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The percutaneous dilatational subcricoid tracheostomy
f 1994132. 24. -25
I
I
The percutaneous dilatational subcricoid tracheostomy P. D. Earl, J. C. Lowry Depurtment of Ornl and Muxillofucid
Surgery, Bolton Gwwrul Hospitd, Bolton
SI!.!MMA R Y. Tracheostomy is frequently required during maxillofacial procedures. The percutaneous technique is described and advocated as a rapid easily mastered procedure, although there is a definite learning curve and it is not without a potential for complications.
Tracheostomy is indicated where there is a need for an artificial airway for longer than two weeks, where there is prolonged absence of laryngeal reflexes, to aid tracheobronchial toilet, in head and neck injury and upper airway obstruction.’ It is frequently necessary in oral and maxillofacial surgical practice as an aid to airway control in the early post operative phase following resection of malignant disease arising in the oral tissues. One difficulty that may be encountered is the merging of the subcutaneous dissection for tracheostomy with that of the inferomedial extent of neck dissection. This could lead to contamination of the neck dissection &Id by organisms colonising the trachcobronchial tree. It can be minimised with a vertical skin incision but some subcutaneous dissection is still required.2 The percutaneous dilatational subcricoid tracheostomy” overcomes these difficulties. A disadvantage is that it is carried out blind although it is as readily mastered as any other technique based on the principle of a guide wire and introducer. There are contra indications and these include the presence of an enlarged thyroid gland, impalpable cricoid cartilage and tracheostomy in young children.3
liig. 1 - Easy aspiration syringe.
of air from
trachea
into saline filled
At this stage it is important to ensure that the nccdlc has not impaled the endotracheal tube. The anaesthetist should therefore withdraw the tube a little and of course if it has been penetrated the introducer will move. In this event the last procedure will need to be repeated. Once it is clear that the tube is unbreached and above the level of the trachcostomy site the needle can be withdrawn and the sheath advanced further into the trachea. The guide wire (Fig. 2C) is then passed through the introducer well down the trachea and the sheath removed. A small initial dilator (Fig. 2E) is then passed over the guide wire into the initial access site. The dilator is removed leaving the guide wire in position and the 8F guiding catheter (Fig. 2H) is passed over the latter. The end with two positioning marks should be introduced towards the patient. The proximal end of the guiding catheter should be aligned with the solder mark on the guide wire. The &wide wire and guiding catheter are then positioned as a unit with the skin level marks at the tracheal entrance site and serial dilation commencing with the 12F dilator. Dilation should be continued until the entrance site is appropriate for the tracheostomy tube of choice. It may be necessary to over dilate to allow adequate space. An appropriately sized dilator (Table) is lubricated
Technique The patient is prepared and towelled as for a standard trachcostomy with the neck extended and shoulders supported. The cricoid cartilage and first tracheal ring arc identified and a small volume of local anaesthetic infiltrated. A vertical incision 1 to 1.5 cm is made in the mid line above the space between the cricoid cartilage and first tracheal ring. The tips of a pair of curved artery forceps are inscrtcd into the incision and the surface of the trachea cleared by blunt dissection. This is especially important if problems are to bc avoided during dilatation. A 10 cc syringe, half filled with stcrilc saline, is attached to the 17 gauge needle and introducer. This is passed through the incision in the sagittal plane at 45 degrees cephalad to the vertical and advanced into the trachea. Confirmation of entry into the trachea is by easy aspiration of air bubbles into the saline (Fig. 1). 24
The percutaneous
