- Email: [email protected]
Translaryngeal tracheotomy
Operative Techniques in Otolaryngology (2007) 18, 99-104
Translaryngeal tracheotomy Dirk Meininger, MD, Christian Byhahn, MD From the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, J.W. Goethe-University Medical School, Frankfurt, Germany. KEYWORDS Tracheotomy; Tracheostomy; Translaryngeal; Percutaneous; Complications; Wound infection; Bleeding
Translaryngeal tracheotomy (TLT) is a retrograde, one-step technique of percutaneous tracheotomy, creating a stoma from inside the trachea to the outside by means of a special cone cannula. After tracheal puncture, a guidewire is inserted and advanced cephalad. Thereafter, the cone cannula is connected to the guidewire and, by pulling the neck end of the wire, advanced through pharynx and larynx into the trachea. The sharp metal cone penetrates the anterior tracheal wall, soft tissues, and skin. The final steps comprise cutting off the cone, straightening and rotating the cannula by 180°, then pushing it down the trachea. Although a meta-analysis did not favor a specific percutaneous tracheotomy technique in terms of overall complications, TLT has specific advantages in high-risk intensive care unit patients, such as in those with critical coagulopathy or severe respiratory failure. Pediatric TLT sets are available; however, clinical experience with TLT in children and infants is still very limited. © 2007 Elsevier Inc. All rights reserved.
Tracheotomy is one of the most frequently performed surgical interventions in the intensive care unit. According to recent postal surveys, minimally invasive, percutaneous techniques are prevalent by far.1,2 The foundation for modern percutaneous tracheotomy was laid in 1953, when the Swedish radiologist Sven Ivar Seldinger reported a new technique of vessel catheterization, in which a guidewire was introduced through the puncture needle into the vessel, the needle withdrawn, and a catheter inserted via the guidewire.3 Salesman Bill Cook from Indiana and his cousin Van Fucilla, a radiologist, were the first to manufacture and distribute sets for vascular catheterization, and after its first use at the Illinois Masonic Hospital, Chicago, IL, in autumn 1963, “Seldinger’s technique” has become part of medical history. All techniques for percutaneous tracheotomy currently available—5 in total—are based on Seldinger’s technique.4-8 A potential disadvantage of percutaneous techniques so far has been that large-bore dilators and the tracheotomy tube itself were inserted into the trachea from anterior. Firm pressure often needs to be applied to the anterior tracheal wall, resulting in compression of the tracheal lumen and loss
Address reprint requests and correspondence: Christian Byhahn, MD, Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, J.W. Goethe-University Medical School, Frankfurt/M, Germany, Theodor-Stern-Kai 7, D-60590 Frankfurt, Germany. E-mail address: [email protected]. 1043-1810/$ -see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.otot.2007.05.009
of the bronchoscopic view. This mechanism is a major contributor to the most serious complication of percutaneous tracheotomy: posterior tracheal wall injury. In the early 1990s, Italian anesthesiologist Antonio Fantoni from Milan invented a retrograde percutaneous tracheotomy technique, translaryngeal tracheotomy (TLT). His idea was to dilate the trachea and the cervical tissue from the inside to the outside, thereby actively lifting the anterior tracheal wall and thus avoiding the risk of posterior tracheal wall injury.6 Four years later, a TLT kit (Tyco Healthcare, Athlone, Ireland) became commercially available, and TLT has gained increasing popularity among intensivists since then.
Indications and contraindications Indications for TLT include the prolonged but temporary need for an artificial airway in patients on intensive care. It has been proven in numerous studies that tracheotomy in critically ill patients facilitates weaning from the ventilator, reduces analgesic and sedative requirements, improves airway toilet, allows for oral feeding and verbal communication, and avoids laryngeal injury due to prolonged endotracheal intubation. However, a few important contraindications exist and should be strictly observed. Digital identification of cricoid cartilage and trachea is essential because accidental injury to the cricoid cartilage may result
100
Operative Techniques in Otolaryngology, Vol 18, No 2, June 2007
Figure 1 Needle and guidewire insertion under bronchoscopic visualization, showing the endotracheal tube withdrawn and wire passing both inside (A) and outside (B) the tube. (Reprinted with permission from Fantoni and Ripamonti.6)
in circumferential shrinking of the cricoid and subsequent subglottic stenosis. Other contraindications comprise emergency airway access, patients with known or expected difficult airway, and the need for permanent tracheotomy, eg, in cancer patients.
