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Percutaneous dilational tracheostomy for airway control
Percutaneous
Dilational Tracheostomy Airway Control
Eddy H. Carrillo, MD, David A. Spain, MD, Jeffrey M. Bumpous, MD, Robert E. Schmieg, Frank B. Miller, MD, J. David Richardson, MD, Louisville, Kentucky
BACKGROUND: Endoscopic percutaneous dilational tracheostomy (PDT) is a good alternative to obtain safe and secure long-term airway control, and is associated with minimal morbidity and mortality. STUDY DESIGN: During a 14-month period, we prospectively studied 35 intensive care unit (ICU) trauma patients who underwent early PDT for the sole purpose of obtaining long-term airway control. All patients were determined to need a tracheostomy owing to extubation inability, need to maintain a patent airway, or need for continuous airway access for management of secretions. RESULTS: All patients had sustained multiple injuries with an average Injury Severity Score (ISS) of 29. The time from ICU admission to placement of the PDT was 8 t 5 days. The mean Glasgow Coma Scale at the time of the PDT was 10 (range 4 to 15), and 11 patients (31%) had an intracranial pressure device in place. The procedure was completed with bronchoscopic guidance in 33 patients, and in 2 it was converted to surgical tracheostomy (ST). There were no significant complications associated with the placement of the PDT. Two deaths were documented, neither related to the PDT placement. Compared with standard ST, charges were reduced by $1,750. CONCLUSIONS: Bedside endoscopic PDT for selected critically ill trauma patients is justified as a safe and effective alternative to ST. The low incidence of complications in PDT suggests that it can be done safely at bedside in the ICU. Am J Surg. 1997;174:489-473.0 1997 by Excerpta Medica, Inc.
T
racheostomy is often performed in patients requiring prolonged mechanical ventilation, to secure a longterm airway, to prevent the complications of longterm translaryngeal intubation, to facilitate withdrawal from a mechanical ventilator, and to provide a route for pulmonary toilet.1’2 Furthermore, a randomized trial by From the Department of Surgery (EHC, DAS, RES, FBM, JDR), Division of Otolaryngologic Surgery (JMB), University of Louisville School of Medicine, Ambulatory Care Building, Louisville, Kentucky. Requests for reprints should be addressed to Eddy H. Carrillo, MD, Department of Surgery, University of Louisville, Louisville, Kentucky 40292. Presented at the 43rd Annual Meeting of the Society of Head and Neck Surgeons, Can&n, Mexico, April lo-12,1997.
0 1997 by Excerpta All rights reserved.
Medica,
Inc.
for MD,
Rodriguez et al3 showed that early tracheostomy (within 72 hours of injury) was associated with a reduced incidence of pneumonia. The standard technique for this procedure has been surgical tracheostomy (ST) performed at the bedside or in the operating room.2 Percutaneous dilational tracheostomy (PDT) as described by Ciaglia et al4 in 1985 and similar techniques5-7 are gaining increased acceptance as an alternative to ST. Various prospective studies have reported a low rate of short- and long-term complications arising from the use of this techniquess” when compared with standard ST. Other advantages of PDT include short procedure time,5’13 fewer hospital charges to the patient,14x1’ r lower infection rate,15 favorable cosmetic results, and no operating room scheduling delays. There have been some concerns regarding the safety of this technique as a bedside alternative for critically ill patients. This review is our prospective clinical experience with bedside PDT in critically ill trauma patients to determine its safety and feasibility in a high-risk population.
PATIENTS
AND
METHODS
Patients Over a l+month period ending in October 1996,35 critically injured patients admitted to the Trauma Service at the University of Louisville Hospital underwent bedside PDT placement in the Surgical Intensive Care Unit (SICU). Demographic information (age, gender, mechanism of injury, Glasgow Coma Scale [GCS], Injury Severity Score [ISS]),16 success rate, short-term and long-term complications, hospital charges, and mortality were evaluated. Anesthesia In all patients 1% lidocaine was used as a local anesthetic. Intravenous sedation was used, with benzodiazepines, barbiturates, and morphine. If necessary, short-term chemical paralysis was achieved with vecuronium bromide. In some patients, propofol was also used as a rapidly acting intravenous anesthetic agent. Surgical Technique All procedures were performed at bedside in the SICU by a general surgery resident under continuous supervision by the trauma attending staff, with the assistance of a respiratory therapist and nursing staff. Universal precautions and sterile conditions were maintained. Blood pressure, pulse oximetry, and cardiac activity were routinely monitored. When available, end-tidal CO2 (PETCOz) and intracranial pressure (ICP), if present, were also monitored. The procedure was performed under endoscopic guidance to aid in 0002-961 O/97/$1 7.00 PII 50002-961 0(97)001.57-8
469
Figure Figure
1. Wire guide introduction, with removal of Teflon courtesy of Cook Inc., Bloomington, Indiana.
sheath.