Fig. 2 - Armamentarium: (A) 28Fr tracheal dilator showing skin mark near tapcrcd end. Largest of six sizes. (B) 8Fr guiding cathctcr with positioning mark at each end. (C) Guide wire within retaining sleeve showing solder mark. (D) 17 gauge needle and introducer. (E) Initial dilator. Table - Relationship Tracheostomy inner diameter
of siles
of trachcostomy
tube (mm)
6 7 8 9
tubes
and dilators
Appropriate dilator for introduction (Fr) IX 21 24 28
for the chosen tracheostomy tube size, the balloon of which should be deflated (Fig. 3). The tube and dilator are then advanced into the trachea over the guide wire and the catheter which
dilatational
subcricoid
tracheostomy
following successful insertion of the tube may be withdrawn. The cuff is inIlated and ventilation vcrilicd as usual. The authors have now used the technique successfully in six cases prior to resection for malignant disease of the oral cavity. Although there is a definite learning curve: once mastered it is straight forward and should with experience, be completed in IO 15 min. It is lklt that wider acceptance in our specialty should prove beneficial. Open trachcostomy has been required following two cases with complications. The first was due to a misplaced guide wire and the second where the dilator passed laterally through the tracheal wall. On this occasion the endotracheal tube had not been withdrawn far enough thereby reducing the space available for the dilators. In general complications have been shown to be less frequent and less severe than those associated with conventional trachcostomy.4.s Keferenca I. Oh TE. Intensive Cart Manual, 3rd Ed. Sydney Butterworth’s. IYYO, p 151. 2. McGregor IA, M&ircgor FM. Cancer of the Face and Mouth Edinburgh: Churchill Livingstone. lY86. p 323. 3. Ciaglia P. Firschirg R, Syniec C. Elective percutaneous tracheostomy. A new simple bedside procedure: preliminary report. Chest 1985; X7: 715. 4. Hazard P. Jones C, Bcnitone J. Comparative clinical trial of standard operative tracheostomy with percutaneous trachcostomy. Critical Cat-c Medicine 1991; 19: IO18 1023. 5. Lcindhart DJ, Tan HKK, Rothcra M. Mughal MD. Comparison of conventional and percutaneous tracheostomy. Journal of the Royal College of Surgeons of Edinburgh. 199 1; 36: 350.
The Authors P. D. Earl FDS, FRCS Department of Oral and Maxillofacial North Manchester General Ilospital Delaunays Road Crumpsall Manchester M8 6RB ,I. C. Lowry FDSRCS, FRCS Department of Oral and Maxillofacial Bolton Generlll Hospital Minerva Road I~arnworth Bolton BL4 OJR Correspondence
Fig. 3 - Tracheostomy tube pre-loaded advanced into the trachea.
on to dilator
being
25
and requests
Paper received 30 April Accepted 3 May 1993
1993
Surgery
Surgery
for otlprints
to P. D. Earl
I
I
The percutaneous dilatational subcricoid tracheostomy P. D. Earl, J. C. Lowry Depurtment of Ornl and Muxillofucid
Surgery, Bolton Gwwrul Hospitd, Bolton
SI!.!MMA R Y. Tracheostomy is frequently required during maxillofacial procedures. The percutaneous technique is described and advocated as a rapid easily mastered procedure, although there is a definite learning curve and it is not without a potential for complications.
Tracheostomy is indicated where there is a need for an artificial airway for longer than two weeks, where there is prolonged absence of laryngeal reflexes, to aid tracheobronchial toilet, in head and neck injury and upper airway obstruction.’ It is frequently necessary in oral and maxillofacial surgical practice as an aid to airway control in the early post operative phase following resection of malignant disease arising in the oral tissues. One difficulty that may be encountered is the merging of the subcutaneous dissection for tracheostomy with that of the inferomedial extent of neck dissection. This could lead to contamination of the neck dissection &Id by organisms colonising the trachcobronchial tree. It can be minimised with a vertical skin incision but some subcutaneous dissection is still required.2 The percutaneous dilatational subcricoid tracheostomy” overcomes these difficulties. A disadvantage is that it is carried out blind although it is as readily mastered as any other technique based on the principle of a guide wire and introducer. There are contra indications and these include the presence of an enlarged thyroid gland, impalpable cricoid cartilage and tracheostomy in young children.3
liig. 1 - Easy aspiration syringe.