Operative technique TLT is typically performed at the patient’s bedside in the intensive care unit under general intravenous anesthesia. Sufficient muscle relaxation should be ensured to eliminate any coughing or gagging during tracheal puncture, which may result in accidental puncture of the posterior tracheal wall. The respirator is set to a controlled mode—typically to volume-controlled ventilation—and 100% oxygen. Next, the patient’s neck is positioned in slight extension to digitally identify the cricoid cartilage and the first 2 or 3 tracheal rings. Because the tracheotomy cannula is pulled through the oral cavity and the trachea before passing the cervical tissue, the procedure per se is not sterile. Sufficient skin disinfection should be performed and sterile gloves must be used, but sterile draping is not necessary. When the skin has been disinfected, secretions are suctioned off from the oral cavity. The endotracheal tube in place is pulled back to the glottic area under direct laryngoscopy, thereby confirming that the glottis can be safely visualized. A flexible bronchoscope (diameter, 3.4-5.0 mm) is introduced into the endotracheal tube, with its tip being inside the tube’s lumen to avoid accidental puncture of the scope. Then, a slightly curved cannula is introduced into the lumen between the second and third tracheal ring and the needle’s outlet pointed toward the lumen of the endotracheal tube. A spe-
cial guidewire is introduced through the needle and advanced retrogradely inside the endotracheal tube. Alternatively, but technically more challenging and time consuming, the guidewire may be advanced alongside the endotracheal tube (Figure 1). The bronchoscope is now withdrawn and the endotracheal tube disconnected from the ventilator. Once the guidewire either exits the tube’s proximal end or is seen in the oral cavity and caught with Magill’s forceps, the tube is withdrawn and the patient’s trachea immediately reintubated with a special ventilation catheter (length, 40 cm; internal diameter, 5.0 mm) from the set, with its cuff positioned distally to the puncture site, typically close to the
Figure 2 By pulling the neck end of the wire, the cone cannula enters the oral cavity. Ventilation is continuously maintained via the small-bore ventilation catheter. (Color version of figure is available online.)
Meininger and Byhahn
Translaryngeal Tracheotomy
Figure 3 The cone penetrates the skin. A small skin incision is made to facilitate cannula extraction. (Color version of figure is available online.)
carina. Despite its small diameter, the ventilation catheter allows for adequate ventilation of the patients, provided volume-controlled ventilation is used or peak inspiratory pressure is adjusted with respect to the smaller diameter of the catheter in pressure-controlled ventilation modes. Even in patients who are dependent on high levels of positive end-expiratory pressure (PEEP), it is possible to maintain the same PEEP level as before (Figure 2). The flexible TLT cannula has a cone-shaped metal tip with a central hole through which the mouth-side end of the guidewire is passed after its stiffer part has been separated at a particular marking from the more flexible portion, using a pair of scissors. A knot is made in the wire, and by pulling
101 the neck end of the wire, the knot is pulled toward the bottom of the cone. With a pull handle, traction on the neck end of the wire is started, thereby stabilizing the anterior cervical tissues by applying firm counterpressure. A skin incision is rarely necessary and should be limited to 1- to 2-mm-long incisions on constricting tissue rings of the skin to reduce resistance (Figure 3). The cone cannula enters the oral cavity, passes between the vocal cords, and exits the patient’s anterior neck through the anterior tracheal wall and the soft tissues of the neck. When anterior tracheal wall and pretracheal fascia are dilated to their fullest degree, a sudden loss of resistance is felt. The conecannula is extracted approximately halfway (Figure 4), and the cone is separated from the cannula with a pair of scissors at the markings on the cannula. Because the end of the cannula still points toward the pharynx, a stiff plastic obturator from the set is introduced into the cannula to straighten it first (Figure 5). When the cannula is perpendicular to the trachea, it is rotated by 180° until the black longitudinal line on the cannula faces cephalad (Figures 6 and 7). The cannula is then pushed down the trachea, assisted by the obturator and the cannula’s natural curvature. Correct intratracheal position of the cannula is confirmed with the flexible bronchoscope. Thereafter, both portions of the inflating tube are joined, the small-bore ventilation catheter is removed, the cannula’s cuff is inflated, and the cannula is fixed with a flange.