positioning and in reducing insertion-related complications, and to facilitate teaching the procedure. In all patients, a percutaneous dilational tracheostomy kit (Cook Critical Care, Bloomington, Indiana) was utilized, following the progressive dilational technique initially described by Ciaglia and associates,4 and more recently by Marelli et all7 The patient was placed in the supine position, the neck hyperextended, and ventilated with 100% FIOz. The operating surgeon normally stood to the right of the patient. An assistant located at the head of the bed attended to the manipulation of the endotracheal tube and endoscopy. In all our cases we used a flexible bronchoscope (Olympus BFT-10) attached to a high-resolution video monitor. The anterior neck was prepared and draped as for standard ST. The area of the tracheostomy was determined, usually 1 cm to 2 cm below the palpable lower edge of the cricoid and centered over the trachea, corresponding to the second or third tracheal ring. Proper selection of the insertion site is critical for the success of this procedure. A vertical incision of 1.0 to 1.5 cm was made, and the underlying tissue was bluntly separated with a clamp. Under endoscopic guidance, the endotracheal tube cuff was deflated and the tube withdrawn 1 cm, making necessary adjustments to the respirator. The proper site was identified by the insertion through the skin incision in the midline of a fine needle attached to a 10 mL syringe partially filled with 1% lidocaine. Once the proper location of the needle in the lumen of the trachea was identified, 2 to 3 mL lidocaine was sprayed and the needle removed. A syringe half filled with 1% lidocaine was attached to the 17-gauge Tef470
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Figure 2. Wire guide and guiding catheter are advanced as a unit into the trachea to position the skin positioning marks (safety ridge) on the guiding catheter to the skin level. Proper positioning is important to prevent trauma to the posterior tracheal wall during subsequent dilations. Figure courtesy of Cook Inc., Bloomington, Indiana.
lon introducer catheter and placed through the insertion site. It is important not to impale the endotracheal tube with the needle; this was usually avoided with the endoscopic guidance. When free flow of air was obtained, the inner needle assembly was removed and the outer Teflon sheath advanced several millimeters. A 0.052 inch (1.32 mm) Safe-T-J wire guide was inserted through the introducer catheter, which was then removed (Figure 1). With the wire guide in place, a small Teflon catheter was first placed over the wire guide into the trachea and then removed. Next, a guiding catheter was advanced into the trachea until the safety ridge was at the skin level. All dilations were done over this “double guide” to avoid any tracheal injury (Figure 2). Dilations usually started with a 12F dilator, and serial dilations of the trachea were then performed. The tapered tip of the serial dilators should point towards the carina during each pass. The stoma was then enlarged by passing progressively larger dilators (Figure 3). Finally, the tracheostomy tube was loaded into the appropriate size dilator (tracheostomy tube sizes 6 and 8 accommodated over tapered dilator sizes 28F and 32F, respectively). The dilator, tracheostomy tube, guiding catheter, and wire guide were advanced as a unit into the trachea (Figure 4), occasionally assisted by a twisting motion as the tube entered the tracheal lumen. The NOVEMBER
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Figure 3. While maintaining the visual reference point and positioning relationships, the guide wire, guiding catheter, and dilator are advanced as a unit, with a twisting motion, to the skin level mark. Figure courtesy of Cook Inc., Bloomington, Indiana.
dilator, guiding catheter, and wire guide were removed, and the inner cannula of the tracheostomy tube was placed. The balloon cuff was inflated, and the ventilator attached to the patient. When available, the PETCOZ waveform was monitored, bilateral breath sounds auscultated, and the tracheostomy tube secured in a standard fashion. We routinely performed a bronchoscopy at the end of the procedure for pulmonary toilet or specimen collection, and obtained a chest x-ray film.
