Long-term outcome after percutaneous dilational tracheostomy Endoscopic and spirometry findings

We studied 41 patients who had previously undergone percutaneous dilational tracheostomy at least 6 months following tracheal decannulation. The patients were examined using laryngotracheoscopy and spirometry to assess the long-term anatomical and functional consequences of percutaneous dilational tracheostomy. Apart from one patient who had requested a scar revision, no patient was symptomatic. A significant (>10%) tracheal stenosis was identified in four asymptomatic patients, two of whom also had spirometric evidence of this obstruction. These results suggest that the long-term outcome after percutaneous tracheostomy is at least as good as that following conventional surgical tracheostomy. Refinements of the percutaneous technique, such as endoscopic guidance, may further improve the results.     

Oesophageal balloon tracheoplasty in early tracheal stenosis following percutaneous tracheostomy

Percutaneous tracheostomy is an efficient technique used in intensive care units. Although a safe procedure, serious early and late complications can occur. A rare complication is suprastomal stenosis following inadvertent tracheal cartilage fracture resulting in stenosis. Management is complicated, often requiring specialised equipment. While surgical treatment techniques are evolving, none are universally applicable. We report a case of early tracheal stenosis following percutaneous tracheostomy, treated successfully using a novel technique of oesophageal balloon tracheoplasty. To our knowledge, this is the first reported case of immediate post percutaneous tracheostomy suprastomal stenosis treated with balloon tracheoplasty using an oesophageal balloon catheter which is readily available in most endoscopy units.     

Ciaglia percutaneous dilational tracheostomy. Early and late complications and follow-up

AIM: Evaluation of the safety of percutaneous dilational tracheostomy (PDT) for perioperative, early and late complications. METHODS: Design: we prospectively collected complications in patients who underwent PDT for mechanical ventilation; patients were interviewed 8 months after discharge, symptomatic cases underwent ENT control. Setting: 10 bed general ICU in a 650 -bed general hospital treating 450 patients per year. Participants and intervention: 181 patients admitted between July 1998 and June 2000 who underwent PDT for mechanical ventilation. Prospe-ctive collection of data on patients and procedures and screening by a phone interview for symptoms possibly related to the tracheostomy. Symptomatic patients were referred to the ENT specialist. RESULTA: We found 17 perioperative minor complications and 10 minor during hospital stay complications. We traced 83 patients, alive 8 months after discharge. Sixty-one patients (73.5%) were symptom free. Four (4.8) complained of minimal dysphonia. Eighteen patients (21.7%) complained of symptoms deserving ENT control. Eleven patients came to the ENT control that was positive in 5 cases. In 2 patients swallowing uncoordination was found, in 1 arytenoid movement uncoordination. In 1 case (1.2%) a 25% tracheal stenosis was found. The stenosis was asymptomatic. One patient (1.2%) had a severe tracheal stenosis and had a Montgomery tracheal stent in place. CONCLUSIONS: In our experience Ciaglia PDT had an overall low rate of complications (21.8%). No patient had severe early complication. We found only 1 (1.2%) severe late complication. In selected patients, Ciaglia PDT with endoscopic control guarantees a high safety standard.     

Percutaneous dilational tracheostomy. Indications--techniques--complications

Tracheostomy is a generally accepted procedure that assures free access to the airways in long-term lung ventilation. Apart from surgical tracheostomy, percutaneous dilational tracheostomy (PDT) has been increasingly employed in intensive care units. Presently, five dilatation methods are available, all equally allowing the performance of a secure and low-risk, bedside tracheostomy in the intensive care unit. Exact knowledge of the anatomy of the neck region and of the entire procedure are preconditions for a safe intervention. Percutaneous procedures offer advantages over surgical tracheostomy in terms of complications. To minimize the risks, expertise in airway management during PDT and knowledge of the particularities of cannula replacement in dilational tracheostoma, are compulsory. Endoscopic control assures that the tracheostoma can be placed correctly and that possible complications can be recognised early. The incidence of a serious tracheal stenosis after PDT is low.     