Discussion Based on a recent meta-analysis,9 no significant differences in terms of perioperative complications were found between
Figure 4 Extraction of the cone cannula, showing digital counterpressure applied from anterior. The small-bore ventilation catheter is placed with its tip distal to the tracheotomy site to ensure continuity of ventilation. (Reprinted with permission from Fantoni and Ripamonti.6)
102
Operative Techniques in Otolaryngology, Vol 18, No 2, June 2007
Severe respiratory insufficiency
Figure 5 The cannula is extracted halfway, and the cone is now being cut off. (Color version of figure is available online.)
the different techniques for percutaneous tracheotomy. The incidence of severe, potentially life-threatening complications (eg, death, tracheoesophageal fistula, posterior tracheal wall injury requiring surgical repair) that are likely to increase patients’ morbidity and mortality was 0.5%. TLT, however, has some specific features that have been proven to be advantageous in high-risk patients.
Perioperative bleeding Compared with standard, surgical tracheotomy, the overall risk of significant hemorrhage, either intra- or postoperatively, is significantly lower with percutaneous techniques and even less with TLT. Bleeding is unlikely because the stoma is created with the cannula itself in a single step instead of dilating the tissues first and subsequently inserting a cannula, which is the case with any other technique than TLT. The perfect adherence of the TLT cannula to the cervical tissues results in sufficient tamponade of eventual bleeding. Therefore, TLT should be the preferred percutaneous technique in patients at high risk for bleeding, ie, in cases of severe coagulopathy or whenever therapeutic anticoagulation is required, such as for hemodialysis, extracorporeal membrane oxygenation, or ventricular-assist devices. In the current literature, there are no cases of significant bleeding associated with TLT. Even the safe use of TLT in a hemophiliac patient with inhibitors to factor VIII has been reported.10
During the entire procedure of TLT, regardless of its duration, the patient can be sufficiently ventilated via the small-bore ventilation catheter. With other percutaneous tracheotomy techniques, large-bore dilators often interfere with sufficient oxygenation and carbon dioxide elimination,11,12 which is a cause of concern in patients with elevated intracranial pressure. High levels of PEEP are also often difficult to maintain during percutaneous tracheotomy, when changing dilators and cannula placement result in unavoidable airway leak and subsequent loss of PEEP, thereby potentially deteriorating gas exchange. With TLT, there is only one brief moment of apnea and loss of PEEP when the endotracheal tube in place is replaced by the small-bore ventilation catheter. As a result, TLT can be safely employed even in patients with poor respiratory function.10
Infectious complications Peristomal infections commonly observed after standard tracheotomy are a rarity when percutaneous techniques are used.11 However, fresh surgical wounds or wound infections in very close proximity to the tracheotomy are still considered a relative contraindication for percutaneous tracheotomy. The risk of cross-contamination of the adjacent surgical wound with bacteria from the airway is deemed high, as is the risk of bacterial spread from an infected cervical region into the patient’s airway. Because of the tight tissue seal around the TLT cannula, there are neither any reports of peristomal infection after TLT nor reports regarding infection of adjacent surgical wounds, eg, after anterior cervical spine surgery or esophageal surgery with cervical anastomosis. TLT should therefore be considered the percutaneous technique of choice whenever tracheotomy is required in patients shortly after cervical surgery or in patients with infected wounds close the tracheotomy site (Figure 8).
Percutaneous tracheotomy in children Percutaneous tracheotomy is considered absolutely contraindicated in children. On one hand, the narrow and soft juvenile trachea is prone to tracheotomy-related injuries when pressure is exerted with dilators from anterior. On the other hand, percutaneous tracheotomy kits are unavailable
Figure 6 A corresponding obturator is introduced into the cannula (left) to straighten it (middle). Thereafter, the cannula is turned 180° by means of the obturator (right). Note that cephalad facing of the cannula markings indicated correct rotation (right). (Color version of figure is available online.)
