Minitracheotomy Seldinger—assessment of a new technique

A multicentre, prospective study of 26 patients was undertaken for the assessment of insertion of minitracheotomy tubes by the Seldinger technique. The technique of insertion is described. There were two misplacements, three blockages of the inserting Tuohy needle with fat, and six cases of difficulty in passing the minitracheotomy tube.     

Is post-sternotomy percutaneous dilatational tracheostomy a predictor for sternal wound infections?

OBJECTIVE: Early post-sternotomy tracheostomy is not infrequently considered in this era of percutaneous tracheostomy. There is, however, some controversy about its association with sternal wound infections. METHODS: Consecutive patients who had percutaneous tracheostomy following median sternotomy for cardiac operation at our institution from March 1998 through January 2007 were studied, and compared to contemporaneous patients. We identified risk factors for tracheostomy, and investigated the association between percutaneous tracheostomy and deep sternal wound infection (mediastinitis) by multivariate analysis. RESULTS: Of 7002 patients, 100 (1.4%) had percutaneous tracheostomy. The procedure-specific rates were: 8.6% for aortic surgery, 2.7% for mitral valve repair/replacement (MVR), 1.1% for aortic valve replacement (AVR), and 0.9% for coronary artery bypass grafting (CABG). Tracheostomy patients differed vastly from other patients on account of older age, severe symptoms, preoperative support, lower ejection fraction, more comorbidities, more non-elective and complex operations and higher EuroScore. Risk factors for tracheostomy were New York Heart Association class III/IV (OR 6.01, 95% CI 2.28-16.23, p<0.0001), chronic obstructive pulmonary disease (OR 1.84, 95% CI 1.01-3.37, p=0.05), preoperative renal failure (OR 3.57, 95% CI 1.41-9.01, p=0.007), prior stroke (OR 3.08, 95% CI 1.75-5.42, p<0.0001), ejection fraction<0.30% (OR 2.73, 95% CI 1.23-6.07, p=0.01), and bypass time (OR 1.008, 95% CI 1.004-1.012, p<0.0001). The incidences of deep (9% vs 0.7%, p<0.0001) and superficial sternal infections (31% vs 6.5%, p<0.0001) were significantly higher among tracheostomy patients. Multivariate analysis identified percutaneous tracheostomy as a predictor for deep sternal wound infection (OR 3.22, 95% CI 1.14-9.31, p<0.0001). CONCLUSIONS: Tracheostomy, often performed in high-risk patients, may further complicate recovery with sternal wound infections, including mediastinitis, therefore, patients and timing should be carefully selected for post-sternotomy tracheostomy.     

Differential lung ventilation with a double-lumen tracheostomy tube in unilateral refractory atelectasis

Two patients with refractory hypoxemia due to unilateral lung atelectasis were treated with differential lung ventilation (DLV) through a Robertshaw-type, double-lumen tracheostomy tube. DLV was applied using two non-synchronized ventilators and maintained for 6 and 3 days, respectively. Ventilator settings were chosen in accord to the clinical, laboratory and chest X-rays results. Particularly, tidal volume and PEEP were set to avoid excessively high alveolar pressure and to obtain the highest possible value of compliance. We investigated the mechanical properties of the two lungs separately by measuring airway pressure and compliance of each lung before the beginning of DLV and at 0, 5, 24, and 48 h after. Initially we observed in both patients very low values of compliance (7–9 cm H₂O/I) and a significant level of PEEPi (12–8 cm H₂O) of the diseased lung, whereas PEEPi in the healthy lung was negligible. The clinical improvement was assessed by sequential chest X-rays and by significant improvement of arterial blood gas and PaO₂/FiO₂ ratios and was associated with a progressive increase of compliance (24–22 cm H₂O/I) and by a fall of PEEPi levels (5–4 cm H₂O) of the diseased lung. We also observed an improvement of S O₂, O₂AVI, PVRI and va/ t values (Case 1). The tracheostomy tube used to apply DLV was very reliable, allowing easy nursing care and selective bronchial aspirations. We conclude that DLV is a very useful technique in unilateral lung pathology, and it can be a life saving procedure in selected patients, by supplying volume and PEEP more efficiently to the affected lung.     

经皮穿刺扩张气管造口术在ICU患者中的应用

目的 比较经皮穿刺扩张气管造口术和传统气管切开术在ICU患者中应用范围及利弊.方法 60例ICU患者根据气管切开方式不同分为两组,即经皮穿刺扩张气管造口术(PDT)组和传统的气管切开术组,比较两组手术时间、术中出血量、切口大小及各种并发症的发生率.结果 PDT组的手术时间明显短于传统的气管切开术组(P<0.01),出血量明显少于传统气管切开术组(P<0.01),手术切口长度也明显短于传统组(P<0.01),两组主要并发症比较差异有显著性(P<0.005).结论 PDT操作快捷,易于掌握,可在床边安全进行,可作为气管切开术的首选方法.     