Perkutane Dilatationstracheotomie

Tracheostomy is a generally accepted procedure that assures free access to the airways in long-term lung ventilation. Apart from surgical tracheostomy, percutaneous dilational tracheostomy (PDT) has been increasingly employed in intensive care units. Presently, five dilatation methods are available, all equally allowing the performance of a secure and low-risk, bedside tracheostomy in the intensive care unit. Exact knowledge of the anatomy of the neck region and of the entire procedure are preconditions for a safe intervention. Percutaneous procedures offer advantages over surgical tracheostomy in terms of complications. To minimize the risks, expertise in airway management during PDT and knowledge of the particularities of cannula replacement in dilational tracheostoma, are compulsory. Endoscopic control assures that the tracheostoma can be placed correctly and that possible complications can be recognised early. The incidence of a serious tracheal stenosis after PDT is low.     

Starplasty: revisiting a pediatric tracheostomy technique.

OBJECTIVE: To determine the efficacy the "starplasty" pediatric tracheostomy technique in reducing the incidence of major complications and tracheotomy-related death. METHODS: Retrospective chart analysis of all the cases of starplasty performed at 2 tertiary care centers between 1990 and 2002. RESULTS: There were 94 children in our cohort ranging in age from 2 days to 14 years. Of the patients, 47 (50%) were females and 47 (50%) were males and 60 of the children (64%) were younger than 1 year of age. Forty-one patients (44%) had neurologically related airway problems as their primary indication for tracheostomy, 34 (36%) had upper airway obstruction, and the remainder had pulmonary diseases, prolonged intubation, or metabolic-related airway problems. There were 41 short-term complications including 5 cases of tracheal tube dislodgement. There were no instances of pneumothorax or tracheostomy-related death. There were 26 long-term complications. There were no cases of clinically relevant suprastomal collapse that compromised decannulation and no instances of tracheal stenosis. Twenty-six patients underwent decannulation, all of whom developed a tracheocutaneous fistula (TCF). Two patients had spontaneous closure of the TCF; 9 patients underwent surgical repair of their fistulas, 53 patients remain tracheostomy-dependent, and 8 patients died of their primary disease. CONCLUSION: The need for pediatric tracheotomy has increased as a consequence of our success in treating chronically ill children. Starplasty reduces the incidence of major complications, including pneumothorax and death from accidental decannulation. Its major drawback is the need for secondary reconstruction of a tracheocutaneous fistula. EBM rating: C.     

A survey of tracheostomy practice in a cardiothoracic intensive care unit

OBJECTIVE: The purpose of this study was to assess current practice of performing tracheostomies in critically ill cardiac surgical patients, to establish complication rates, and to identify areas of this clinical practice that could be improved. DESIGN: Retrospective observational study. SETTING: A cardiothoracic intensive care unit in a teaching hospital. PARTICIPANTS: The most recent series of 100 tracheostomies performed in patients admitted to the intensive care unit. INTERVENTIONS: Percutaneous or surgical tracheostomy for respiratory management. MEASUREMENTS AND MAIN RESULTS: A total of 95 patients had 1 tracheostomy performed. One patient had a tracheostomy performed twice, and 1 patient had a tracheostomy performed 3 times; these repetitions were caused by recurrent respiratory failure. The median time from tracheal intubation to tracheostomy was 5 days (range, 1-23 days; interquartile range, 4-8 days), and median period between insertion and decannulation was 20 days (range, 2-77 days; interquartile range, 12-25 days). The most common reason for insertion was an anticipated long weaning time (55%) followed by insertion after failed extubation (32%). The Ciaglia percutaneous dilational technique was used for 89% of tracheostomies, whereas surgical techniques were used for 8%. The most common complication was either complete or partial obstruction of the tracheostomy tube (24%) followed by infection of the tracheostomy site in 18% (17/94) and bleeding at the time of insertion (11%). CONCLUSION: The percutaneous dilational technique of tracheostomy was used predominantly in this unit. The median time from tracheal intubation to tracheostomy was 5 days. The most common complications were bleeding at the time of insertion, obstruction of the tracheostomy tube, and stomal infection.     