Meininger and Byhahn
Translaryngeal Tracheotomy
103
Figure 7 Positioning of the cannula in 3 steps: (1) initial position of the cannula; (2) cannula in fully straightened position (the rotation maneuver is being performed); (3) cannula in final position. Alternatively to the obturator (B), a rigid optical lens (A) can be used. (Reprinted with permission from Fantoni and Ripamonti.6)
in pediatric sizes. Toursarkissian and colleagues13 published a case series (n ⫽ 11) of classic Ciaglia dilational tracheotomies performed in teenagers aged 10 to 20 years. Apart from this report, only a few other cases of percutaneous tracheotomy in children have been published during the past 2 decades. To date, TLT is the first and only percutaneous tracheotomy technique that has been successfully employed in small children and even infants aged 2 months to 10
years.6,14 Because of its retrograde dilational technique, injuries to the particularly vulnerable pediatric posterior tracheal wall are much less likely than with antegrade techniques. Even though the TLT kit is currently available in various cannula sizes as small as 5.5 mm, experiences in small children are still limited to Fantoni and Ripamonti’s reports.6,14
Conclusion TLT represents the only retrograde technique for percutaneous tracheotomy. Because stoma dilation is achieved with the tracheotomy cannula itself, bleeding and stomal infection are highly unlikely, making TLT an attractive alternative to other percutaneous techniques, especially in high-risk patients. Although pediatric-sized TLT kits are available, experience in children is still very limited.
References
Figure 8 TLT performed in a patient with wound infection after esophageal surgery. Despite the close proximity of the infected surgical wound to the tracheostomy site, spread of bacteria into the stoma or the airway is highly unlikely. Ventilation is currently maintained with the small-bore ventilation catheter. (Color version of figure is available online.)
1. Krishnan K, Elliot SC, Mallick A: The current practice of tracheostomy in the United Kingdom: A postal survey. Anaesthesia 60:360364, 2005 2. Fikkers BG, Fransen GA, van der Hoeven JG, et al: Tracheostomy for long-term ventilated patients: A postal survey of ICU practice in The Netherlands. Intensive Care Med 29:1390-1393, 2003 3. Seldinger SI: Catheter replacement of the needle in percutaneous arteriography: A new technique. Acta Radiol 39:368-376, 1953 4. Ciaglia P, Firsching R, Syniec C. Elective percutaneous dilatational tracheostomy: A new simple bedside procedure: Preliminary report. Chest 87:715-719, 1985
104
Operative Techniques in Otolaryngology, Vol 18, No 2, June 2007
5. Griggs WM, Worthley LI, Gilligan JE, et al: A simple percutaneous tracheostomy technique. Surg Gynecol Obstet 170:543-545, 1990 6. Fantoni A, Ripamonti D: A non-derivative, non-surgical tracheostomy: The translaryngeal method. Intensive Care Med 23:386-392, 1997 7. Byhahn C, Wilke HJ, Halbig S, et al: Percutaneous tracheostomy: Ciaglia blue rhino versus the basic Ciaglia technique of percutaneous dilational tracheostomy. Anesth Analg 91:882-886, 2000 8. Frova G, Quintel M: A new simple method for percutaneous tracheostomy: Controlled rotating dilation: a preliminary report. Intensive Care Med 28:299-303, 2002 9. Byhahn C, Westphal K, Zwissler B: Percutaneous tracheostomy. Anaesth Intensivmed 46:125-137, 2005
10. Byhahn C, Lischke V, Westphal K: Translaryngeal tracheostomy in highly unstable patients. Anaesthesia 55:678-682, 2000 11. Westphal K, Byhahn C, Rinne T, et al: Tracheostomy in cardiosurgical patients: Surgical tracheostomy versus Ciaglia and Fantoni methods. Ann Thorac Surg 68:486-492, 1999 12. Reilly PM, Anderson HL 3rd, Sing RF, et al: Occult hypercarbia: an unrecognized phenomenon during percutaneous endoscopic tracheostomy. Chest 107:1760-1763, 1995 13. Toursarkissian B, Fowler CL, Zweng TN, et al: Percutaneous dilational tracheostomy in children and teenagers. J Pediatr Surg 29:14211424, 1994 14. Fantoni A, Ripamonti D: Tracheostomy in pediatrics patients. Minerva Anestesiol 68:433-442, 2002
Translaryngeal tracheotomy Dirk Meininger, MD, Christian Byhahn, MD From the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, J.W. Goethe-University Medical School, Frankfurt, Germany. KEYWORDS Tracheotomy; Tracheostomy; Translaryngeal; Percutaneous; Complications; Wound infection; Bleeding
