Percutaneous dilatational tracheostomy

Methods: Fifteen patients electively selected for percutaneous dilatational tracheostomy as performed with the Ciaglia Percutaneous Tracheostomy Introducer Set are reported in this preliminary study.
Results: The median time for insertion of the tracheostomy tube was 13.9 min. Complications were cuff puncture of the translaryngeal tube at an early stage of the procedure in one case, and minor bleeding controllable by the compressible effect of the dilatational procedure in three cases. During the posttracheostomy period, complications were one case of minor bleeding controllable by digital compression and one case of minor infection, i.e. cellulitis in a few millimetres around the stoma without purulent secretion.
Conclusions: Our preliminary results indicate the technique as performed with the Ciaglia Introducer Set to be effective and safe with only minor complications. Furthermore, we now use it as a bedside procedure in the ICU, thus avoiding the transportation of critically. ill patients to the operating theatre. The conclusion of the superiority of percutaneous tracheostomy to dissectional tracheostomy has to await clinical randomized studies, including more patients.     

Evaluation of a new percutaneous dilatational tracheostomy set apparatus

Percutaneous tracheostomy is a well established technique used primarily to assist weaning from mechanical ventilation on many intensive care units. We report our experiences of a total of 36 procedures performed with the new Blue Rhino Percutaneous Tracheostomy Introducer Set developed by Ciaglia. The technique was successful in all cases and was simpler and quicker to perform than with the earlier Ciaglia percutaneous tracheostomy set. Difficulties were encountered when using Shiley tracheostomy tubes. Significant complications included one posterior wall tear and one tracheal cartilage ring fracture.     

Percutaneous tracheostomy with the Blue Rhino trade mark technique: presentation of 100 consecutive patients

We assessed the peri-operative, early and late complications in 100 percutaneous tracheostomies performed with the Blue Rhino trade mark kit. The success rate was 98%. Peri-operative complications occurred in 30 patients. Six major complications occurred; these included bleeding which required surgical exploration (n = 3), and pneumothoraces (n = 2) and one false passage. Cannula insertion was made easier by blunt dissection of the cervical tissues anterior to the trachea. The median duration of the procedure was 8.5 min, which is significantly longer than other authors' results. Only one major complication occurred while the patient was cannulated (serious bleeding requiring exploration). Finally, in a single patient a tracheal stenosis occurred as a major late complication which eventually was treated by a successful tracheal resection. Percutaneous tracheostomy with the Blue Rhino trade mark kit is safe with a low incidence of major complications.     

Complications of percutaneous dilatational tracheostomy in children

Experience with percutaneous dilatational tracheostomy in children is limited. This report discusses two significant complications which occurred following the use of this technique     

纤支镜导引下经皮扩张气管造口术的临床研究

目的 探讨纤支镜导引下经皮扩张气管造口术相对于常规经皮扩张气管造口术（PDT）的优点。方法 60例患者随机分为两组，即纤支镜导引组（A组，n=28），常规组（B组，n=32）。记录两组的手术时间，近期远期并发症例数，作统计分析。结果 A组有更大的成功率，更少的近期和远期并发症，手术时间并没有延长。结论 纤支镜导引下经皮扩张气管造口术相对于常规经皮扩张气管造口术有更高的安全性与实用性。     

Use of the Combitube for airway maintenance during percutaneous dilatational tracheostomy

The Combitube airway allows short-term ventilation during cardiopulmonary resuscitation and can be useful in the management of the difficult airway. In a prospective observational study we assessed its use during percutaneous dilatational tracheostomy (PDT). Twenty-one intensive care patients scheduled for elective PDT had their tracheal tube replaced by a Combitube airway retaining the same ventilator settings. Arterial blood gases, airway pressures, SpO₂ and end-tidal CO₂ were measured as were the transmural pressures exerted by the Combitube cuffs. Combitube placement was successful in 20 of 21 patients although adequate ventilation was possible in only 17 (85%). There was no significant change in P a O ₂, S p O ₂, end-tidal CO₂, P a CO ₂ or mean airway pressure during Combitube ventilation. A high mean (SD) transmural pressure of 14.7 (5) kPa was exerted by the distal cuff. The Combitube provided a satisfactory alternative airway to the tracheal tube during performance of PDT in 85% of our patients. Potential problems associated with its use in intensive care patients are outlined.     

Percutaneous dilatational tracheostomy for ICU patients with severe brain injury

Objective： To sum up our experience in percutaneous dilatational tracheostomy （PDT） in ICU patient with severe brain injury. Methods： Between November 2011 and April 2014, PDTs were performed on 32 severe brain injury patients in ICU by a team of physicians and intensivists. The success rate, efficacy, safety, and complications including stomal infection and bleeding, paratracheal insertion, pneumothorax, pneumomediastinum, tracheal laceration, as well as clinically significant tracheal stenosis were carefully monitored and recorded respectively. Results： The operations took 4-15 minutes （mean 9.1 minutes±4.2 minutes）. Totally 4 cases suffered from complications in the operations： 3 cases of stomal bleeding, and 1 case of intratracheal bloody secretion, but none required intervention. Paratracheal insertion,pneumothorax, pneumomediastinum, tracheal laceration, or clinically significant tracheal stenosis were not found in PDT patients. There was no procedure-related death occurring during or after PDT. Conclusion： Our study demonstrats that PDT is a safe, highly effective, and minimally invasive procedure. The appropriate sedation and airway management perioperatively help to reduce complication rates. PDT should be performed or supervised by a team of physicians with extensive experience in this procedure, and also an intensivist with experience in difficult airway management.     