RESULTS Thirty-five multiple trauma patients aged 18 to 63 years (average 34) underwent attempted bedside PDT placement in the SICU. There were 29 men and 6 women. All patients were determined to be in need of a tracheostomy owing to inability to proceed with extubation secondary to multiple conditions, especially severe injuries to the central nervous system in 16 patients (46%), need of continuous airway access for management of secretions or pulmonary toilet in 8 patients (23%), multiple facial injuries in 6 patients, and other conditions requiring long-term airway control in 5 patients. The mechanism of injury was blunt trauma in 21 (motor vehicle accident in 18, fall in 3), gunshot wounds in 8, and various other injuries in 6 patients. All patients had sustained multiple associated injuries with an average of 4 per patient, with a mean ISS of 29 (range 13 to 39). Glasgow Coma Scores upon admission were 3 to 12 (mean 8), and on the day of PDT, 4 to 15 THE AMERICAN
Figure 4. Preloaded tracheostomy tube is advanced over wire guide and guiding catheter into the trachea as a unit. Dilator, guiding catheter, and wire guide are then removed. Figure courtesy of Cook Inc., Bloomington, Indiana.
(mean 10). All but 3 patients underwent different major surgical procedures, including 12 early fixations of long bone fractures, 9 craniotomies, and 8 exploratory laparotomies; and 6 patients required delayed reconstruction of maxillofacial injuries. At the time of PDT all patients were endotracheally intubated and on a mechanical ventilator. The time from the SICU admission to the placement of the PDT was 8 days (range 3 to 13). Eleven patients (31%) had an ICP monitoring device in place. For the first 20 patients, the average time for completion of the procedure was 28 minutes, whereas for the last 10 patients, the procedure was completed in less than 15 minutes. In all patients a Shiley disposable cannula low pressure cuff tracheostomy tube (Mallinckrodt Medical TPI, Inc., Irvine, California) was used. A #8 (inner diameter 8.5 mm, outer diameter 12.0 mm) was used in 30 patients, and a #6 (inner diameter 7.0 mm, outer diameter 10.0 mm) in 3 patients. Compared with standard ST, hospital charges were reduced by approximately $1,750 per patient. Complications and Mortality There were no significant clinical complications associated with or as a result of the placement of the PDT. One patient developed a transient elevation of the ICP during a rather long procedure. One patient developed localized peristomal subcutaneous emphysema that resolved spontaneously. Another patient with a neck hematoma developed JOURNAL
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a bloody drainage of the retained hematoma that stopped spontaneously. There was no documented evidence of stoma1 infection in any patient. In 5 patients, it was felt that the PDT facilitated successful ventilator weaning after prolonged and unsuccessful previous attempts. The procedure was completed in 33 patients (94%), and in 2 it was converted to a ST after a failed percutaneous attempt. There were 2 deaths documented in this group of patients, neither related to the PDT placement.
COMMENTS The current technique of PDT, initially described by Ciaglia et al4 in 1985, is a modification of the Amplatz percutaneous dilational nephrostomy. The technique is fast, consistent, easy to teach, and relatively inexpensive compared with ST by standard operating room methods. Currently, we use the technique described by Marelli and associates,17 where the bronchoscope is used to identify the site of PDT by transillumination and palpation. The use of bronchoscopy adds an element of safety, especially when the procedure is being taught to residents. On our Trauma Service, the indications for PDT are basically the same as for ST, and include (1) airway control in patients who need prolonged mechanical ventilation, (2) airway access for management of secretions and pulmonary toilet, (3) upper airway obstructions, and (4) extensive and severe maxillofacial injuries. In emergency situations, PDT should not be used as an alternative to either cricothyroidotomy or ST. Hyperextension of the neck for anterior displacement of the trachea is a crucial technical point. The procedure is not recommended, therefore, when neck manipulation is contraindicated. Its use should be considered carefully for patients with (1) hemodynamic instability, (2) high levels of ventilatory support, (3) patients with enlarged thyroids, (4) pediatric population, (5) coagulopathy, (6) recent neck surgery, and (7) documented or suspected cervical spine injuries. A standard tracheostomy tray should be available during the procedure, and all cases should be performed or supervised by someone experienced with standard ST. It is important to emphasize that proper sedation, local pain control, and occasionally chemical paralysis should be obtained to avoid sudden increases in the ICI’ in patients with severe head injuries. No significant technical complications were observed during the performance of this procedure. The decrease in the length of operative time during the last half of this experience is a reflection of our learning curve as well as of the introduction of larger dilators (38F) in the newer PDT kits. A transient but significant elevation of the ICI’ was noted in 1 patient with a small (7.5 inner diameter) endotracheal tube and a difficult PDT placement. Currently, in patients with small endotracheal tubes, we attempt to replace the tube with a larger one or proceed with a PDT without endoscopic guidance to avoid technical difficulties, or sudden increases in the ICP, a complication that has been previously described.18 The procedure was successfully completed in 33 patients (94%). In 2 patients, the procedure was not completed because of a very small and pliable trachea in a 21-year-old woman and a calcified trachea in a 61-year-old man. We have found that using a curved mosquito clamp as described by Moore at al’* to gently dissect vertically and 472