of air from
trachea
into saline filled
At this stage it is important to ensure that the nccdlc has not impaled the endotracheal tube. The anaesthetist should therefore withdraw the tube a little and of course if it has been penetrated the introducer will move. In this event the last procedure will need to be repeated. Once it is clear that the tube is unbreached and above the level of the trachcostomy site the needle can be withdrawn and the sheath advanced further into the trachea. The guide wire (Fig. 2C) is then passed through the introducer well down the trachea and the sheath removed. A small initial dilator (Fig. 2E) is then passed over the guide wire into the initial access site. The dilator is removed leaving the guide wire in position and the 8F guiding catheter (Fig. 2H) is passed over the latter. The end with two positioning marks should be introduced towards the patient. The proximal end of the guiding catheter should be aligned with the solder mark on the guide wire. The &wide wire and guiding catheter are then positioned as a unit with the skin level marks at the tracheal entrance site and serial dilation commencing with the 12F dilator. Dilation should be continued until the entrance site is appropriate for the tracheostomy tube of choice. It may be necessary to over dilate to allow adequate space. An appropriately sized dilator (Table) is lubricated
Technique The patient is prepared and towelled as for a standard trachcostomy with the neck extended and shoulders supported. The cricoid cartilage and first tracheal ring arc identified and a small volume of local anaesthetic infiltrated. A vertical incision 1 to 1.5 cm is made in the mid line above the space between the cricoid cartilage and first tracheal ring. The tips of a pair of curved artery forceps are inscrtcd into the incision and the surface of the trachea cleared by blunt dissection. This is especially important if problems are to bc avoided during dilatation. A 10 cc syringe, half filled with stcrilc saline, is attached to the 17 gauge needle and introducer. This is passed through the incision in the sagittal plane at 45 degrees cephalad to the vertical and advanced into the trachea. Confirmation of entry into the trachea is by easy aspiration of air bubbles into the saline (Fig. 1). 24
The percutaneous
Fig. 2 - Armamentarium: (A) 28Fr tracheal dilator showing skin mark near tapcrcd end. Largest of six sizes. (B) 8Fr guiding cathctcr with positioning mark at each end. (C) Guide wire within retaining sleeve showing solder mark. (D) 17 gauge needle and introducer. (E) Initial dilator. Table - Relationship Tracheostomy inner diameter
of siles
of trachcostomy
tube (mm)
6 7 8 9
tubes
and dilators
Appropriate dilator for introduction (Fr) IX 21 24 28
for the chosen tracheostomy tube size, the balloon of which should be deflated (Fig. 3). The tube and dilator are then advanced into the trachea over the guide wire and the catheter which
dilatational
subcricoid
tracheostomy
following successful insertion of the tube may be withdrawn. The cuff is inIlated and ventilation vcrilicd as usual. The authors have now used the technique successfully in six cases prior to resection for malignant disease of the oral cavity. Although there is a definite learning curve: once mastered it is straight forward and should with experience, be completed in IO 15 min. It is lklt that wider acceptance in our specialty should prove beneficial. Open trachcostomy has been required following two cases with complications. The first was due to a misplaced guide wire and the second where the dilator passed laterally through the tracheal wall. On this occasion the endotracheal tube had not been withdrawn far enough thereby reducing the space available for the dilators. In general complications have been shown to be less frequent and less severe than those associated with conventional trachcostomy.4.s Keferenca I. Oh TE. Intensive Cart Manual, 3rd Ed. Sydney Butterworth’s. IYYO, p 151. 2. McGregor IA, M&ircgor FM. Cancer of the Face and Mouth Edinburgh: Churchill Livingstone. lY86. p 323. 3. Ciaglia P. Firschirg R, Syniec C. Elective percutaneous tracheostomy. A new simple bedside procedure: preliminary report. Chest 1985; X7: 715. 4. Hazard P. Jones C, Bcnitone J. Comparative clinical trial of standard operative tracheostomy with percutaneous trachcostomy. Critical Cat-c Medicine 1991; 19: IO18 1023. 5. Lcindhart DJ, Tan HKK, Rothcra M. Mughal MD. Comparison of conventional and percutaneous tracheostomy. Journal of the Royal College of Surgeons of Edinburgh. 199 1; 36: 350.
The Authors P. D. Earl FDS, FRCS Department of Oral and Maxillofacial North Manchester General Ilospital Delaunays Road Crumpsall Manchester M8 6RB ,I. C. Lowry FDSRCS, FRCS Department of Oral and Maxillofacial Bolton Generlll Hospital Minerva Road I~arnworth Bolton BL4 OJR Correspondence
Fig. 3 - Tracheostomy tube pre-loaded advanced into the trachea.
on to dilator
being
25
and requests
Paper received 30 April Accepted 3 May 1993
1993
Surgery
Surgery
for otlprints
to P. D. Earl