Evaluation and management of acute upper airway obstruction

Upper airway obstruction can occur suddenly and result in a patient's rapid deterioration. In this article we provide a structured approach to identifying those patients with acute airway compromise and stratifying them according to clinical urgency. This includes ways of distinguishing both the level of obstruction and its severity, based on the clinical signs and symptoms, and the role and timing of investigations. We describe the key aspects of emergency management, including temporizing measures and airway adjuncts. Management of rare, but important, situations are discussed such as post-thyroidectomy haematoma, occlusion of tracheostomy and laryngectomy stomas and post-obstruction pulmonary oedema (POPE) is discussed. We describe the situation when an emergency surgical airway should be considered, along with our technique of performing one.     

Management of and indications for tracheostomy in care of the critically ill patient

Tracheostomy is a procedure that has evolved over many hundreds of years. In the 21st century, the majority of tracheostomies are now inserted by intensivists in the intensive care unit (ICU). Commonly performed to assist in weaning patients from mechanical ventilation, the procedure is performed using a percutaneous dilatational technique. Percutaneous tracheostomy can generally be performed safely in the ICU, although a number of contra-indications and complications do exist. Recent publications have highlighted weaknesses in the quality of care both in the immediate and longer term. Consequently, a number of organizations, based in the UK and internationally, have turned the focus in recent years to improving the quality of care delivered to these patients. Clinicians caring for patients with tracheostomies should not only be familiar with the indications, anatomy and insertion techniques, but also current guidance on routine care and the emergency management of complications.     

经皮快速气管切开在救治严重急性喉梗阻中的应用

目的:观察经皮快速气管切开术在救治严重急性喉梗阻中的应用价值.方法:对13例严重急性喉梗阻患者采用经皮快速气管切开,对解除喉梗阻的效果、手术操作时间、并发症方面进行评价.结果:13例患者均成功手术,手术操作时间在20分钟内完成,无并发症发生,完全解除喉梗阻所引起的窒息症状.结论:经皮快速气管切开术操作简单,手术时间短,适用于抢救严重急性喉梗阻的患者.     

经皮扩张气管切开术在ICU中的应用研究

目的评价经皮扩张气管切开术（PDT）在重症监护病房（ICU）危重症患者人工气道建立中的应用价值。方法将46例收住ICU的危重症患者随机分为两组。PDT组23例实施PDT建立人工气道,对照组23例实施传统开放式气管切开术（OT）。比较两组镇静剂用量、手术操作时间、切口大小、出血量、切口愈合时间、疤痕大小、手术过程中患者生命体征变化、手术相关并发症发生率。结果 PDT组和对照组丙泊酚用量分别为（45.88±14.53）mg和（117.18±22.55）mg,手术时间分别为（9.66±3.25）min和（17.63±3.86）min,术中出血量分别为（5.17±2.41）ml和（14.18±3.61）ml,切口大小分别为（1.52±0.38）cm和（3.72±0.27）cm,切口愈合时间分别为（3.87±0.32）d和（6.63±1.15）d,手术疤痕大小分别为（0.26±0.04）cm2和（1.39±0.26）cm2,两组比较差异有统计学意义（P〈0.01或0.05）;手术前监测PDT组和对照组患者平均动脉压（MAP）分别为（77.44±3.17）mmHg（1mmHg=0.133kPa）和（76.15±3.86）mmHg,心率（HR）分别为（81.67±5.37）次/min和（80.69±4.82）次/min,SpO2分别为（97.92±1.76）%和（97.83±1.86）%,两组比较差异均无统计学意义;术中监测MAP分别为（82.81±4.20）mmHg和（88.63±8.96）mmHg,HR分别为（85.35±7.77）次/min和（92.17±12.23）次/min,SpO2分别为（95.22±2.73）%和（91.38±3.67）%,两组比较差异有统计学意义（P〈0.05）;PDT组和对照组患者手术前后MAP变化值分别为（5.37±1.18）mmHg和（12.48±4.52）mmHg,HR变化值分别为（3.68±2.03）次/min和（11.48±6.02）次/min,SpO2变化值分别为（2.70±0.89）%和（6.45±1.63）%,两组比较差异有统计学意义（P〈0.05）。PDT组术后并发症发生率明显小于对照组（χ2=8.1778,P〈0.01）。结论 PDT是一种安全、有效、快捷的微创急救技术,值得在ICU推广应用。