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transversely down to the anterior tracheal wall, and then spread horizontally the tracheal opening, greatly facilitates the procedure. Some concerns about the potential long-term complications of PDT have been addressed by Ciaglia and Graniero,’ who reported that one of their original 26 patients developed delayed subcricoidal tracheal stenosis. Hazard et al5 reported that 2 of 11 (18%) patients who underwent PDT had tomographic evidence of subcricoid stenosis. However, they reported an incidence of tracheal stenosis of 63% in the patients who underwent ST. In a more recent report, Rosenbower et alI9 described their long-term complication rate of PDT in critically injured patients; of 95 PDT performed, 55 patients were available for evaluation, and of those, 40 (73%) were completely asymptomatic. Of the 15 symptomatic patients, 2 patients had acute airway compromise after decanulation secondary to subglottic stenosis. Both were recanulated and subsequently decannulated uneventfully. Six patients refused direct fiberoptic laryngoscopy (DFL) because their symptoms were minimal, and 9 patients underwent DFL; all examinations were determined to be normal. Of the 33 patients who underwent PDT in the current series, 1 patient has developed subglottic stenosis, confirmed by DFL. This is a patient who sustained 40% burns, with significant upper airway inhalation injury, and the PDT was performed after 2 weeks of translaryngeal intubation. The mechanism of injury in this patient may have contributed to her subglottic stenosis more than technical aspects of PDT. We believe that to minimize this catastrophic complication, the PDT should be performed through the second or third tracheal ring, rather than through a subcricoid approach.
CONCLUSION Percutaneous dilational tracheostomy is an easy, rapid, and minimally invasive technique, for secure and long-term airway control. The surgeon requires not only precise knowledge of cervical anatomy and manual skills to perform this technique but also an awareness of contraindications and how to proceed if there are technical problems. In patients with severe brain injuries, adequate sedation, chemical paralysis, and the presence of an ICP monitor helps to minimize secondary insults to the brain. We believe that for critically ill trauma patients, PDT is a reliable and costeffective technique that can be performed as safely at bedside as ST can be performed in the operating room; and in this particular group of patients, it must be considered a superior alternative to the traditional ST.
REFERENCES 1. Heffner care unit.
JE, Miller KS, Sahn SA. Tracheostomy in the intensive Part I: indications, technique, management. Chest.
1986;90:269-274. 2. Hill BB, Zweng TN, Maley RH, et al. Percutaneous dilational tracheostomy: report of 356 Cases. J Trauma. 1996;40:238-243. 3. Rodriguez JL, Steinberg SM, Luchette FA, et al. Early tracheostomy for primary airway management in the surgical critical care setting. Surgery. 1990;108:655-659. 4. Ciaglia P, Firsching R, Syniec C. Elective percutaneous dilational tracheostomy. A new simple bedside procedure; preliminary report. Chest. 1985;87:715-719. 5. Hazard P, Jones C, Benitone J. Comparative clinical trial of standard operative tracheostomy with percutaneous tracheostomy. Crit Care Med. 1991;19:1018-1024. NOVEMBER
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1 PERCUTANEOUS 6. Schachner A, Ovil Y, Sidi J, et al. Percutaneous tracheostomya new method. Crit Care Med. 1989;17:1052-1056. 7. Griggs WM, Worthley LIG, Gilligan JE, et al. A simple percutaneous tracheostomy technique. Surgery. 1990;170:543-545. 8. Bodenham A, Diment R, Cohen A, Webster N. Percutaneous dilational tracheostomy. A bedside procedure in the intensive care unit. Anesthesia. 1991;46:570-572. 9. Ciaglia I’, Graniero KD. Percutaneous dilational tracheostomy. Results and long-term follow-up. Chest. 1992;101:464-467. 10. Friedman Y, Mayer AD. Bedside percutaneous tracheostomy in critically ill patients. Chest. 1993;104:532-535. 11. Hazard PB, Garrett H Jr, Adams JW, et al. Bedside percutaneous tracheostomy: experience with 55 elective procedures. Ann Thorac Surg. 1988;46:63-67. 12. Fischler MP, Kuhn M, Cantieni R, Frutiger A. Late outcome of percutaneous dilational tracheostomy in intensive care patients. Intens Care Med. 1995;21:475-481. 13. Leinhardt DJ, Mughal M, Bowles B, et al. Appraisal of percutaneous tracheostomy. Br J Surg. 1992;79:255-258.