Symptomatic tracheal stenosis in burns

Tracheal stenosis in burns is rare and usually results from prolonged intubation or tracheostomy. Inhalation injury itself has the potential risk of tracheal stenosis. We reviewed the records of 1878 burn patients during 1987 to 1995 and found seven with tracheal stenosis (0.37%) after an average of 4.4 years follow up. There were 4 males and 3 females with an average age of 27.3 years. The tracheal stenosis developed 1-22 months after burn (average 7 months). Five patients had their inhalation injury confirmed by bronchoscopic examination. The incidence of tracheal stenosis among inhalation injury patients was 5.49% (5/92). Six patients needed intubation in the initial stage either for respiratory distress or prophylaxis, with an average duration of 195.2 h. In addition to prolonged intubation, the presence of inhalation injury, repeated intubations and severe neck scar contractures are also contributors to tracheal stenosis in burns. We favor T-tube insertion as the first treatment choice; permanent tracheostomy was unsatisfactory in our study.     

PercuTwist-Dilatationstracheotomie

BACKGROUND: Percutaneous dilational tracheostomy (PDT) is considered to be an accepted method in intensive care patients. In 2002 Frova and Quintel described a method of dilation that employed controlled rotation of the PercuTwist dilational device. The goal of the present study was to evaluate the new technique employed by an experienced team. PATIENTS AND METHODS: Prospective, observational clinical study in 54 intensive care patients who required PDT. All tracheostomies were accompanied by bronchoscopic control. Vital parameters and perioperative complications were registered. RESULTS: In all 54 consecutive PercuTwist tracheostomies no severe complications were noted. Accidental tracheal ring fracture was noted in 7 patients while bleeding that needed surgical care occurred in 1 patient. CONCLUSION: The PercuTwist tracheostomy is a safe procedure for intensive care patients. More prospective studies that would compare the PercuTwist tracheostomy with the other PDT methods are necessary.     

Extensive posterior-lateral tracheal laceration complicating percutaneous dilational tracheostomy

BACKGROUND: An extensive posterior-lateral longitudinal tracheal laceration is an uncommon but serious complication of percutaneous dilational tracheostomy (PDT). We report the successful management of three ventilator-dependent patients whose percutaneous tracheostomy was complicated by an extensive longitudinal posterior-lateral tracheal laceration requiring operative repair. METHODS: A retrospective review of 134 cases of PDT with concurrent bronchoscopy was performed between April 1997 and July 1999 and compared with a review of 124 cases of open tracheostomy. Tracheal lacerations were primarily repaired and augmented with intercostal muscle pedicle buttress. RESULTS: Three cases of an extensive posterior-lateral longitudinal tracheal laceration that required operative repair were reported in the PDT group. None were reported in the open tracheostomy group. The 3 patients were managed with an adult high-frequency oscillating ventilator or pressure control ventilation during the postoperative period to limit barotrauma, and all healed without evidence of tracheal leak or stenosis. CONCLUSIONS: The increasing popularity of PDT, particularly among nonsurgical disciplines, may generate an increasing number of complications requiring operative attention. Thoracic surgeons need to be cognizant of the pitfalls of PDT technique and be prepared to manage these difficult clinical scenarios.     

Tracheal stenosis complicated with tracheoesophageal fistula.

