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* From the Department of Surgery "A", Meir Hospital, Sapir Medical Center, and the Sackler School of Medicine, Tel-Aviv University, Israel.
Correspondence to: Haim Paran, MD, Department of Surgery "A", Meir Hospital, Sapir Medical Center, Kfar Sava, 44281, Israel; e-mail: Paran620{at}green.co.il
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Abstract |
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Methods: The modified technique was adopted and prospectively evaluated in an observational clinical study over a 30-month period, in patients requiring elective tracheostomy. Two commercially available kits were used. Patients’ records were kept in files, and they were evaluated with regard to operative technique, complications, failure rate, and loss of airway.
Results: During the study period, 61 procedures were attempted. All were performed at the patients’ bedside. In three patients (4.9%), the percutaneous procedure was deferred due to anatomic problems: cervical venous engorgement in one patient, and difficulty in dissection in another patient. In the third patient, the trachea could be felt, but the tube provided with the kit was not long enough. One patient had persistent wound bleeding, requiring revision in the operating room. No other procedure-related complications were reported. In three patients, early tube dislodgement occurred, but whether this was related to the percutaneous procedure is debatable. Bronchoscopy was not used.
Conclusions: The modified percutaneous technique, with limited surgical dissection, without routine bronchoscopy, is simple and safe when performed by physicians with surgical training. It is relatively easy to learn, saves costs and operating room burden, and carries low morbidity rates.
Key Words: bronchoscopy • mechanical ventilation • percutaneous tracheostomy
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Introduction |
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A modification of the technique, performed by surgeons and using a limited blunt dissection of the subcutaneous and pretracheal tissues, has been described and has been shown to be safe without routine bronchoscopic guidance.13 This procedure can be performed at the patient’s bedside, without the need of the operating room. We prospectively assessed this technique in a university hospital setting, to further evaluate the safety and effectiveness of the technique of combining a limited blunt dissection and the "Seldinger over the wire percutaneous tracheostomy," using both commercially available kits.
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Materials and Methods |
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The procedure was performed at bedside, either in the ICU or in the various hospital departments, without transporting the patient to any other facility. The procedure was performed by one attending surgeon or by a surgical resident under the guidance of the attending surgeon. When the procedure was performed in the ICU, an anesthetist was present and manipulated the endotracheal tube. When the procedure was performed in other departments, another surgical resident managed the tube. Sedation was achieved by incremental doses of propofol, until desired sedation was obtained. All patients had continuous monitoring of BP, heart rate, respiratory rate, and oxygen saturation. Diathermy was not used. Mechanical ventilation was maintained throughout the procedure with mandatory mechanical ventilation and a fraction of inspired oxygen of 1.0. The patients were followed up prospectively with regard to complications: bleeding, failure to cannulate or to intubate the trachea, loss of airway, inadequate ventilation, and injury to the surrounding structures.
Operative Technique
With the patient in the supine position, and the neck mildly hyperextended, the anterior neck is prepared with chlorhexidine solution and alcohol. A midline, vertical, 2-cm incision is made just above the suprasternal notch to allow insertion of the operator’s index finger through the incision (Fig 1 ). Using a hemostat, the subcutaneous tissues are dissected bluntly down to the pretracheal fascia. The trachea is then manually palpated. The endotracheal tube cuff is deflated and retracted under guidance of the finger palpating the trachea. The retraction of the tube is easily felt by the operator’s finger, and then the cuff is re-inflated (Fig 2
). The angiocath included in the kit is introduced into the trachea, between the second and third tracheal rings under the guidance of the operator’s finger palpating the trachea, and airflow in the syringe confirms the right position of the angiocath tip (Fig 3
). The needle is withdrawn, leaving only the cannula tip inside the trachea. The Seldinger wire is introduced through the cannula and the dilator is advanced over the wire, while the wire is firmly anchored to avoid sliding of the dilator over the wire and injury to the surrounding structures. Depending on which kit was used, either the guidewire dilator forceps or the long cone-shaped dilator is advanced, dilating the opening on the anterior trachea, and then the tracheostomy tube is inserted. The correct positioning of the tube is confirmed either by end-tidal volume carbon dioxide monitoring, when available, or simply by the end-expiratory volume in the respirator. The tube is then secured in place by silk sutures to the skin. A chest radiograph is routinely performed after the procedure.
