Bedside Percutaneous Tracheostomv: Experience with 55 Elective Procedures

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1 Bedside Percutaneous Tracheostomv: Experience with 55 Elective Procedures Patrick B. Hazard, M.D., H. Edward Garrett, Jr., M.D., James W. Adams, M.D., E. Todd Robbins, M.D., and Robert N. Aguillard, M.D. ABSTRACT Over a 24-month period, tracheostomy was performed in 55 patients using a percutaneous, wireguided, dilatational technique. All such procedures were undertaken at the patient s bedside in the intensive care unit, with the patient under local anesthesia and mechanically ventilated through an oral endotracheal tube. A variety of guidewires, dilators, and tracheal tubes were used as experience and proficiency were gained with the approach, and eventually, a simple modification of a standard low-pressure cuffed endotracheal tube was found to facilitate the procedure. The percutaneous method was found to be rapid and simple, to leave almost no cosmetic deformity, and to be almost totally free from infectious complications. This technique should be considered for routine use in critically ill, ventilator-dependent patients. Since Seldinger s introduction of his wire-guided approach to arterial catheterization [l], it has been widely adapted to such assorted tasks as central venous cannulation, tube nephrostomy, placement of transtracheal oxygen catheters, drainage of abnormal fluid collections, and epidural catheterization for anesthetic purposes. One recently described application of the Seldinger technique has been for percutaneous tracheostomy [2], reported to be rapid, technically simple, and remarkably free from technical misadventure. It is common practice at our institution to perform tracheostomy in patients requiring mechanical ventilation for prolonged periods, to improve patient comfort and to facilitate nutritional support and clearance of secretions [3, 41. As we have noted a significant incidence of complications associated with operative tracheostomy, similar to the experiences of others [%lo], we were attracted by the prospect of a relatively complication-free approach. With some modification, we began to use the percutaneous method of tracheostomy in our own critically ill patients with respiratory failure, and herein report our results. Patients and Methods Percutaneous tracheostomy was performed for airway access in 55 patients requiring mechanical support for respiratory failure. All patients were intubated orotracheally at the time of tracheostomy. The indications for From the University of Tennessee Center for the Health Sclences, Memphis, TN. Accepted for publication Dec 31, Address reprint requests to Dr. Hazard, 910 Madison Ave, Suite 825, Memphis, TN percutaneous tracheostomy were similar to those proposed for the standard operation [3, 91 and included prolonged ventilator dependence, difficulty in clearing airway secretions, the desire to provide oral feedings and better oral hygiene, the risk of laryngeal injury, and patient discomfort from the endotracheal tube. The procedure was always done in the intensive care unit with the patient under local anesthesia. Several minutes before the start of operation, the inspired oxygen fraction was increased to 100%. The head of the bed was raised to approximately 30 degrees, and the patient was positioned with the neck hyperextended and the relevant landmarks easily identifiable. The anterior neck was then prepared and draped in the usual manner. The cricothyroid, subcricoid, and any palpable intertracheal ring spaces were identified. The site for tracheostomy was chosen based on ease of identification and access, although the space below the second tracheal cartilage was generally preferred. The overlying skin was anesthetized with 1 to 2 ml of 1% lidocaine solution. The essential materials for the procedure are shown in Figure 1 and the technique is illustrated in Figure 2. A 14-gauge needle was attached to a syringe containing lidocaine, and the deeper tissues were infiltrated with 4 to 8 ml of lidocaine. The cuff of the endotracheal tube was deflated, and the tube was partially withdrawn. The cricoid cartilage was stabilized between the thumb and forefinger of the surgeon s left hand, and the needle was introduced through a midline puncture site into the tracheal lumen. Air was immediately aspirated into the syringe, and 3 to 4 ml of lidocaine was flushed into the trachea. The syringe was then