There are 2 different techniques to install minitracheotomy, with similar excellent results, and several commercial kits are available (trocar-guided Minitrach Portex II, Minitrach Portex II-Seldinger kit [Smiths Medical Group, Carlsbad, CA]; Cook Minitracheostomy Seldinger kit [Cook Medical, Bloomington, IN]). With both methods, thorough knowledge of anatomy and careful adherence to the technical guidelines are essential to prevent unnecessary complications. The patient should be placed in a semisitting position, with the neck extended. Accurate identification of anatom-
106
Operative Techniques in Otolaryngology, Vol 18, No 2, June 2007
Figure 1 Local anesthesia is applied in the proper location. Special attention is paid to withdraw air from the trachea when the cricothyroid membrane is penetrated.
Figure 2
Horizontal skin incision followed by a blunt dissection of the soft tissues down to the cricothyroid membrane.
Ben-Nun et al
Minitracheotomy
Figure 3
107
Horizontal incision in the cricothyroid membrane is carefully performed.
ical landmarks (thyroid cartilage, cricoid cartilage, cricothyroid membrane, manubrium, and midline) is crucial. The surgical field is prepared with an alcoholic chlorhexidine solution and draped in a standard manner. Local anesthesia
Figure 4
is applied using a 5-mL syringe with a 25-gauge needle and 2% lidocaine solution (Figure 1). The skin, the subcutaneous soft tissue, and the cricothyroid membrane are systematically infiltrated with lidocaine. Special attention is paid to
MTT on a trocar, covered with a thin film of lidocaine gel, is inserted into the trachea.
108
Operative Techniques in Otolaryngology, Vol 18, No 2, June 2007
Figure 5
Suction of pulmonary secretions confirms appropriate tube location.
withdraw air from the trachea when the cricothyroid membrane is penetrated by the needle. Failure to extract air is a sign of needle misplacement and the procedure should not be continued before reevaluation. Two milliliters of lidocaine is injected into the trachea once the needle penetrates the cricothyroid membrane and air is withdrawn. Horizontal skin incision, followed by a cautious blunt dissection of the soft tissues down to the cricothyroid membrane with a Péan clamp (Figure 2), is recommended to reduce the risk of bleeding.8 Horizontal puncture of the cricothyroid membrane is carefully performed with the appropriate scalpel (Figure 3). The MTT on a trocar, covered with a thin film of 2% lidocaine gel, is then inserted into the trachea (Figure 4). Suction of pulmonary secretions confirms successful tube location (Figure 5). The Seldinger technique is performed in a similar manner. The technical steps are almost identical to those described for percutaneous dilational tracheotomy.9,10 Following local anesthesia and skin incision, the cricothyroid membrane is punctured with an 18-gauge cannulated needle attached to a syringe with lidocaine. The intratracheal position of the needle is confirmed by the aspiration of air into the syringe. A J-tipped guidewire is placed inside the trachea. The dilator is then passed on the guidewire and into the tracheal lumen with gentle pressure, followed by the minitracheotomy cannula.