Repeat percutaneous dilatational tracheostomy in an awake and unintubated patient

Bedside percutaneous dilatational tracheostomy (PDT) has become an accepted method for securing airways in patients requiring prolonged ventilatory support. Repeat PDT in patients who have had a tracheostomy earlier is considered a relative contraindication as a result of distorted anatomy. Three case series have been reported supporting the safety of repeat bedside PDT in experienced hands, but there is no previously published data regarding repeat PDT in awake and unintubated patients. We report a case in which a repeat PDT was done on an awake 20-year-old female patient with cerebral palsy and kyphoscoliosis admitted owing to pneumonia and respiratory failure. This facilitated tracheal toilet in this patient without resorting to general anaesthesia and mechanical ventilation. In conclusion, both repeat PDT and awake PDT, both separately or together, can be very useful in the management of critical care and pre-critical care patients and merit wider use.     

Percutaneous tracheostomy by forceps dilation: report of 162 cases

A prospective, observational clinical study evaluated the safety of percutaneous single-step dilatational tracheostomy over a 43-month period. One hundred and sixty-two patients were deemed suitable for the procedure. The mean duration of tracheal intubation prior to tracheostomy was 6 days. The mean duration of the procedure was 9.3 min. Intra-operative complications occurred in 27 patients (16.6%), most of which were minor technical difficulties without morbidity. Postoperative complications, some of which were associated with morbidity, occurred in 16 patients. There were two deaths secondary to premature decannulation, one case of severe bleeding and five pneumothoraces. Long-term complications were assessed in 81 patients; there were four tracheal stenoses requiring surgery or laser therapy and seven patients with granulation tissue at the stoma site which did not require treatment. Forceps dilatational percutaneous tracheostomy appeared to be a convenient bedside procedure. However, complications do occur and further studies should address late sequellae, such as tracheal stenosis.     

Percutaneous dilatational tracheostomy in a patient with thyroid cancer and severe airway obstruction

A patient with extensive metastatic thyroid cancer scheduled for palliative tracheostomy is presented. He had laryngeal dislocation with severe airway obstruction and few anatomical landmarks due to tumour infiltration and radiation. Successful percutaneous dilatational tracheostomy was performed under local anaesthesia.     

Acute fatal haemorrhage during percutaneous dilatational tracheostomy

Percutaneous dilatational tracheostomy (PDT) is associated witha number of life-threatening complications. We present a caseof massive and fatal arterial haemorrhage that occurred in theintensive care unit during an elective PDT on an 86-year-oldwoman following earlier evacuation of a traumatic subdural haematoma.An avulsed right subclavian artery was found at post mortem.Previous thyroid surgery and aberrant arterial anatomy contributedto the fatal outcome. Br J Anaesth 2003; 90: 517–20     

Percutaneous tracheostomy: a guide wire complication

We report an unusual complication of percutaneous dilatationaltracheostomy, in which the guide wire became lodged in the bronchialtree. The assistance of an expert bronchoscopist resulted insuccessful removal of a fractured J wire with no adverse sequelaefor the patient. A subsequent incident has given insight intothe mechanism of damage to the guide wire. Br J Anaesth 2004; 92: 891–3     

Percutaneous dilational tracheostomy

Tracheostomy is performed commonly to aid weaning from assisted ventilation in patients who require intensive care. The procedure carries a significant mortality and morbidity, in part due to problems in moving unstable patients. We report the use of a bedside percutaneous tracheostomy technique for use in adult patients who require intensive care. The procedure was successful in 19 of 20 cases. The one failure, in the first case, resulted from transection of a superficial midline vein. The lack of significant haemorrhage was notable in all other cases. The procedure has proved to be efficient and cost-effective in this unit and has now replaced conventional surgical tracheostomy in this group of patients.     

Laryngotracheal stenosis: a serious complication of percutaneous tracheostomy

Tracheostomy in patients requiring prolonged artificial ventilation in intensive care is increasingly being performed by a percutaneous dilatational technique, in preference to the standard surgical method. Since its introduction numerous series have reported favourably on its general safety in the short-term, but there have been few reports of longer term follow-up of patients. We present four cases of laryngotracheal stenosis, a previously unreported complication associated with the technique, and discuss the relevance of these to the future practice of percutaneous tracheostomy.     