disconnected from the needle, and a 0.13-cm diameter spring-tipped or J- tipped guidewire was introduced through the needle into the tracheal lumen. The needle was then withdrawn, leaving the wire in place. Slight up-and-down motion of the endotracheal tube ensured that it was not impaled by the wire. A 1-cm midline vertical incision was made at the entrance site of the guidewire. Bleeding was usualiy minimal and easily controlled by manual compression. An 8F tapered Teflon dilator was then passed over the guidewire into the trachea. As the operation was originally performed, this step was followed by successive introduction of larger dilators, progressing in even French sizes from 10 through 30. With each insertion the endotracheal position of the dilator tip was confirmed by sliding the guidewire freely within the dilator. Subsequently, the procedure was streamlined by using more sharply tapered dilators 63 Ann Thorac Surg 46:63-67, July Copyright by The Society of Thoracic Surgeons

2 64 The Annals of Thoracic Surgery Vol 46 No 1 July 1988 Fig I. The basic materials required for percutaneous tracheostomy include a 14-gauge needle attached to a disposable syringe (A), a simple J-wire, or spring-tipped guidezoire (B), 8, 20, and 30F dilators (C), and an endotracheal tube modified for use as a tracheostomy tube (D) or a standard tracheostomy tube (El. manufactured specifically for this purpose by Cook Critical Care (Bloomington, IL). These implements allowed the creation of an adequate stoma in all instances with two dilations, using first the 20F and then the 30F dilator. This modification greatly reduced operative time and patient discomfort. Once a suitable orifice had been created, the 20F dilator was fit snugly through the lumen of a standard 7-mm tracheostomy tube and then advanced over the guidewire into the trachea. The dilator and wire were removed, leaving the tracheostomy tube in place, and the endotracheal tube was removed. A recurring problem was the tendency of the tracheostomy tube to catch on the tracheal cartilage as it was pushed into the trachea. Although several commercially available tubes were tried, none proved entirely satisfactory. Eventually, the problem was rectified by modification of a standard cuffed endotracheal tube for use as a tracheostomy tube (see Fig 1). The gradual taper of the endotracheal tube permitted it to enter the trachea smoothly in virtually every instance, and this tube was used with excellent results in the last 30 procedures of the series, some of which were accomplished in less than five minutes. Efforts are currently under way to develop and manufacture a tracheal tube adapted specifically to this approach. General medical and nursing care followed standard practices, depending on the underlying disease pro- cesses, and frequently was directed by physicians other than the authors. The tracheostomy tubes were secured with simple ties around the neck. Cuffs were inflated to a pressure just adequate to seal the airway. Suctioning was performed as frequently as necessary using a standardized, sterile technique with disposable suction catheters. Results Percutaneous tracheostomy was performed in 55 patients (29 men, 26 women) ranging in age from 15 to 88 years (mean age, 63 * 2 years). All required ventilatory support for prolonged respiratory failure, and the decision to perform tracheostomy was made after an average of 10 days of endotracheal intubation (mean intubation time, 9.9 * 0.7 days). The mean duration of tracheostomy was days. The total mean duration of intubation was 35.4? 4.1 days. Although the majority of patients were eventually weaned (30 patients; 55%) from mechanical ventilation, only 38% (21 patients) were extubated and 36% (20 patients) survived to leave the hospital. There were no statistically significant differences (p < 0.05) between survivors and nonsurvivors in terms of age, duration of translaryngeal intubation, or duration of tracheostomy. The patients suffered from a wide variety of disease processes (Table), the single common denominator being respiratory failure, necessitating prolonged positive pressure ventilation. Because most attending physicians generally preferred prolonged endotracheal intubation, patients undergoing tracheostomy represented a select minority of mechanically ventilated patients. They were severely ill, and their problems were difficult to manage; their 64% mortality reflects this selection bias.