Translaryngeal tracheotomy (TLT) is a retrograde, one-step technique of percutaneous tracheotomy, creating a stoma from inside the trachea to the outside by means of a special cone cannula. After tracheal puncture, a guidewire is inserted and advanced cephalad. Thereafter, the cone cannula is connected to the guidewire and, by pulling the neck end of the wire, advanced through pharynx and larynx into the trachea. The sharp metal cone penetrates the anterior tracheal wall, soft tissues, and skin. The final steps comprise cutting off the cone, straightening and rotating the cannula by 180°, then pushing it down the trachea. Although a meta-analysis did not favor a specific percutaneous tracheotomy technique in terms of overall complications, TLT has specific advantages in high-risk intensive care unit patients, such as in those with critical coagulopathy or severe respiratory failure. Pediatric TLT sets are available; however, clinical experience with TLT in children and infants is still very limited. © 2007 Elsevier Inc. All rights reserved.
Tracheotomy is one of the most frequently performed surgical interventions in the intensive care unit. According to recent postal surveys, minimally invasive, percutaneous techniques are prevalent by far.1,2 The foundation for modern percutaneous tracheotomy was laid in 1953, when the Swedish radiologist Sven Ivar Seldinger reported a new technique of vessel catheterization, in which a guidewire was introduced through the puncture needle into the vessel, the needle withdrawn, and a catheter inserted via the guidewire.3 Salesman Bill Cook from Indiana and his cousin Van Fucilla, a radiologist, were the first to manufacture and distribute sets for vascular catheterization, and after its first use at the Illinois Masonic Hospital, Chicago, IL, in autumn 1963, “Seldinger’s technique” has become part of medical history. All techniques for percutaneous tracheotomy currently available—5 in total—are based on Seldinger’s technique.4-8 A potential disadvantage of percutaneous techniques so far has been that large-bore dilators and the tracheotomy tube itself were inserted into the trachea from anterior. Firm pressure often needs to be applied to the anterior tracheal wall, resulting in compression of the tracheal lumen and loss
Address reprint requests and correspondence: Christian Byhahn, MD, Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, J.W. Goethe-University Medical School, Frankfurt/M, Germany, Theodor-Stern-Kai 7, D-60590 Frankfurt, Germany. E-mail address: [email protected]. 1043-1810/$ -see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.otot.2007.05.009
of the bronchoscopic view. This mechanism is a major contributor to the most serious complication of percutaneous tracheotomy: posterior tracheal wall injury. In the early 1990s, Italian anesthesiologist Antonio Fantoni from Milan invented a retrograde percutaneous tracheotomy technique, translaryngeal tracheotomy (TLT). His idea was to dilate the trachea and the cervical tissue from the inside to the outside, thereby actively lifting the anterior tracheal wall and thus avoiding the risk of posterior tracheal wall injury.6 Four years later, a TLT kit (Tyco Healthcare, Athlone, Ireland) became commercially available, and TLT has gained increasing popularity among intensivists since then.
Indications and contraindications Indications for TLT include the prolonged but temporary need for an artificial airway in patients on intensive care. It has been proven in numerous studies that tracheotomy in critically ill patients facilitates weaning from the ventilator, reduces analgesic and sedative requirements, improves airway toilet, allows for oral feeding and verbal communication, and avoids laryngeal injury due to prolonged endotracheal intubation. However, a few important contraindications exist and should be strictly observed. Digital identification of cricoid cartilage and trachea is essential because accidental injury to the cricoid cartilage may result
100
Operative Techniques in Otolaryngology, Vol 18, No 2, June 2007
Figure 1 Needle and guidewire insertion under bronchoscopic visualization, showing the endotracheal tube withdrawn and wire passing both inside (A) and outside (B) the tube. (Reprinted with permission from Fantoni and Ripamonti.6)
in circumferential shrinking of the cricoid and subsequent subglottic stenosis. Other contraindications comprise emergency airway access, patients with known or expected difficult airway, and the need for permanent tracheotomy, eg, in cancer patients.