Ultrasonographically guided percutaneous dilatational tracheostomy after anterior cervical spine fixation

Patients with anterior cervical spine fixation (ACSF) after acute spinal cord injury often require tracheostomy for prolonged ventilatory support and upper respiratory tract clearance. The authors report two patients with ACSF who underwent a successful ultrasonographically guided percutaneous tracheostomy with dilatation forceps technique. Possible advantages of the ultrasonographically guided method with dilatation forceps in patients with ACSF are discussed.     

Use and safety of percutaneous tracheostomy in intensive care. Report of a postal survey of ICU practice

A brief questionnaire was sent to 231 clinical directors of intensive care units in England and Wales to investigate the use of percutaneous tracheostomy. There was a 76% response rate. Percutaneous tracheostomies were in use in 78.4% of units. The Ciaglia technique was the most commonly used, with 31.3% routinely using fibreoscopy as part of their technique. Only 12% of units routinely provided long-term follow up of their percutaneous tracheostomies. Overall, 78.4% thought that percutaneous tracheostomy was safe and 66.7% considered percutaneous tracheostomy to be the technique of choice for Intensive Care patients. Percutaneous tracheostomy is now a well-established technique. However, the limited use of fibreoscopy and the lack of long-term follow-up are areas of concern.     

Percutaneous dilational and surgical tracheostomy in burn patients: Incidence of complications and dysphagia

The aim of this study is to evaluate the incidence of complications and dysphagia in relation to the timing of tracheostomy and tracheostomy technique in 49 consecutive adult burn patients. We analysed prospectively collected data. Bronchoscopy was used to diagnose tracheal stenosis and a modified Evans blue dye test was used to diagnose dysphagia. Eighteen patients received a percutaneous dilatational tracheostomy (PDT) and thirty-one patients received an open surgical tracheostomy (OST). Eight patients developed significant complications (16%) following tracheostomy, there is no difference in the incidence of complications; post op infection, stoma infection or tracheal stenosis between PDT and OST groups. Patients with full thickness neck burn who developed complications had a tracheostomy significantly earlier following autografting (p = 0.05). Failed extubation is associated with dysphagia (p = 0.02) whereas prolonged intubation and ventilation prior to tracheostomy independently predicts dysphagia (p = 0.03).     

Percutaneous tracheostomy: one center’s experience with a new modality

Background

A retrospective review of our experience with percutaneous tracheostomy was performed to determine our complication rate and pattern of use since this modality was introduced at our institution.

Methods

A retrospective chart review captured all patients in whom tracheostomy was performed or supervised by a trauma/critical care faculty member. Dates of hospital admission, ICU admission, intubation, discontinuation of mechanical ventilation, type and location of procedure, procedural complications, Injury Severity Score, charges, and patient demographics were collected. Percutaneous tracheostomy (PT) and open tracheostomy (OT) experiences were compared.

Results

Three hundred sixty-eight tracheostomies were performed (190 OT and 178 PT). The average time to tracheostomy (TTT) for PT patients decreased from 12.7 to 7.4 days. The average TTT for OT patients remained stable at 14.0 days. The complication rate was 3.5%, with 4 complications (1.5%) associated with OT and 9 complications (5.1%) associated with PT. All complications in the PT group occurred before using a single dilator system. The 9 complications in the PT group occurred among 5 surgeons, all before their 11th attempt. PT saves $444 in charges per procedure.

Conclusion

OT continues to be a safe method of performing tracheostomies. PT has a steep learning curve but can be mastered quickly. Benefits include a shorter time to tracheostomy, elimination of patient transport, and saving in charges. Initial PT attempts should be supervised by an experienced surgeon.     

Intubating laryngeal mask as a ventilatory device during percutaneous dilatational tracheostomy: a descriptive study

BACKGROUND: We use an intubating laryngeal mask (ILM) in preference to an endotracheal tube (ETT) as the ventilatory device during percutaneous dilatational tracheostomy (PDT) to overcome potential problems such as difficult ventilation, accidental extubation, damage of the ETT or of the bronchoscope, and need for additional assistant to secure the airway. We report our experience with this method. METHODS: In this prospective observational study, PDT was performed using the ILM in 86 patients. The insertion of the ILM, the quality of ventilation, and the view of the tracheal puncture site were rated as: 'very good', 'good', 'difficult', and 'not possible with ILM'. RESULTS: The bronchoscope was not damaged during any case, and all PDTs were performed by two physicians, without the need for an additional assistant. PDTs with ILM were successful in 95% of the patients (n=82). The ratings were 'very good' or 'good' in 80% of cases with regards to ventilation, in 90% for identification of relevant structures and tracheal puncture site, and in 85% for the view inside the trachea during PDT. Tracheal re-intubation was required for inadequate ventilation with ILM in four patients. CONCLUSIONS: The advantages of this procedure were lack of damage to the bronchoscope, the need for two instead of three persons to perform the PDT, and the excellent view inside the trachea. We recommend the ILM as a standard device for ventilation during bronchoscope-guided PDT.