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14. Barba CA, Angood PB, Kauder DR, et al. Endoscopically guided percutaneous dilational tracheostomy: a safe, easy and costsaving procedure. Crit Care Med. 1993;21:S251. Abstract. 15. Toursarkissian B, Zweng TN, Kearney PA, et al. Percutaneous dilational tracheostomy: report of 141 cases. Ann Thorax Surg. 1994;57:862-867. 16. Baker SF’, O’Neill B, Haddon W, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. ] Trauma. 1974;14:187-196. 17. Marelli D, Paul A, Manolidis S, et al. Endoscopic guided percutaneous tracheostomy: Early results of d consecutive trial. J Traunla. 1990;30:433-435. 18. Moore FA, Haenel JB, Moore EE, Read RA. Percutaneous tracheostomy/gastrostomy in brain injured patients. A minimally invasive alternative. J Trauma. 1992;33:435-439. 19. Rosenbower TJ, Morris JA, Eddy VA, Ries WR. The long-term complication rate of percutaneous tracheostomy. Annual Scientific Meeting of the Southeastern Surgical Congress, Nashville, Tenn., February 1-5, 1997.
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Dilational Tracheostomy Airway Control
Eddy H. Carrillo, MD, David A. Spain, MD, Jeffrey M. Bumpous, MD, Robert E. Schmieg, Frank B. Miller, MD, J. David Richardson, MD, Louisville, Kentucky
BACKGROUND: Endoscopic percutaneous dilational tracheostomy (PDT) is a good alternative to obtain safe and secure long-term airway control, and is associated with minimal morbidity and mortality. STUDY DESIGN: During a 14-month period, we prospectively studied 35 intensive care unit (ICU) trauma patients who underwent early PDT for the sole purpose of obtaining long-term airway control. All patients were determined to need a tracheostomy owing to extubation inability, need to maintain a patent airway, or need for continuous airway access for management of secretions. RESULTS: All patients had sustained multiple injuries with an average Injury Severity Score (ISS) of 29. The time from ICU admission to placement of the PDT was 8 t 5 days. The mean Glasgow Coma Scale at the time of the PDT was 10 (range 4 to 15), and 11 patients (31%) had an intracranial pressure device in place. The procedure was completed with bronchoscopic guidance in 33 patients, and in 2 it was converted to surgical tracheostomy (ST). There were no significant complications associated with the placement of the PDT. Two deaths were documented, neither related to the PDT placement. Compared with standard ST, charges were reduced by $1,750. CONCLUSIONS: Bedside endoscopic PDT for selected critically ill trauma patients is justified as a safe and effective alternative to ST. The low incidence of complications in PDT suggests that it can be done safely at bedside in the ICU. Am J Surg. 1997;174:489-473.0 1997 by Excerpta Medica, Inc.
T
racheostomy is often performed in patients requiring prolonged mechanical ventilation, to secure a longterm airway, to prevent the complications of longterm translaryngeal intubation, to facilitate withdrawal from a mechanical ventilator, and to provide a route for pulmonary toilet.1’2 Furthermore, a randomized trial by From the Department of Surgery (EHC, DAS, RES, FBM, JDR), Division of Otolaryngologic Surgery (JMB), University of Louisville School of Medicine, Ambulatory Care Building, Louisville, Kentucky. Requests for reprints should be addressed to Eddy H. Carrillo, MD, Department of Surgery, University of Louisville, Louisville, Kentucky 40292. Presented at the 43rd Annual Meeting of the Society of Head and Neck Surgeons, Can&n, Mexico, April lo-12,1997.
0 1997 by Excerpta All rights reserved.
