Assessment of Ventilation During the Performance of Elective Endoscopic-Guided Percutaneous Tracheostomy: Clinical Evaluation of a New Method

doi:10.1378/chest.126.1.159

Chest

Volume 126, Issue 1, July 2004, Pages 159-164

https://doi.org/10.1378/chest.126.1.159 Get rights and content

Study objectives:

To evaluate the feasibility of uninterrupted translaryngeal open ventilation delivered through a pediatric, uncuffed endotracheal tube during percutaneous endoscopic tracheostomy (PET).

Design and setting:

Prospective, observational clinical study in a six-bed ICU of a university hospital.

Patients:

Forty consecutive adult patients requiring an elective tracheostomy.

Interventions:

We employed the basic Ciaglia technique with multiple dilators (n = 10), a single dilator (n = 15), and the Fantoni method (n = 15). During PET, pressure-controlled ventilation was maintained through an uncuffed, 4-mm inner-diameter pediatric tube. The fraction of inspired oxygen was 1.0. Ventilator settings were as follows: pressure-controlled ventilation, 40 cm H₂O; respiratory rate, 25/min; inspiratory time, 1.2 s of inspiratory time (inspiratory/expiratory ratio, 1:1); and positive end-expiratory pressure, 0 cm H₂O.

Measurements and results:

Measurements of arterial blood gas (ABG) tensions were obtained before the start of each tracheostomy and every 3 min during the procedure. An average of 8.28 ± 2.28 ABG measurements were obtained from each patient (± SD). All patients were successfully assisted during performance of the tracheostomy, and no patient required ventilation through a cuffed endotracheal tube. The maximum increase in Paco₂ was 8.49 ± 5.50 mm Hg, and the maximum decrease in pH related to hypercarbia was 0.04 ± 0.04. The Pao₂ increased in all patients (maximum change, 69.75 ± 57.00 mm Hg; p < 0.01), and no patient had desaturation during the procedure.

Conclusions:

The technique that we propose for airway management during PET was safe and effective. A mild increase in Paco₂ was not associated with significant metabolic and hemodynamic consequences, and an adequate Pao₂ was maintained throughout the study.

Section snippets

Patients

We prospectively studied 40 consecutive adult patients requiring elective tracheostomy in a general ICU of an academic institution (six beds equipped with ventilators) over a 2-year period. The study was conducted according to the principles established in the Declaration of Helsinki. Informed consent was obtained from the patients or their next of kin before each procedure. The main indications for tracheostomy were anticipated prolonged dependency on mechanical ventilation, control of the

Results

Forty adult patients underwent elective PET (Table 1). There were no significant differences between the three groups in terms of age, sex, timing, acute physiology and chronic health evaluation (APACHE) III score, and gas exchange values. All tracheostomies were successful; no significant intraprocedural complications (eg, hypoxia, bleeding, hypotension, lesion of posterior tracheal wall) were noted. In one case, during the performance of a CBR procedure, we observed the fracture of the

Discussion

Percutaneous tracheostomy has been proven to be a valid alternative to traditional, surgical tracheostomy performed in the operating room. The addition of bronchoscopic guidance has increased the safety of the procedure and may prevent complications such as the creation of a false passage, posterior tracheal wall damage, pneumothorax, and subcutaneous emphysema.^4,^7,¹⁶ However, the presence of the bronchoscope and of the dilators inside the lumen of the trachea could produce airway obstruction

Conclusions

The new technique we propose for the airway management during tracheostomy performance seems to be safe and effective. It is a simple and rapid technique that can be performed with materials commonly available in the ICU. This technique ensures adequate ventilation even if complications such as bleeding protract the surgical time. The results of this preliminary experience show that the method proposed might substitute for the other techniques of airway management currently in use. However, we

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Cited by (31)

