Original Article
Real time ultrasound-guided percutaneous tracheostomy: Is it a better option than bronchoscopic guided percutaneous tracheostomy?

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Abstract

Background

The purpose of this study was to evaluate the efficacy of ultrasound guided percutaneous tracheostomy (USPCT) and bronchoscopic guided percutaneous tracheostomy (BPCT) and the incidence of complications in critically ill, obese patients.

Methods

Seventy four consecutive patients were included in a prospective study and randomly divided into USPCT and BPCT. Incidence of complications, ease and efficacy were compared in obese USPCT (n = 38)and BPCT (n = 36). Results are expressed as the median (25th–75th percentile) or number (percentage).

Results

The median times for tracheostomy were 12 min (9–14) in USPCT patients and 18 min (12–21.5) in BPCT (p = 0.05). The overall complication rate was higher in BPCT than USPCT patient group (75% vs. 321%, p < 0.05). Most complications were minor (hypotension, desaturation, tracheal cuff puncture and minor bleeding) and of higher number in the BPCT. Ultrasound-guided PCT was possible in all enrolled patients and there were no surgical conversions or deaths.

Conclusions

This study demonstrated that real US-guided PCT is a favourable alternative to BPCT with a low complication rate and ease, thus proving more efficacious. A US examination provides information on cervical anatomy, vasculature etc. and hence modifies and guides choice of the PCT puncture site.

Introduction

Percutaneous tracheostomy (PT) is a commonly performed bedside procedure in the Intensive Care Unit (ICU). Several studies have demonstrated that PCT is a safe and cost-effective alternative to open, surgical tracheostomy.1, 2, 3 Bronchoscopic guidance during PT may be useful in avoiding injury to surrounding structures, high placement of the tube, injury to the posterior tracheal wall and in confirming endotracheal placement.4, 5 However, bronchoscopy does not identify the vascular structures or the thyroid gland in the neck region and thus does not prevent complications linked to local organ lesions (punctured vessels or a punctured thyroid) and in patients with acute brain injury, it can cause acute elevations in intracranial pressure.

Preliminary reports suggest that sonographic delineation of anatomy prior to tracheal puncture during PT may help prevent bleeding from pre-tracheal vascular structures and placement of the tracheal tube above the first tracheal ring.6, 7 The use of real-time ultrasonography, with actual visualization of the needle path up to the anterior tracheal wall should further decrease the risk of puncture above the first tracheal ring as well as the risk of injury to surrounding structures and the posterior tracheal wall. Real-time guidance during PT may be particularly useful when factors that increase the technical difficulty of the procedure (morbid obesity, difficult anatomy, cervical spine precautions) are present. However, to the best of our knowledge, there are no published data comparing the US guided and bronchoscopic guided percutaneous tracheostomy. Hence, the objectives of our study were to compare the efficacy of these two methods and to evaluate the incidence of complications in intensive care units.

Section snippets

Materials and methods

This study was a prospective, single centre randomised control trial (RCT) study of 74 consecutive patients. All patients (or, for unconscious patients, the next of kin) gave their written informed consent to participation. We enrolled all patients who were hospitalized in the ICU and HDU on whom PCT was indicated. Exclusion criteria were as follows: age under 18 years, coagulation disorders (platelet count of below 80,000 mm−3 and an international normalized ratio of at least 1.5), and

Results

Seventy four patients were prospectively enrolled between March 2012 and December 2013. Twenty-six patients were obese -median BMI of 34 kg/m2 (32–38) – and five of the latter were morbidly obese. The median ages were 58 years (50–66) (mean 61 yrs, 1.2SD) in the (Bronchoscopic assisted Percutaneous Tracheostomy (BPCT)) group and 62 years (56–64) (mean 58 yrs, 1.6SD) in the Ultrasound assisted percutaneous tracheostomy (USPCT) group (P = 0.62) (Table 2). Of the 74 patients, 60 patients (81%) had

Discussion

Our results demonstrate that PCT can be performed under real-time US guidance as efficacious if not with better results in comparison bronchoscopic guided PCT and with a short completion time. Several studies have emphasized the value of pre-PCT US examination of the neck region to reduce the incidence of complications.9 Recently, Rajajee et al demonstrated the feasibility of US guidance during the implementation of PCT in a population of neuro-intensive care patients.10 USPCT has many

Conclusions

US-guided PCT can be performed in safely in critically ill patients, and the incidence of complications is low. Use of US provides a better understanding of the anatomy of the neck, prevents vascular puncture, and helps guide the tracheostomy procedure.

Key messages

  • •

    Ultrasound-guided percutaneous tracheostomy is feasible in place of BPCT and has a low complication rate.

  • •

    Ultrasound provides a better understanding of the anatomy of the neck, prevents vascular puncture, and helps guide the

Conflicts of interest

All authors have none to declare.

References (16)

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Available online 12 March 2015

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