Operative technique TLT is typically performed at the patient’s bedside in the intensive care unit under general intravenous anesthesia. Sufficient muscle relaxation should be ensured to eliminate any coughing or gagging during tracheal puncture, which may result in accidental puncture of the posterior tracheal wall. The respirator is set to a controlled mode—typically to volume-controlled ventilation—and 100% oxygen. Next, the patient’s neck is positioned in slight extension to digitally identify the cricoid cartilage and the first 2 or 3 tracheal rings. Because the tracheotomy cannula is pulled through the oral cavity and the trachea before passing the cervical tissue, the procedure per se is not sterile. Sufficient skin disinfection should be performed and sterile gloves must be used, but sterile draping is not necessary. When the skin has been disinfected, secretions are suctioned off from the oral cavity. The endotracheal tube in place is pulled back to the glottic area under direct laryngoscopy, thereby confirming that the glottis can be safely visualized. A flexible bronchoscope (diameter, 3.4-5.0 mm) is introduced into the endotracheal tube, with its tip being inside the tube’s lumen to avoid accidental puncture of the scope. Then, a slightly curved cannula is introduced into the lumen between the second and third tracheal ring and the needle’s outlet pointed toward the lumen of the endotracheal tube. A spe-
cial guidewire is introduced through the needle and advanced retrogradely inside the endotracheal tube. Alternatively, but technically more challenging and time consuming, the guidewire may be advanced alongside the endotracheal tube (Figure 1). The bronchoscope is now withdrawn and the endotracheal tube disconnected from the ventilator. Once the guidewire either exits the tube’s proximal end or is seen in the oral cavity and caught with Magill’s forceps, the tube is withdrawn and the patient’s trachea immediately reintubated with a special ventilation catheter (length, 40 cm; internal diameter, 5.0 mm) from the set, with its cuff positioned distally to the puncture site, typically close to the
Figure 2 By pulling the neck end of the wire, the cone cannula enters the oral cavity. Ventilation is continuously maintained via the small-bore ventilation catheter. (Color version of figure is available online.)
Meininger and Byhahn
Translaryngeal Tracheotomy
Figure 3 The cone penetrates the skin. A small skin incision is made to facilitate cannula extraction. (Color version of figure is available online.)
carina. Despite its small diameter, the ventilation catheter allows for adequate ventilation of the patients, provided volume-controlled ventilation is used or peak inspiratory pressure is adjusted with respect to the smaller diameter of the catheter in pressure-controlled ventilation modes. Even in patients who are dependent on high levels of positive end-expiratory pressure (PEEP), it is possible to maintain the same PEEP level as before (Figure 2). The flexible TLT cannula has a cone-shaped metal tip with a central hole through which the mouth-side end of the guidewire is passed after its stiffer part has been separated at a particular marking from the more flexible portion, using a pair of scissors. A knot is made in the wire, and by pulling
101 the neck end of the wire, the knot is pulled toward the bottom of the cone. With a pull handle, traction on the neck end of the wire is started, thereby stabilizing the anterior cervical tissues by applying firm counterpressure. A skin incision is rarely necessary and should be limited to 1- to 2-mm-long incisions on constricting tissue rings of the skin to reduce resistance (Figure 3). The cone cannula enters the oral cavity, passes between the vocal cords, and exits the patient’s anterior neck through the anterior tracheal wall and the soft tissues of the neck. When anterior tracheal wall and pretracheal fascia are dilated to their fullest degree, a sudden loss of resistance is felt. The conecannula is extracted approximately halfway (Figure 4), and the cone is separated from the cannula with a pair of scissors at the markings on the cannula. Because the end of the cannula still points toward the pharynx, a stiff plastic obturator from the set is introduced into the cannula to straighten it first (Figure 5). When the cannula is perpendicular to the trachea, it is rotated by 180° until the black longitudinal line on the cannula faces cephalad (Figures 6 and 7). The cannula is then pushed down the trachea, assisted by the obturator and the cannula’s natural curvature. Correct intratracheal position of the cannula is confirmed with the flexible bronchoscope. Thereafter, both portions of the inflating tube are joined, the small-bore ventilation catheter is removed, the cannula’s cuff is inflated, and the cannula is fixed with a flange.