A modified technique for percutaneous dilatational tracheostomy: A retrospective review of 60 cases
2016, Journal of Critical Care
Citation Excerpt :
The best attributes of all known PDT techniques were used to invent a slightly modified PDT technique that aims to (1) prevent accidental intraprocedural airway loss, (2) allow for uninterrupted gas exchange during PDT, (3) prevent major intraprocedural bleeding, and (4) reduce operating costs and resources. In the modified technique, the operator starts with pushing the patient's ETT distally (Fig. 1 Step 1) until a depth of 26 cm at the lips is reached or change of ventilator pressures suggest entry into a mainstem broncus at which point the ETT is slightly withdrawn so as to lie approximately at the level of the carina [19,22]. This is done to prevent puncture of the ETT balloon during needle insertion.
We describe a modified technique for percutaneous dilatational tracheostomy (PDT) using intermittent bronchoscopy and ultrasound (US). This method requires 1 single physician operator and no special airway adjuncts. Our aim is to reduce the complications associated with the current popular PDT technique, that is, accidental intraprocedural airway loss, intraprocedural bleeding, and hypoventilation associated with use of continuous bronchoscopy.
This is a retrospective review of all PDTs performed on intensive care unit patients at a single nonacademic hospital by a pulmonologist using the modified PDT technique.
Sixty consecutive PDT procedures were performed using the modified technique. Forty-five percent of the patients were considered high-risk individuals for PDT. There were no deaths from the modified PDT procedure. There were no major complications including accidental extubation, major bleeding, posterior tracheal wall laceration, pneumothorax, hemodynamic instability, severe hypoxemia, or infection. The failure rate of PDT was 1.6%. There was no puncture of the bronchoscope, endotracheal tube, or endotracheal tube balloon. All procedures were performed by 1 single physician operator.
Our modified technique demonstrates a potential to reduce accidental intraprocedural airway loss and intraoperative bleeding associated with PDT while possibly improving gas exchange and saving procedural costs. This technique needs to be comparatively studied with current popular PDT technique in a prospective trial to firmly establish associated risks and benefits.
Response
2015, Chest
Assessment of ventilation during the performance of elective endoscopic-guided percutaneous tracheostomy: What's new 10 years later?
2015, Chest
Tracheal ring fracture secondary to percutaneous tracheostomy: Is tracheal flaccidity a risk factor?
2015, Journal of Cardiothoracic and Vascular Anesthesia
To evaluate the risk factors of tracheal ring fracture and whether previous tracheal ring flaccidity predisposes to it in consecutive, mechanically ventilated, intensive care unit patients undergoing different percutaneous dilatational tracheostomy procedures (Ciaglia Blue Rhino, PercuTwist, and Ciaglia BlueDolphin).
Single-center retrospective study performed between November 2006 and July 2013.
Single-center university hospital.
Two hundred nineteen consecutive intensive care unit patients.
Video bronchoscopic percutaneous dilatational tracheostomies using different techniques, including Ciaglia Blue Rhino, PercuTwist, and Ciaglia BlueDolphin, were performed consecutively. During the procedure, the tracheal wall response to the routine external palpation was evaluated endoscopically to find the interanular space. An abnormal change in the tracheal ring shape (fingerprint) with anterior airway wall collapse was diagnosed as tracheal flaccidity.
Tracheal ring fracture occurred in 21 patients (9.6%). The proportion of tracheal ruptures was 16 (76.2%) after PercuTwist, 3 (14.3%) after Ciaglia Blue Dolphin, and 2 (9.5%) after the Blue Rhino technique. Significant risk factors for tracheal rupture were PercuTwist procedure (p = 0.02), tracheal flaccidity (p = 0.0001), and a period of intubation before a percutaneous dilatational tracheostomy procedure>14 days (p = 0.01).
In addition to the PercuTwist technique and intubation>14 days before tracheostomy, tracheal flaccidity was a significant risk factor for tracheal ring fracture. In the presence of this finding, a less traumatic tracheostomy procedure should be applied.
Defining an ideal technique for percutaneous dilatational tracheostomy - is real-time ultrasound guidance the final piece of the puzzle?
2015, Journal of Critical Care
Translaryngeal open ventilation for percutaneous endoscopic tracheostomy
2014, British Journal of Anaesthesia

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Chest

Clinical Investigations in Critical CareAssessment of Ventilation During the Performance of Elective Endoscopic-Guided Percutaneous Tracheostomy: Clinical Evaluation of a New Method

Study objectives:

Design and setting:

Patients:

Interventions:

Measurements and results:

Conclusions:

Section snippets

Patients

Results

Discussion

Conclusions

Chest

Chest

Chest

Br J Anaesth

Chest

A non-derivative, non-surgical tracheostomy: the translaryngeal method

Intensive Care Med

Endoscopic guided percutaneous tracheostomy: early results of a consecutive trial

J Trauma

Bedside percutaneous dilational tracheostomy with endoscopic guidance: experience with 71 ICU patients

Intensive Care Med

Bronchoscopic guidance makes percutaneous tracheostomy a safe, cost-effective, and easy-to-teach procedure

Surgery

Complications of bronchoscopically guided percutaneous dilational tracheostomy: beyond the learning curve

Intensive Care Med

Percutaneous tracheostomy: a clinical comparison of dilational (Ciaglia) and translaryngeal (Fantoni) techniques

Anesth Analg

The use of the laryngeal mask airway as an alternative to the endotracheal tube during percutaneous dilational tracheostomy

Intensive Care Med

Clinical Investigations in Critical Care
Assessment of Ventilation During the Performance of Elective Endoscopic-Guided Percutaneous Tracheostomy: Clinical Evaluation of a New Method