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Results |
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In three patients, MPT was deferred: in one patient due to cervical venous engorgement in the area of the skin incision, and in the other patient because of morbid obesity and subcutaneous edema, which did not allow effective blunt dissection for the trachea to be felt. Both patients were transferred to the operating room, and operated on in the conventional way. In a third patient, a longer tube was required due to body habitus. The tube included in the Portex kit was not long enough; since the Cook kit was not available at that time, the operation was converted to the open procedure so a longer tube could be inserted. In one patient, persistent bleeding from the subcutaneous tissues required revision in the operating room, where a small subcutaneous artery was ligated. No other operative complications related to the procedure were observed, and loss of airway did not occur in any of the patients. No pneumothorax occurred. In three patients, early dislodgement of the tube occurred, within 48 h, after the operation using the Portex kit. They were immediately intubated and placed on ventilation; later, a new tube was inserted, one percutaneously while the other two required an open exploration in the operating theater. Twenty-three patients died in the hospital during the same admission due to their original diseases.
In 34 patients, the cannulas were removed after a mean of 16 days. Two patients required mechanical ventilation again after the cannula was removed. Both patients were intubated, and new cannulas could be inserted by the same technique. Five patients eventually required a permanent tracheostomy. In one patient, MPT was performed 3 years after a previous tracheostomy was performed. In spite of the scarring, the procedure was completed without complications. No patient selection concerning body habitus, general condition, or obesity was done, but for one patient cited before who had massive subcutaneous edema.
After the initial 10 procedures, performed by one attending surgeon (H.P.), all the following MPTs were performed by surgical residents, under the attending surgeon’s guidance. Usually, after 6 to 10 procedures performed under guidance, the resident could perform MPT alone. It is important to stress that all residents had performed open-neck operations before they started performing MPT.
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Discussion |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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In the present study, we prospectively evaluated this method, performed over a 30-month period, by our surgical service. During this time period, 61 procedures were attempted. In three patients (4.9%), the percutaneous procedure was deferred due to anatomic problems: cervical venous engorgement in one patient, and difficulty in the dissection in another patient. In the third patient, the trachea could be felt, but the tube from the kit was not long enough. This problem does not occur with the Blue Rhino kit since tubes of different length can be used. One patient had persistent bleeding, requiring revision of the incision in the operating room. No other procedure-related complications were reported. In three patients, early tube dislodgement occurred; whether this was related to the percutaneous procedure is debatable. Bronchoscopic guidance was not used. No long-term complications were reported, but the follow-up is relatively short.
In conclusion, the above-described modification of the percutaneous technique is simple and safe when performed by personnel with surgical training and knowledge of the surgical anatomy of the neck. It is relatively easy to learn and has low morbidity rates. The method is presently our method of choice for patients who need elective tracheostomy for prolonged mechanical ventilation.
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Footnotes |
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Received for publication August 25, 2003. Accepted for publication March 2, 2004.
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References |
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This article has been cited by other articles:
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  G. Melloni, L. Libretti, M. Casiraghi, P. Zannini, H. Paran, and M. Gutman A Modified Percutaneous Tracheostomy Technique Without Bronchoscopic Guidance: A Note of Concern Chest, December 1, 2005; 128(6): 4050 - 4051. [Full Text] [PDF]
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M. Grundling, D. Pavlovic, S.-O. Kuhn, and F. Feyerherd Is the Method of Modified Percutaneous Tracheostomy Without Bronchoscopic Guidance Really Simple and Safe? Chest, November 1, 2005; 128(5): 3774 - 3775. [Full Text] [PDF]
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