Discussion Based on a recent meta-analysis,9 no significant differences in terms of perioperative complications were found between
Figure 4 Extraction of the cone cannula, showing digital counterpressure applied from anterior. The small-bore ventilation catheter is placed with its tip distal to the tracheotomy site to ensure continuity of ventilation. (Reprinted with permission from Fantoni and Ripamonti.6)
102
Operative Techniques in Otolaryngology, Vol 18, No 2, June 2007
Severe respiratory insufficiency
Figure 5 The cannula is extracted halfway, and the cone is now being cut off. (Color version of figure is available online.)
the different techniques for percutaneous tracheotomy. The incidence of severe, potentially life-threatening complications (eg, death, tracheoesophageal fistula, posterior tracheal wall injury requiring surgical repair) that are likely to increase patients’ morbidity and mortality was 0.5%. TLT, however, has some specific features that have been proven to be advantageous in high-risk patients.
Perioperative bleeding Compared with standard, surgical tracheotomy, the overall risk of significant hemorrhage, either intra- or postoperatively, is significantly lower with percutaneous techniques and even less with TLT. Bleeding is unlikely because the stoma is created with the cannula itself in a single step instead of dilating the tissues first and subsequently inserting a cannula, which is the case with any other technique than TLT. The perfect adherence of the TLT cannula to the cervical tissues results in sufficient tamponade of eventual bleeding. Therefore, TLT should be the preferred percutaneous technique in patients at high risk for bleeding, ie, in cases of severe coagulopathy or whenever therapeutic anticoagulation is required, such as for hemodialysis, extracorporeal membrane oxygenation, or ventricular-assist devices. In the current literature, there are no cases of significant bleeding associated with TLT. Even the safe use of TLT in a hemophiliac patient with inhibitors to factor VIII has been reported.10
During the entire procedure of TLT, regardless of its duration, the patient can be sufficiently ventilated via the small-bore ventilation catheter. With other percutaneous tracheotomy techniques, large-bore dilators often interfere with sufficient oxygenation and carbon dioxide elimination,11,12 which is a cause of concern in patients with elevated intracranial pressure. High levels of PEEP are also often difficult to maintain during percutaneous tracheotomy, when changing dilators and cannula placement result in unavoidable airway leak and subsequent loss of PEEP, thereby potentially deteriorating gas exchange. With TLT, there is only one brief moment of apnea and loss of PEEP when the endotracheal tube in place is replaced by the small-bore ventilation catheter. As a result, TLT can be safely employed even in patients with poor respiratory function.10
Infectious complications Peristomal infections commonly observed after standard tracheotomy are a rarity when percutaneous techniques are used.11 However, fresh surgical wounds or wound infections in very close proximity to the tracheotomy are still considered a relative contraindication for percutaneous tracheotomy. The risk of cross-contamination of the adjacent surgical wound with bacteria from the airway is deemed high, as is the risk of bacterial spread from an infected cervical region into the patient’s airway. Because of the tight tissue seal around the TLT cannula, there are neither any reports of peristomal infection after TLT nor reports regarding infection of adjacent surgical wounds, eg, after anterior cervical spine surgery or esophageal surgery with cervical anastomosis. TLT should therefore be considered the percutaneous technique of choice whenever tracheotomy is required in patients shortly after cervical surgery or in patients with infected wounds close the tracheotomy site (Figure 8).
Percutaneous tracheotomy in children Percutaneous tracheotomy is considered absolutely contraindicated in children. On one hand, the narrow and soft juvenile trachea is prone to tracheotomy-related injuries when pressure is exerted with dilators from anterior. On the other hand, percutaneous tracheotomy kits are unavailable
Figure 6 A corresponding obturator is introduced into the cannula (left) to straighten it (middle). Thereafter, the cannula is turned 180° by means of the obturator (right). Note that cephalad facing of the cannula markings indicated correct rotation (right). (Color version of figure is available online.)