OBJECTIVE: The aim of the present study was to evaluate the results of surgical treatment in patients with simultaneous occurrence of postintubation tracheal stenosis (TS) and tracheoesophageal fistula (TEF). METHODS: In the group of 51 patients with postcannulation tracheal stenosis who underwent segmental resection, TEF was identified simultaneously in five (10%) of them. The mean age of the TS-TEF patients was 43 years (range 35-60 years). The patients underwent a single-stage operation during which TEF was sealed and resection of the stenotic tracheal segment was performed. RESULTS: The cause of TEF and of TS was artificial pulmonary ventilation by tracheostomy tube (n=4) or by endotracheal tube (n=1) with a simultaneous insertion of nasogastric tube. In one of the patients with tracheostomy the fistula resulted from an injury to the pars membranacea tracheae and the esophageal wall during tracheostomy. All the patients were respiring spontaneously before the surgical treatment. The mean length of the fistula was 24.0 mm (range 15-30 mm), the fistulae were located at the junction of the upper and middle third of the trachea. The mean length of the resected tracheal segment was 29.6 mm (range 26-32 mm). Postoperative complications were not observed in the group of the TS-TEF patients, none of them died. CONCLUSIONS: The method of choice of the surgical treatment of TEF associated with TS is a single-stage procedure in the patient who respires spontaneously.     

Conservative treatment of tracheal injuries

Tracheal injuries, independent of their origin, may be life-threatening. Surgical repair is regarded as the treatment of choice but has not been compared with other approaches. We hypothesized that defects bridgeable by an artificial airway may enable conservative treatment. We report on five patients with tracheal injuries, two in the trachea's upper third resulting from trauma and intubation and three in its middle third after percutaneous dilational tracheostomy. Tracheal defects were bridged by endotracheal or tracheostomy tubes under bronchoscopic guidance and the cuff was inflated distal to the lesion. Air leakage stopped immediately and all tracheal defects healed without further interventions. No case of stenosis or mediastinitis was observed. These results suggest that treating tracheal injuries conservatively by placing an artificial airway under bronchoscopic guidance may be effective and offers a convenient starting position for secondary surgical repair in selected patients when conservative treatment fails.     

Prospective randomized comparison of progressive dilational vs forceps dilational percutaneous tracheostomy

This trial prospectively compares two methods of percutaneous tracheostomy, both routinely used in ICU: the Ciaglia progressive dilational tracheostomy and the Griggs forceps dilational tracheostomy. One hundred patients were randomized using a single-blinded envelope method to receive progressive or forceps percutaneous tracheostomy performed at the bedside. Operative time, the occurrence of hypoxaemia or hypercapnia and complications were recorded. The progressive technique took longer than the forceps technique (median 7 (range 2-26) vs. 4 (1-16) minutes, P = 0.0005). Hypercapnia occurred in both groups but was more marked with the progressive technique (56 (16) vs. 49 (13) mmHg, P = 0.0082). Minor complications (minor bleeding, transient hypoxaemia, damage to posterior tracheal wall without emphysema) were also more frequent with the progressive technique (31 vs. 9 complications, P < 0.0001). Six major complications occurred with the progressive technique, none with the forceps technique (P = 0.0085): tension pneumothorax, posterior tracheal wall injury with subcutaneous emphysema, loss of airway with hypoxaemia, loss of stoma with impossible re-catheterization, and two conversions to another technique. In conclusion, progressive dilational tracheostomy took longer, caused more hypercapnia and more minor and major difficulties than forceps dilational tracheostomy.     

A comparison of percutaneous and operative tracheostomies in intensive care patients

The aim of our study was to compare the complication rate of convenional surgical and percutaneous dilational tracheostomies performed under general anaesthesia in critically ill patients. Fifty-three consecutive patients whose lungs were mechanically ventilated and who required tracheostomy were randomised to undergo either conventional surgical tracheostomy (n = 28) in the operating room or percutaneous dilational tracheostomy (n = 25) in the intensive care unit under general anaesthesia. All of the procedures were successfully completed. No deaths were related to the performance of either tracheostomy technique. Three patients in each group required a dressing change for minor bleeding at the tracheostomy site. There was no major bleeding requiring blood transfusion. One patient in each group developed atelectasis detected on chest x-ray postoperatively. In the surgical tracheostomy group, there were two patients with cuff leaks, one with a stomal infection and one with a pneumothorax. None of these complications occurred after percutaneous, dilational tracheostomy. We conclude that the low incidence of complications in both groups indicates that percutaneous dilational tracheostomy can be performed as safely in the intensive care unit with general anaesthesia as surgical tracheostomy can be performed in the operating room.     