3 65 Hazard et al: Percutaneous Tracheostomy Major Clinical Disorders Encountered Disorder No. of Patients Septic syndrome 20 (36) A C B D Complicated obstructive lung disease 16 (29) Malignancy 13 (24) Pneumonia 12 (22) Acute gastroenterological problem 12 (22) Disorders of coagulation 10 (18) Cerebrovascular accident 10 (18) Congestive heart failure 9 (16) Acute renal failure 7 (13) Complicated coronary artery disease 6 (11) Noncardiac pulmonary edema 6 (11) Postcraniotomy 6 (11) Major skeletal trauma 5 (9) Postcoronary revascularization 3 (5) Percentage of total patients is shown in parentheses. Fig 2. Percutalicous tracheostorny technique. (A) Follou~ing prepration of the site selected for traclieostoimy and local nriestlictic- infiltration, a 14-gauge needle is advanced into the traclrea. (B) A flexible guide?c~iri~ is threaded through the rzredlc into tkc traclieal Iuinen. (C) Follozc~irig rcvzovnl of the needlc, a 30F Teflon dilator is passed oz~er the zc~irc to create a siritable opeiiing irrto the trac/iea. (D) A 20F dilator then is passed t/iroucc$ the traclirostonry tube and introduced into tlic stonia created b y the larger dilator. (E) The tracheostoiny tube tlierz is adr~ariced into the trachea, and the dilator and pideoclire are reiiroosd. Complications were limited mainly to our earlier experience. In no instance was percutaneous tracheostomy considered a cause or major contributing factor to death. While trivial oozing from the fresh stomal orifice was not uncommon, bleeding was severe enough to require single-unit blood transfusion in only 2 patients, both with coagulation disorders. Ten other patients with coagulopathies (mostly disseminated intravascular coagulation) underwent tracheostomy without marked hemorrhage. No patient required operative intervention to control bleeding. In most cases, the entire procedure was performed using no more than two gauze sponges. Subcutaneous emphysema developed in 2 patients, and pneumothorax developed in 1 patient after percutaneous tracheostomy. In all of these patients, the procedure was prolonged and required multiple dilator insertions. We suspected that tears or punctures may have been created in the tracheal wall. In 1 of these patients, bronchoscopy demonstrated a small puncture of the posterior tracheal wall. The pneumothorax was evacuated by chest tube. The extrapulmonary air resolved in 2 patients and was in the process of resolving in the third at the time of her death from unrelated causes. The series was remarkably free from infection. No purulent drainage from the stoma appeared in any patient, and only 1 exhibited notable cellulitis around the stoma. In this patient, a woman who failed to recover consciousness after subarachnoid hemorrhage and who experienced at least three separate episodes of septicemia during her hospital course, the tracheostomy remained in place without complication for 119 days before any cellulitis appeared. The tube was removed, and the patient was intubated orotracheally, resulting in clinical resolution of the infection within three days; she died without evidence of stomal infection five days after reinsertion of the tracheostomy tube. Although several patients had pneumonia at the time tracheostomy was performed, none experienced new parenchymal infection after tracheostomy. Of the 12 with pneumonia at outset, clinical resolution occurred in 8 patients, 6 of whom survived. Thus, there was no apparent' adverse relationship between percutaneous tracheostomy and parenchymal lung infection. There were no instances of mediastinitis, late bleeding, aspiration, or tracheoesophageal fistula associated with percutaneous tracheostomy. No problems with malposition, accidental dislodgement, or obstruction of the tracheal tube were encountered. In all of the patients who were decannulated, the stoma closed completely within 72 hours, and often within 24 hours. There were no patients in whom the stoma failed to heal completely. Cosmetic deformity was almost nonexistent in all survivors at the time of hospital discharge.

4 66 The Annals of Thoracic Surgery Vol 46 No 1 July 1988 Of the 20 survivors, 14 have been seen in follow-up without symptoms or signs suggestive of tracheal stenosis, although neither bronchoscopy nor flow-volume loops have been done. Comment Tracheostomy is performed for a variety of reasons [3,5, 101, but primarily to facilitate prolonged positive pressure ventilation. While it is generally accepted that mechanical ventilation should use translaryngeal intubation initially, there is wide disagreement regarding the optimal timing of tracheostomy in patients requiring long-term ventilatory support [3, 4, 9, 111. Among the proposed advantages of tracheostomy are greater patient comfort, the ability to take food and medicines orally, reduced dead space and total airway resistance, improved clearance of bronchopulmonary secretions, improved communication, more secure tube position, and ease of tube changes [3, 4, 111. Problems associated with translaryngeal intubation include injury and infection of the larynx, oropharynx, and nasopharynx [12-141; these problems are held to be less common with tracheostomy [3, 15, 161. Unfortunately, tracheostomy may be associated with a substantial morbidity of its own, and perioperative mortality has been variously