Medica,
Inc.
for MD,
Rodriguez et al3 showed that early tracheostomy (within 72 hours of injury) was associated with a reduced incidence of pneumonia. The standard technique for this procedure has been surgical tracheostomy (ST) performed at the bedside or in the operating room.2 Percutaneous dilational tracheostomy (PDT) as described by Ciaglia et al4 in 1985 and similar techniques5-7 are gaining increased acceptance as an alternative to ST. Various prospective studies have reported a low rate of short- and long-term complications arising from the use of this techniquess” when compared with standard ST. Other advantages of PDT include short procedure time,5’13 fewer hospital charges to the patient,14x1’ r lower infection rate,15 favorable cosmetic results, and no operating room scheduling delays. There have been some concerns regarding the safety of this technique as a bedside alternative for critically ill patients. This review is our prospective clinical experience with bedside PDT in critically ill trauma patients to determine its safety and feasibility in a high-risk population.
PATIENTS
AND
METHODS
Patients Over a l+month period ending in October 1996,35 critically injured patients admitted to the Trauma Service at the University of Louisville Hospital underwent bedside PDT placement in the Surgical Intensive Care Unit (SICU). Demographic information (age, gender, mechanism of injury, Glasgow Coma Scale [GCS], Injury Severity Score [ISS]),16 success rate, short-term and long-term complications, hospital charges, and mortality were evaluated. Anesthesia In all patients 1% lidocaine was used as a local anesthetic. Intravenous sedation was used, with benzodiazepines, barbiturates, and morphine. If necessary, short-term chemical paralysis was achieved with vecuronium bromide. In some patients, propofol was also used as a rapidly acting intravenous anesthetic agent. Surgical Technique All procedures were performed at bedside in the SICU by a general surgery resident under continuous supervision by the trauma attending staff, with the assistance of a respiratory therapist and nursing staff. Universal precautions and sterile conditions were maintained. Blood pressure, pulse oximetry, and cardiac activity were routinely monitored. When available, end-tidal CO2 (PETCOz) and intracranial pressure (ICP), if present, were also monitored. The procedure was performed under endoscopic guidance to aid in 0002-961 O/97/$1 7.00 PII 50002-961 0(97)001.57-8
469
Figure Figure
1. Wire guide introduction, with removal of Teflon courtesy of Cook Inc., Bloomington, Indiana.
sheath.
positioning and in reducing insertion-related complications, and to facilitate teaching the procedure. In all patients, a percutaneous dilational tracheostomy kit (Cook Critical Care, Bloomington, Indiana) was utilized, following the progressive dilational technique initially described by Ciaglia and associates,4 and more recently by Marelli et all7 The patient was placed in the supine position, the neck hyperextended, and ventilated with 100% FIOz. The operating surgeon normally stood to the right of the patient. An assistant located at the head of the bed attended to the manipulation of the endotracheal tube and endoscopy. In all our cases we used a flexible bronchoscope (Olympus BFT-10) attached to a high-resolution video monitor. The anterior neck was prepared and draped as for standard ST. The area of the tracheostomy was determined, usually 1 cm to 2 cm below the palpable lower edge of the cricoid and centered over the trachea, corresponding to the second or third tracheal ring. Proper selection of the insertion site is critical for the success of this procedure. A vertical incision of 1.0 to 1.5 cm was made, and the underlying tissue was bluntly separated with a clamp. Under endoscopic guidance, the endotracheal tube cuff was deflated and the tube withdrawn 1 cm, making necessary adjustments to the respirator. The proper site was identified by the insertion through the skin incision in the midline of a fine needle attached to a 10 mL syringe partially filled with 1% lidocaine. Once the proper location of the needle in the lumen of the trachea was identified, 2 to 3 mL lidocaine was sprayed and the needle removed. A syringe half filled with 1% lidocaine was attached to the 17-gauge Tef470
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Figure 2. Wire guide and guiding catheter are advanced as a unit into the trachea to position the skin positioning marks (safety ridge) on the guiding catheter to the skin level. Proper positioning is important to prevent trauma to the posterior tracheal wall during subsequent dilations. Figure courtesy of Cook Inc., Bloomington, Indiana.
