The authors have no funding, financial relationships or conflicts of interest to disclose.
How I Do It
Percutaneous dilatational tracheotomy using the tracheotomy endoscope†
Version of Record online: 6 JUN 2011
Copyright © 2011 The American Laryngological, Rhinological, and Otological Society, Inc.
Volume 121, Issue 7, pages 1490–1494, July 2011
How to Cite
Nowak, A. and Klemm, E. (2011), Percutaneous dilatational tracheotomy using the tracheotomy endoscope. The Laryngoscope, 121: 1490–1494. doi: 10.1002/lary.21849
- Issue online: 16 JUN 2011
- Version of Record online: 6 JUN 2011
- Manuscript Accepted: 29 MAR 2011
- Manuscript Revised: 22 MAR 2011
- Manuscript Received: 24 FEB 2011
Open tracheotomies are safe procedures even when performed in high-risk patients by inexperienced surgeons.1 Reported complications associated with the well-known percutaneous dilatational tracheotomy (PDT) techniques are due to either predilatory dissection or the downward forces applied to the surrounding tissues and posterior tracheal wall during dilation.2 The use of PDT has resulted in a range of complications that are difficult to quantify on a scientific basis due to the fact that more than half of the tracheotomized patients in intensive care units die from their underlying diseases. Additionally, late complications are seen less often by critical care physicians because they usually become apparent after discharge from the intensive care unit. These late complications become apparent during rehabilitation therapy or during check-ups by primary care physicians, who then refer these patients back into the realm of otorhinolaryngology.
Despite the rapid evolution and improvements in PDT techniques, the discussion concerning its benefits, risks, and possible complications has continued in the medical community. Potential complications of current dilatational techniques include perforation of the posterior tracheal wall during puncture or insertion of the dilatational device, major bleeding, desaturation, hypoventilation, airway loss, tracheal tube punctures, cuff defect, and development of a tracheal stenosis.3–8 Tracheal stenosis following PDT may occur for numerous reasons, including cartilage fractures, displacement after PDT,8 or performing PDT at an incorrect location. The optimum level for a tracheostomy is between the second and fourth tracheal cartilages. We have developed a technique that combines the advantages of PDT using the Seldinger guidewire technique with rigid endoscopy, thus eliminating the risk of hypoventilation during the PDT. This innovative technique for PDT could be an alternative to current endoscopic techniques used during PDT. To secure the airway and prevent complications, we perform PDT using a rigid tracheotomy endoscope (TED) (Fig. 1).
MATERIALS AND METHODS
Twenty-four intensive care patients underwent PDT using a TED (Karl Storz, Tuttlingen, Germany; Carl Reiner, Vienna, Austria); these patients were on long-term ventilation with orotracheal intubation (average, 10 days). A single dilatator from the Ciaglia Percutaneous Tracheostomy Introducer Kit Tracoe Twist (Tracoe Medical, Frankfurt/Main, Germany) was used. Continuous gas monitoring was used. Patients were sedated with intravenous application of remifentanil (Glaxo Smith Kline, Brentford, UK) titrated to effect and intravenous application of 4 to 6 mg/kg/h propofol (Ratiopharm, Ulm, Germany). During PDT, anesthesia was accomplished with intravenous application of 0.1 mg/kg body weight cisatracurium (Glaxo Smith Kline). Heart rate and rhythm were monitored, and blood pressure was monitored by arterial catheterization of the radial artery. Oximetry was monitored using a finger probe.
After the mouth and pharynx of the orotracheal-intubated patient are suctioned and cleaned, the TED is introduced at a right angle to the mouth and advanced into the larynx along the indwelling endotracheal tube. The beveled distal opening of the TED is faced laterally along the tube during introduction (Fig. 2). The patient is not extubated until the endoscope is in the laryngeal inlet. After the laryngeal structures are identified, the balloon cuff of the endotracheal tube is deflated under continuous endoscopic supervision by the physician, who removes the tube as the TED is carefully advanced into the trachea. From this point on, the patient is ventilated by superimposed high-frequency jet ventilation (SHFJV), using a TwinStream (Carl Reiner, Vienna, Austria), through the built-in channels of the TED. The trachea is then visually inspected, and secretions are suctioned from the lumen. After evaluation of the palpable anatomy of the neck, the optimal puncture site is marked by transillumination with a curved fiber optic light carrier inserted through the TED (Fig. 3). The trachea is punctured with a 17-gauge needle at the center of the light spot between the second and fourth tracheal ring. Large blood vessels in the anterior part of the neck are clearly outlined by the transilluminating effect of the TED. Using this good illumination of the trachea, the customized, stiff 0.38 mm × 100 cm Seldinger guidewire is introduced through the 17-gauge puncture needle, and the needle is removed. Clear bronchoscopic visualization with the TED ensures that the initial needle puncture is midline and between the second and fourth tracheal ring (Fig. 4). A 1.5-cm skin incision is made with an 11-blade scalpel in a longitudinal direction, followed by the passage and immediate removal of a 14 F punch dilator obtained from the tracheotomy introducer kit to dilate the subcutaneous and tracheal tissues. Placement of the tracheotomy tube is confirmed by endoscopy, and the posterior tracheal wall is further visualized for any evidence of trauma via the endotracheal tube and the tracheotomy tube. The newly placed tracheotomy tube is then used to successfully ventilate the patient. As the endoscope is withdrawn, the upper trachea and the larynx are checked for any lesions caused by long-term intubation. Abnormalities in the form of granulations, polyps, or dislodged cartilage fractures can be treated immediately with good endoscopic visualization (Fig. 5). If no abnormalities are found following treatment, the endoscope is withdrawn completely, and the TED-based PDT procedure is complete.
