Elsevier

Journal of Critical Care

Volume 31, Issue 1, February 2016, Pages 144-149
Journal of Critical Care

Clinical Potpourri
A modified technique for percutaneous dilatational tracheostomy: A retrospective review of 60 cases

https://doi.org/10.1016/j.jcrc.2015.09.012Get rights and content

Abstract

Background

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.

Study design

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.

Results

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.

Conclusion

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.

Section snippets

The modified PDT technique

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

Study design

This is a retrospective review of all the modified PDT procedures performed by a single intensivist in a 300-bed nonacademic community hospital (PRMC) with a 24-bed open mixed medical-surgical ICU. All procedures took place between July 1, 2011, and June 30th, 2015. The intensivist performed only the modified PDT procedure during this period on the cases that were referred to him during his ICU rotations. Sixty patients were identified using our Electronic Medical Record system.

After

Results

The patient characteristics are presented in Table 1. Forty-five percent PDTs were performed on high-risk individuals. No patient had a large goiter, 6 had large veins in the area of insertion but no arteries, 2 had previous tracheostomies, 1 had a significantly deviated trachea due to lobectomy, and 1 had history of neck radiation for cancer. Our patient population consisted of 3 multitrauma, 3 neurosurgery, 3 anoxic brain injury, 4 cardiothoracic surgery, 4 abdominal surgery, 2 vascular

Discussion

We present, to our knowledge, a modified PDT technique, which has not yet been reported in literature.

The modified PDT technique–related mortality of zero compares favorably with the aggregate mortality seen in randomized controlled trials, large single-center studies, systematic review, and meta-analysis (0.16% [0%-0.6%]). Our conversion rate to ST of 1.6% compares well with the 0% to 10% rate seen in literature [1], [2], [3], [4], [5], [6], [7], [8]. Our complication rate is no different than

Conclusions

The simple modification of inserting the guide wire before ETT withdrawal during PDT has the potential to significantly reduce accidental intraprocedural airway loss, time pressure faced by the operator, and the time for which the bronchoscope is present inside the ETT hindering gas exchange. The addition of real-time US can potentially reduce intraoperative bleeding, tracheal tube malpositioning, and posterior tracheal wall laceration. Because our technique can be performed by a single

Author contributions

Dr Sangwan is the originator of the slightly modified PDT technique (The PRMC tracheostomy technique) studied in this article. He came up with the study concept, collected the data and drafted the manuscript.

Dr. Chasse performed more than 350 single physician operator PDTs at PRMC since 1996 using a technique similar to Kornblith's. The PDT technique shown here is a modification of his technique. He critically revised the manuscript, interpreted the data, and is the guarantor of the content of

Funding and financial conflicts of interest

The authors have received no funding or compensation for this study.

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