lon introducer catheter and placed through the insertion site. It is important not to impale the endotracheal tube with the needle; this was usually avoided with the endoscopic guidance. When free flow of air was obtained, the inner needle assembly was removed and the outer Teflon sheath advanced several millimeters. A 0.052 inch (1.32 mm) Safe-T-J wire guide was inserted through the introducer catheter, which was then removed (Figure 1). With the wire guide in place, a small Teflon catheter was first placed over the wire guide into the trachea and then removed. Next, a guiding catheter was advanced into the trachea until the safety ridge was at the skin level. All dilations were done over this “double guide” to avoid any tracheal injury (Figure 2). Dilations usually started with a 12F dilator, and serial dilations of the trachea were then performed. The tapered tip of the serial dilators should point towards the carina during each pass. The stoma was then enlarged by passing progressively larger dilators (Figure 3). Finally, the tracheostomy tube was loaded into the appropriate size dilator (tracheostomy tube sizes 6 and 8 accommodated over tapered dilator sizes 28F and 32F, respectively). The dilator, tracheostomy tube, guiding catheter, and wire guide were advanced as a unit into the trachea (Figure 4), occasionally assisted by a twisting motion as the tube entered the tracheal lumen. The NOVEMBER
1997
PERCUTANEOUS
DILATIONAL
TRACHEOSTOMY/CARRILLO
ET AL
PROXIMAL DllAfOR WlREGUIDE MARK POSlTlONlNG
I L-i
POSlTlONlNG .__-..
Figure 3. While maintaining the visual reference point and positioning relationships, the guide wire, guiding catheter, and dilator are advanced as a unit, with a twisting motion, to the skin level mark. Figure courtesy of Cook Inc., Bloomington, Indiana.
dilator, guiding catheter, and wire guide were removed, and the inner cannula of the tracheostomy tube was placed. The balloon cuff was inflated, and the ventilator attached to the patient. When available, the PETCOZ waveform was monitored, bilateral breath sounds auscultated, and the tracheostomy tube secured in a standard fashion. We routinely performed a bronchoscopy at the end of the procedure for pulmonary toilet or specimen collection, and obtained a chest x-ray film.
RESULTS Thirty-five multiple trauma patients aged 18 to 63 years (average 34) underwent attempted bedside PDT placement in the SICU. There were 29 men and 6 women. All patients were determined to be in need of a tracheostomy owing to inability to proceed with extubation secondary to multiple conditions, especially severe injuries to the central nervous system in 16 patients (46%), need of continuous airway access for management of secretions or pulmonary toilet in 8 patients (23%), multiple facial injuries in 6 patients, and other conditions requiring long-term airway control in 5 patients. The mechanism of injury was blunt trauma in 21 (motor vehicle accident in 18, fall in 3), gunshot wounds in 8, and various other injuries in 6 patients. All patients had sustained multiple associated injuries with an average of 4 per patient, with a mean ISS of 29 (range 13 to 39). Glasgow Coma Scores upon admission were 3 to 12 (mean 8), and on the day of PDT, 4 to 15 THE AMERICAN
Figure 4. Preloaded tracheostomy tube is advanced over wire guide and guiding catheter into the trachea as a unit. Dilator, guiding catheter, and wire guide are then removed. Figure courtesy of Cook Inc., Bloomington, Indiana.
(mean 10). All but 3 patients underwent different major surgical procedures, including 12 early fixations of long bone fractures, 9 craniotomies, and 8 exploratory laparotomies; and 6 patients required delayed reconstruction of maxillofacial injuries. At the time of PDT all patients were endotracheally intubated and on a mechanical ventilator. The time from the SICU admission to the placement of the PDT was 8 days (range 3 to 13). Eleven patients (31%) had an ICP monitoring device in place. For the first 20 patients, the average time for completion of the procedure was 28 minutes, whereas for the last 10 patients, the procedure was completed in less than 15 minutes. In all patients a Shiley disposable cannula low pressure cuff tracheostomy tube (Mallinckrodt Medical TPI, Inc., Irvine, California) was used. A #8 (inner diameter 8.5 mm, outer diameter 12.0 mm) was used in 30 patients, and a #6 (inner diameter 7.0 mm, outer diameter 10.0 mm) in 3 patients. Compared with standard ST, hospital charges were reduced by approximately $1,750 per patient. Complications and Mortality There were no significant clinical complications associated with or as a result of the placement of the PDT. One patient developed a transient elevation of the ICP during a rather long procedure. One patient developed localized peristomal subcutaneous emphysema that resolved spontaneously. Another patient with a neck hematoma developed JOURNAL
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a bloody drainage of the retained hematoma that stopped spontaneously. There was no documented evidence of stoma1 infection in any patient. In 5 patients, it was felt that the PDT facilitated successful ventilator weaning after prolonged and unsuccessful previous attempts. The procedure was completed in 33 patients (94%), and in 2 it was converted to a ST after a failed percutaneous attempt. There were 2 deaths documented in this group of patients, neither related to the PDT placement.