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).     

Tracheoplasty for tracheal cuff stenosis post long-term tracheostomy

We encountered a case of tracheal stenosis post tracheostomy, so-called cuff stenosis. A 43-year-old man with ventricular septal defect (VSD) was treated by oral endotracheal intubation because of heart-failure and pneumonia, and tracheostomy was performed. He was placed on artificial ventilation for almost 3 months. Four months after discharge, he complained of dyspnea and was treated by oral endotracheal intubation again. At that time bronchofiberscopy demonstrated severe circumferential stenosis of the trachea 4 cm from the tracheostomy spot and that was compatible with the cuff site. Although the stenotic portion was dilated by an endotracheal tube, 47-days after dilation, the portion was restenosed to almost 7 mm in diameter. Therefore, surgical treatment was necessary and tracheoplasty was performed by end-to-end suture after 2 cm (4 ring) resection of trachea. Tracheoplasty is the most reliable method of treating cuff stenosis after tracheostomy.     

Percutaneous versus Conventional Tracheostomy in Burned Patients with Inhalation Injury

The aim of the study was to compare conventional tracheostomy with percutaneous dilatational tracheostomy in patients with inhalation burn injury. A total of 37 patients with severe burn injuries and associated inhalation injury, underwent percutaneous tracheostomy in our burn unit and were retrospectively compared with 22 patients who underwent conventional surgical tracheostomy. In the first group, 25 of 37 patients and in the second group 17 of 22 patients presented with partial or full-thickness burn injuries (or both) in the neck region. The cost of the procedure, operating time, complications, and incidence of pulmonary infection were recorded. There were no significant perioperative complications in the percutaneous tracheostomy group, and no patient required surgical revision or conversion to surgical tracheostomy. In the conventional tracheostomy group, 2 patients developed tracheal stenosis, 1 had a tracheoesophageal fistula, and 10 had stomal infections. The average procedure time in the first group was 9 minutes, and in the second group it was 22 minutes. The cost of the bedside percutaneous tracheostomy was one-fifth the cost of a conventional tracheostomy. The incidence of pulmonary sepsis was 45% after percutaneous tracheostomy compared to 68% after conventional tracheostomy. With the percutaneous technique, spontaneous closure of the stoma occurred within 1 to 3 days after removal of the tracheostomy tube, whereas with the conventional technique it was within 5 to 7 days. Percutaneous tracheostomy is associated with a lower complication rate and can be safely performed at the bedside. Moreover, it is faster and can be done at a lower cost than conventional open tracheostomy.     

A single-center 8-year experience with percutaneous dilational tracheostomy

OBJECTIVE: To determine surgical, postoperative, and postdischarge complications associated with percutaneous dilational tracheostomy (PDT) in an 8-year experience at the University of Kentucky. SUMMARY BACKGROUND DATA: There are known risks associated with the transport of critically ill patients to the operating room for elective tracheostomy, and less-than-optimal conditions may interfere with open bedside tracheostomy. PDT has been introduced as an alternative to open tracheostomy. Despite information supporting its safety and utility, the technique has been criticized because advocates had not provided sufficient information regarding complications. METHODS: A prospective database was initiated on all patients who underwent PDT between September 1990 and May 1998. The database provided indication, procedure time, duration of intubation before PDT, and intraoperative and postoperative complications. Retrospective review of medical records and phone interviews provided long-term follow-up information. RESULTS: In the 8-year period, 827 PDTs were performed in 824 patients. Two patients were excluded because PDT could not be completed for technical reasons. There were 519 male and 305 female patients. Mean age was 56 years. Prolonged mechanical ventilatory support was the most common indication. Mean procedure time was 15 minutes, and the average duration of intubation before PDT was 10 days. The intraoperative complication rate was 6%, with premature extubation the most common complication. The procedure-related death rate was 0.6%. Postoperative complications were found in 5%, with bleeding the most common. With a mean follow-up of greater than 1 year, the tracheal stenosis rate was 1.6%. CONCLUSIONS: On the basis of this large, single-center study, the authors conclude that when performed by experienced surgeons, PDT is a safe and effective alternative to open surgical tracheostomy for intubated patients who require elective tracheostomy.     