All of the patients in our intensive care unit had undergone PDT tube placement facilitated by a TED (Tables I and II). No immediately detectable adverse events or complications have occurred from this procedure. There was no complication from major bleeding at the tracheotomy site, neither externally nor into the trachea. Proper placement of the tracheotomy tube was confirmed by endoscopy via the TED, and all patients were successfully ventilated. Heart rate, heart rhythm, blood pressure, and oximetry results did not show any distinguishable change at any time during or after the procedure. The extended posterior lip of the endoscope tube provides optimum protection from injuries to the posterior tracheal wall during puncture and dilatation. The excellent visibility obtained with the rigid endoscope facilitates this procedure. The raised, rounded upper edge of the endoscope provides a natural abutment to the pressure from the dilatation. Incidences of dislocated tracheal cartilage fractures were repaired immediately using the TED. Other damage within the trachea, either above or below the tracheostomy site, were not detected by endoscopic examination via the TED. In all cases, introduction of the TED along the tracheal tube was accomplished without problems (Fig. 2), and identification of the second and fourth tracheal rings via the TED was also achieved (Fig. 4). The extended posterior lip prevents puncture of the posterior wall (Fig. 6), and the rigid configuration of the endoscope prevents tracheal injuries (e.g., contusions). In all cases, the lumen used for ventilation remained open. We did not observe any pneumothoraces or other life-threatening complications (Tables III and IV).
|Total||Mean BMI||Mean Age (yr)||%|
|Male||13||25.9 ± 3.4||63.9 ± 14.69||54.2|
|Female||11||28.1 ± 7.8||63.9 ± 14.69||45.8|
|Total||24||26.9 ± 5.8||63.9 ± 14.69||100.0|
|Patients with body mass index >30||5||20.8|
|Major bleeding (>20 mL)||0||0.0|
|Injuries to the posterior tracheal wall||0||0.0|
|Tracheal ring fractures||2||8.3|
|Hypercarbia (ETCO2 > 45 mm Hg)||0||0.0|
|Hypoxia (SpO2 < 90%)||0||0.0|
|Management of PDT With Rigid Endoscope||No.||%|
|Difficult identification of optimal puncture site||0||0.0|
|Introduction of the rigid endoscope with problems||0||0.0|
|Removal of residual displaced cartilage fragments||2||8.3|
Tracheal Ring Fractures
The downward force necessary for dilatation displaces the anatomy in an unpredictable manner, potentially enabling predictable complications to occur. Tracheal stenosis has numerous causes, but no specific studies have been performed on the importance of tracheal ring fractures in the development of tracheal stenosis. Because of the abutment of the TED, the dilation itself has very little effect on the trachea.
Effective ventilation must be maintained throughout the PDT procedure. The use of a TED in PDT eliminates the challenge faced in previous PDT techniques, in which the flexible endoscope so restricts the lumen of the endotracheal tube that the procedure must be repeatedly interrupted to optimize ventilation (Fig. 7). This problem is particularly common when small- diameter tubes are used. The decreased cross-sectional area of the tube lumen presents risks of hypoxia, hypercarbia, and pneumothorax (Table V). A critical care physician begins the PDT procedure using a flexible endoscope to create an artificial tracheal stenosis. Residual secretions are almost always present in the endotracheal tube and further hamper the return of respiratory gases, compounding the risk of pneumothorax. Various types of ventilation may be used with TED. The use of intermittent positive pressure ventilation, either high-frequency jet ventilation or SHFJV, provides sufficient ventilation with a high level of safety during all steps of the PDT in critically ill patients. With the TED, there is virtually no risk that airway loss will occur during the PDT procedure.
|Tube Inside Diameter, mm|
|Residual lumen (%)||26.5||36||44||50|
|Projected remaining tube inside diameter (mm)||3.6||4.5||5.3||6.0|
The elongated posterior lip of the TED provides optimum protection from injuries to the posterior tracheal wall (Fig. 6). During puncture and dilatation of the anterior tracheal wall, the TED is advanced so far into the trachea that it virtually eliminates any risk of injury to the posterior tracheal wall and esophagus. The excellent visibility obtained with the rigid TED facilitates determination of the correct intratracheal level and puncture site (Fig. 3 and Fig. 4). External palpation of the neck alone is unreliable, and fatty deposits in the neck may make it impossible to establish clear orientation, particularly in patients with a higher body mass index. The location of the internal anatomy is very important in PDT. The correct puncture site and removal of residual displaced cartilage fragments may be the most significant factors in preventing the subsequent development of tracheal stenosis (Fig. 5). Of course, further studies must be performed and are currently ongoing.
Another important consideration related to PDT is bleeding. Major bleeding with resulting asphyxia is a potential cause of death during PDT. Bleeding is always a potential risk in any surgical procedure, but in theory, our proposed TED technique offers a very low risk of inducing major bleeding. The diagnostic and therapeutic capabilities of flexible endoscopes are inadequate for the effective control of major intratracheal bleeding. Potential bleeding into the trachea can be safely managed with good endoscopic visibility and high-capacity suction tubes. When there is significant bleeding with risk of aspiration, the patient can be reintubated with a cuffed endotracheal tube through the indwelling rigid TED, and the surgeon can quickly convert the procedure to an open operation (Fig. 1 and Fig. 8).
Our approach raises expectations for a reduced rate of complications when the TED is used during PDT. If this technique is equally successful in broader clinical applications as it is in our practice, then the potential for lower morbidity and mortality resulting from PDT is enormous. Following the first description of its use9 and the good results documented in a pilot study,10 we have routinely performed PDT using the TED in intensive care medicine. A multicenter study using our technique is currently underway.
- 10Use of a tracheotomy endoscope for percutaneous dilatational tracheostomy. Results of a pilot study. Anesthesiology 2007; 107: A961., , .