Meininger and Byhahn
Translaryngeal Tracheotomy
103
Figure 7 Positioning of the cannula in 3 steps: (1) initial position of the cannula; (2) cannula in fully straightened position (the rotation maneuver is being performed); (3) cannula in final position. Alternatively to the obturator (B), a rigid optical lens (A) can be used. (Reprinted with permission from Fantoni and Ripamonti.6)
in pediatric sizes. Toursarkissian and colleagues13 published a case series (n ⫽ 11) of classic Ciaglia dilational tracheotomies performed in teenagers aged 10 to 20 years. Apart from this report, only a few other cases of percutaneous tracheotomy in children have been published during the past 2 decades. To date, TLT is the first and only percutaneous tracheotomy technique that has been successfully employed in small children and even infants aged 2 months to 10
years.6,14 Because of its retrograde dilational technique, injuries to the particularly vulnerable pediatric posterior tracheal wall are much less likely than with antegrade techniques. Even though the TLT kit is currently available in various cannula sizes as small as 5.5 mm, experiences in small children are still limited to Fantoni and Ripamonti’s reports.6,14
Conclusion TLT represents the only retrograde technique for percutaneous tracheotomy. Because stoma dilation is achieved with the tracheotomy cannula itself, bleeding and stomal infection are highly unlikely, making TLT an attractive alternative to other percutaneous techniques, especially in high-risk patients. Although pediatric-sized TLT kits are available, experience in children is still very limited.
References
Figure 8 TLT performed in a patient with wound infection after esophageal surgery. Despite the close proximity of the infected surgical wound to the tracheostomy site, spread of bacteria into the stoma or the airway is highly unlikely. Ventilation is currently maintained with the small-bore ventilation catheter. (Color version of figure is available online.)
1. Krishnan K, Elliot SC, Mallick A: The current practice of tracheostomy in the United Kingdom: A postal survey. Anaesthesia 60:360364, 2005 2. Fikkers BG, Fransen GA, van der Hoeven JG, et al: Tracheostomy for long-term ventilated patients: A postal survey of ICU practice in The Netherlands. Intensive Care Med 29:1390-1393, 2003 3. Seldinger SI: Catheter replacement of the needle in percutaneous arteriography: A new technique. Acta Radiol 39:368-376, 1953 4. Ciaglia P, Firsching R, Syniec C. Elective percutaneous dilatational tracheostomy: A new simple bedside procedure: Preliminary report. Chest 87:715-719, 1985
104
Operative Techniques in Otolaryngology, Vol 18, No 2, June 2007
5. Griggs WM, Worthley LI, Gilligan JE, et al: A simple percutaneous tracheostomy technique. Surg Gynecol Obstet 170:543-545, 1990 6. Fantoni A, Ripamonti D: A non-derivative, non-surgical tracheostomy: The translaryngeal method. Intensive Care Med 23:386-392, 1997 7. Byhahn C, Wilke HJ, Halbig S, et al: Percutaneous tracheostomy: Ciaglia blue rhino versus the basic Ciaglia technique of percutaneous dilational tracheostomy. Anesth Analg 91:882-886, 2000 8. Frova G, Quintel M: A new simple method for percutaneous tracheostomy: Controlled rotating dilation: a preliminary report. Intensive Care Med 28:299-303, 2002 9. Byhahn C, Westphal K, Zwissler B: Percutaneous tracheostomy. Anaesth Intensivmed 46:125-137, 2005
10. Byhahn C, Lischke V, Westphal K: Translaryngeal tracheostomy in highly unstable patients. Anaesthesia 55:678-682, 2000 11. Westphal K, Byhahn C, Rinne T, et al: Tracheostomy in cardiosurgical patients: Surgical tracheostomy versus Ciaglia and Fantoni methods. Ann Thorac Surg 68:486-492, 1999 12. Reilly PM, Anderson HL 3rd, Sing RF, et al: Occult hypercarbia: an unrecognized phenomenon during percutaneous endoscopic tracheostomy. Chest 107:1760-1763, 1995 13. Toursarkissian B, Fowler CL, Zweng TN, et al: Percutaneous dilational tracheostomy in children and teenagers. J Pediatr Surg 29:14211424, 1994 14. Fantoni A, Ripamonti D: Tracheostomy in pediatrics patients. Minerva Anestesiol 68:433-442, 2002