Complications The complication rate of MTT is very low. In experienced hands, it should not exceed 5% to 10%. The most common
complications are minor and include insignificant bleeding and local subcutaneous emphysema. In most cases, no further treatment is required. Pursestring suture may be used in cases with ongoing external bleeding. Major complications are uncommon. Approximately 100 MTT procedures were performed by our team from 1998 to 2006, with only 2 major complications. In both patients, there was significant intratracheal bleeding, necessitating endotracheal intubation. In 2 patients, MTT misplacement was diagnosed at the end of the procedure and the tube was removed without further damage. A search of the medical literature, using MEDLINE, came across the following documented complications: (1) minor complications: local hematoma, subcutaneous emphysema, hoarseness or voice changes, minor local infection, tube misplacement with no damage; (2) major complications: intratracheal bleeding necessitating endotracheal intubation, massive external bleeding requiring exploration, respiratory deterioration, severe local infection, descending mediastinitis, delayed subglottic stenosis. MTTrelated morbidity and mortality are minimal.2,3,11
Discussion Minitracheotomy gives permanent access to the trachea, without impairment of laryngeal function,12 and makes frequent aspiration of bronchial secretions possible. For this purpose, it is superior to both orotracheal intubation and full-sized tracheotomy. Orotracheal intubation is uncomfortable for the patient, often requires sedation, and makes eating, speaking, and coughing impossible. “Full-size” tracheotomy cannula with an outside diameter of 12 to 13 mm
Ben-Nun et al
Minitracheotomy
significantly impairs the ability to speak, eat, and generate a normal cough. Furthermore, tracheotomy carries the uncommon but important risk for devastating complications such as subglottic stenosis and tracheoesophageal fistula. In a computerized search of the literature and from our own experience, the risk for these severe complications following MTT is practically zero. MTT may also be employed for short-term ventilatory support.5-7 We find that for this purpose MTT is not the procedure of choice and better results are achieved with full-size percutaneous tracheotomy.9 The best position for the minitracheotomy cannula may be open to question.11 MTT is most commonly inserted through the cricothyroid membrane, although the subcricoid position has also been used. The most important advantages of cricothyroidotomy are relatively easy identification of anatomical landmarks (ie, thyroid and cricoid cartilages) and the protection of the esophagus by the posterior wall of the cricoid cartilage. Access to the trachea below the cricoid cartilage appears to be more difficult and may be associated with more operative complications. Subcricoid position may also carry a minimal but important risk for posterior tracheal wall damage during the procedure. Many clinicians are reluctant to use a cannula placed in the subcricoid position because of this risk. Although the rate of this complication is probably negligible, it remains a devastating complication. In conclusion, we believe that MTT inserted in the cricothyroid membrane is an easy procedure to perform and is very effective in the prevention and treatment of sputum retention.
109
References 1. Matthews HR, Hopkinson RB: Treatment of sputum retention by minitracheostomy. Br J Surg 71:147-150, 1984 2. Ben-Nun A, Altman E, Best LA: Treatment of sputum retention by minitracheostomy. Harefuah 139:195-198, 2000 3. Wain JC, Wilson DJ, Mathieson DJ: Clinical experience with minitracheostomy. Ann Thorac Surg 49:881-886, 1990 4. Issa MM, Healy DM, Maghur HA, et al: Prophylactic minitracheotomy in lung resections: A randomized controlled study. J Thorac Cardiovasc Surg 101:895-900, 1991 5. Matthews HR, Fischer BJ, Smith BE, et al: Minitracheostomy: A new delivery system for jet ventilation. J Thorac Cardiovasc Surg 92:673675, 1986 6. Nomori H, Horio H, Suemasu K: Assisted pressure control ventilation via a mini-tracheostomy tube for postoperative respiratory management of lung cancer patients. Respir Med 94:214-220, 2000 7. Nomori H, Ishihara T: Pressure-controlled ventilation via a minitracheostomy tube for patients with neuromuscular disease. Neurology 55:698-702, 2000 8. Parry GW, Batrick NC, Lau OJ, et al: Modification of minitracheostomy technique to limit bleeding complications. Eur J Cardiothorac Surg 9:659-660, 1995 9. Ben-nun A, Altman E, Best LA: Extended indications for percutaneous tracheostomy. Ann Thorac Surg 80:1276-1279, 2005 10. Ben-Nun A, Orlovsky M, Best LA: Percutaneous tracheostomy in patients with cervical spine fracture. ICVTS 2007 (in press) 11. van Heurn LW, van Geffen GJ, Brink PR: Percutaneous subcricoid minitracheostomy: Report of 50 procedures. Ann Thorac Surg 59:707709, 1995 12. Campbell JB, Watson MG, Povery L, et al: Minitracheostomy and laryngeal function. J Laryngol Otolaryngol 1102:49-52, 1988