Evaluation and outcome of different surgical techniques for postintubation tracheoesophageal fistulas

OBJECTIVE: We evaluated the outcome of different surgical techniques for postintubation tracheoesophageal fistula. METHODS: Thirty-two consecutive patients aged 51 +/- 23 years had tracheoesophageal fistulas resulting from a median of 30 days of mechanical ventilation via endotracheal (n = 12) or tracheostomy (n = 20) tubes. Tracheoesophageal fistulas were 2.5 +/- 1.2 cm long and were associated with a tracheal (n = 10) or subglottic (n = 3) stenosis in 13 patients. RESULTS: All but 3 patients were weaned from respirators before repair. All operations were done through cervical incisions and included direct division and closure (n = 9), esophageal diversion (n = 3), muscle interposition (n = 6), or, more recently, tracheal or laryngotracheal resection and anastomosis with primary esophageal closure (n = 14). Nine thyrohyoid and two supralaryngeal releases reduced anastomotic tension. Twenty-three patients (74%) were extubated after the operation (n = 16) or within 24 hours (n = 7), and 7 required a temporary tracheotomy tube. One postoperative death (3%) was associated with recurrent tracheoesophageal fistula. Seven complications (22%) included recurrent tracheoesophageal fistula (n = 1), delayed tracheal stenosis (n = 2), dysphagia (n = 2), and recurrent nerve palsy (n = 2). Complications necessitated reoperation (n = 1), dilation (n = 2), definitive tracheostomy (n = 1), Montgomery T tubes (n = 1), and Teflon injection of the vocal cords (n = 1). Twenty-nine patients (93%) had excellent (n = 24) or good (n = 5) anatomic and functional long-term results. Complications have been less common (7% vs 38%) and long-term results better (93% vs 65%) recently with tracheal or laryngotracheal resection and anastomosis with primary esophageal closure as compared with previous procedures. CONCLUSIONS: Postintubation tracheoesophageal fistula is usually best treated with tracheal or laryngotracheal resection and anastomosis with primary esophageal closure even in the absence of tracheal damage.     

Intubación en dos pacientes con vía aérea difícil y estenosis traqueal tras traqueostomía en cirugía torácica

Lung isolation in thoracic surgery is a challenge, this is even more complex in the presence of unknown tracheal stenosis (TS). We report two cases of unknown TS and its airway management. TS appears most frequently after long term intubation close to the endotracheal tube cuff or in the stoma of tracheostomy that appears as a consequence of the granulation tissue after the surgical opening of the trachea. Clinical history, physical examination, difficult intubating predictors and imaging tests (CT scans) are crucial, however most of tracheal stenosis may be unnoticed and symptoms depend on the degree of obstruction. In our cases, the patients presented anatomical changes due to surgery and previous tracheostomy that led to a TS without symptoms. There is scarce literature about the intubation in patients with previous tracheostomy in thoracic surgery. In the first case, a Univent^® tube was used using a flexible fiberscope but an acute tracheal hemorrhage occurred. In the second case, after intubation with VivaSight SL^® in an awake patient, the insertion of a bronchial blocker was performed through an endotracheal tube guided by its integrated camera without using flexible fiberscopy.