COMMENTS The current technique of PDT, initially described by Ciaglia et al4 in 1985, is a modification of the Amplatz percutaneous dilational nephrostomy. The technique is fast, consistent, easy to teach, and relatively inexpensive compared with ST by standard operating room methods. Currently, we use the technique described by Marelli and associates,17 where the bronchoscope is used to identify the site of PDT by transillumination and palpation. The use of bronchoscopy adds an element of safety, especially when the procedure is being taught to residents. On our Trauma Service, the indications for PDT are basically the same as for ST, and include (1) airway control in patients who need prolonged mechanical ventilation, (2) airway access for management of secretions and pulmonary toilet, (3) upper airway obstructions, and (4) extensive and severe maxillofacial injuries. In emergency situations, PDT should not be used as an alternative to either cricothyroidotomy or ST. Hyperextension of the neck for anterior displacement of the trachea is a crucial technical point. The procedure is not recommended, therefore, when neck manipulation is contraindicated. Its use should be considered carefully for patients with (1) hemodynamic instability, (2) high levels of ventilatory support, (3) patients with enlarged thyroids, (4) pediatric population, (5) coagulopathy, (6) recent neck surgery, and (7) documented or suspected cervical spine injuries. A standard tracheostomy tray should be available during the procedure, and all cases should be performed or supervised by someone experienced with standard ST. It is important to emphasize that proper sedation, local pain control, and occasionally chemical paralysis should be obtained to avoid sudden increases in the ICI’ in patients with severe head injuries. No significant technical complications were observed during the performance of this procedure. The decrease in the length of operative time during the last half of this experience is a reflection of our learning curve as well as of the introduction of larger dilators (38F) in the newer PDT kits. A transient but significant elevation of the ICI’ was noted in 1 patient with a small (7.5 inner diameter) endotracheal tube and a difficult PDT placement. Currently, in patients with small endotracheal tubes, we attempt to replace the tube with a larger one or proceed with a PDT without endoscopic guidance to avoid technical difficulties, or sudden increases in the ICP, a complication that has been previously described.18 The procedure was successfully completed in 33 patients (94%). In 2 patients, the procedure was not completed because of a very small and pliable trachea in a 21-year-old woman and a calcified trachea in a 61-year-old man. We have found that using a curved mosquito clamp as described by Moore at al’* to gently dissect vertically and 472
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transversely down to the anterior tracheal wall, and then spread horizontally the tracheal opening, greatly facilitates the procedure. Some concerns about the potential long-term complications of PDT have been addressed by Ciaglia and Graniero,’ who reported that one of their original 26 patients developed delayed subcricoidal tracheal stenosis. Hazard et al5 reported that 2 of 11 (18%) patients who underwent PDT had tomographic evidence of subcricoid stenosis. However, they reported an incidence of tracheal stenosis of 63% in the patients who underwent ST. In a more recent report, Rosenbower et alI9 described their long-term complication rate of PDT in critically injured patients; of 95 PDT performed, 55 patients were available for evaluation, and of those, 40 (73%) were completely asymptomatic. Of the 15 symptomatic patients, 2 patients had acute airway compromise after decanulation secondary to subglottic stenosis. Both were recanulated and subsequently decannulated uneventfully. Six patients refused direct fiberoptic laryngoscopy (DFL) because their symptoms were minimal, and 9 patients underwent DFL; all examinations were determined to be normal. Of the 33 patients who underwent PDT in the current series, 1 patient has developed subglottic stenosis, confirmed by DFL. This is a patient who sustained 40% burns, with significant upper airway inhalation injury, and the PDT was performed after 2 weeks of translaryngeal intubation. The mechanism of injury in this patient may have contributed to her subglottic stenosis more than technical aspects of PDT. We believe that to minimize this catastrophic complication, the PDT should be performed through the second or third tracheal ring, rather than through a subcricoid approach.
CONCLUSION Percutaneous dilational tracheostomy is an easy, rapid, and minimally invasive technique, for secure and long-term airway control. The surgeon requires not only precise knowledge of cervical anatomy and manual skills to perform this technique but also an awareness of contraindications and how to proceed if there are technical problems. In patients with severe brain injuries, adequate sedation, chemical paralysis, and the presence of an ICP monitor helps to minimize secondary insults to the brain. We believe that for critically ill trauma patients, PDT is a reliable and costeffective technique that can be performed as safely at bedside as ST can be performed in the operating room; and in this particular group of patients, it must be considered a superior alternative to the traditional ST.
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