Clinical PotpourriA modified technique for percutaneous dilatational tracheostomy: A retrospective review of 60 cases
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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A safer placement technique for percutaneous dilatational tracheostomy
2021, American Journal of SurgeryUltrasound-guided percutaneous dilatational tracheostomy using a saline-filled endotracheal tube cuff as an ultrasonographic puncture target: A feasibility study
2018, Journal of Critical CareCitation Excerpt :Bronchoscopy guidance was the established standard and the initially recommended method for PDT [5]. However, there were clinical burdens [6-8], including accidental loss of the airway, needle damage to the optical fiber, and a shortage of devices and operators, which made many specialists reluctant to perform it with bronchoscopy [9]. With easy accessibility in the ICU, ultrasound has been increasingly used as an alternative to guide the PDT procedure [10,11].
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