reported as 3 to 5% [5-71. The overall complication rate for standard operative tracheostomy [5-10] ranges from 33 to 66% and includes stomal infection (17-36%), local hemorrhage (>36%), and pneumothorax or subcutaneous emphysema (617%). Tracheostomy is comparatively free from adverse effects on the upper airway but has greater potential for structural damage to the trachea [4, 9, 11, 171. Tracheal stenosis eventuates in 7 to 65% of surviving patients [5-7, 91, depending on the site and duration of intubation as well as the vigor with which it is sought. In direct comparisons between tracheostomy and translaryngeal intubation, complications have been more severe with the former [9, 16, 171. In particular, evidence suggests that tracheostomy may predispose to infection. Patients with tracheostomy seem to be at high risk for pneumonia [9, 17, 181. In addition, stomal infection can be a very troublesome complication in its own right [9, 191, aside from whatever role it may play in the pathogenesis of parenchymal lung infection. Furthermore, local infection may influence the later development of tracheal stenosis [8]. Percutaneous dilatational tracheostomy offers several advantages over standard operative procedures. Although 2 patients required transfusion and 3 patients exhibited subcutaneous emphysema or pneumothorax in our series, to our knowledge our overall complication rate of 11% is less than that of any major series of operative tracheostomies. Morbidity probably can be reduced further as more experience with the technique is gained. After the procedure was refined to a double dilation, followed by insertion of a modified endotracheal tube, no complications were encountered. The procedure is technically simple and generally requires less than 10 minutes to perform. The virtual absence of infectious complications is especially advantageous. In addition, the procedure can be performed at the bedside and does not require exposure of the patient to the risks of transport outside the intensive care unit [20]. Finally, the cosmetic deformity after decannulation is trivial. No statement regarding late tracheal stenosis can be made at this time; however, the lack of tracheal destruction and infections associated with the percutaneous technique will likely diminish the subsequent risk of stenosis. In conclusion, the percutaneous tracheostomy is an effective elective technique in critically ill patients. Because of its simplicity and speed, it may also offer an advantage when emergency tracheostomy is required. Although not currently available, an inexpensive disposable kit with the necessary materials conveniently arrayed may soon allow widespread application of this technique. The procedure compares favorably with operative tracheostomy and deserves further clinical evaluation. The clinical assistance of the medical and surgical house staffs and of the critical care nurses and respiratory therapists of Baptist Memorial Hospital is gratefully acknowledged. We are especially thankful to Carol Jones, R.N., for her help with data acquisition and to Dr. H. Edward Garrett, Sr., for his clinical guidance and critical review of the manuscript. References 1. Seldinger 51: Catheter replacement of the needle in percutaneous arteriography: a new technique. Acta Radio1 39:368, Ciaglia P, Firsching R, Syniec C: Elective percutaneous dilatational tracheostomy: a new simple bedside procedure: preliminary report. Chest 87715, Heffner JE, Miller KS, Sahn SA: Tracheostomy in the intensive care unit: I. Indications, technique, management. Chest 90:269, Colice GL: Prolonged intubation versus tracheostomy in the adult. J Intensive Care Med 2235, Head JM: Tracheostomy in the management of respiratory problems. N Engl J Med 264:587, McClelland RMA: Complications of tracheostomy. Br Med J 2:567, Mulder DS, Rubush JL: Complications of tracheostomy: relationship to long term ventilatory assistance. J Trauma 9:389, Andrews MJ, Pearson FG: Incidence and pathogenesis of tracheal injury following cuffed tube tracheostomy with assisted ventilation: analysis of a two-year prospective study. Ann Surg 173:249, Stauffer JL, Olson DE, Petty TL: Complications and consequences of endotracheal intubation and tracheotomy: a prospective study of 150 critically ill adult patients. Am J Med 70:65, Heffner JE, Miller KS, Sahn SA: Tracheostomy in the

5 67 Hazard et a1 Percutaneous Tracheostomy intensive care unit: 11. Complications. Chest 90:430, Berlauk JF: Prolonged endotracheal intubation vs. tracheostomy. Crit Care Med 14:742, Kastanos N, Miro RE, Perez AM, et al: Laryngotracheal injury due to endotracheal intubation: incidence, evolution, and predisposing factors: a prospective long-term study. Crit Care Med 11:362, Bishop MJ, Hibbard A], Fink BR, et al; Laryngeal injury in a dog model of prolonged endotracheal intubation. Anesthesiology 62:770, Grindlinger GA, Niehoff J, Hughes SL, et al: Acute paranasal sinusitis related to nasotracheal intubation of headinjured patients. Crit Care Med 15:214, Stock MC, Woodward CG, Shapiro BA, et al: Perioperative complications of elective tracheostomy in critically ill patients. Crit Care Med 14:861, Lund T, Goodwin CW, McManus WF, et al: Upper airway sequelae in burn patients requiring endotracheal intubation or tracheostomy. Ann Surg 201:374, El-Naggar M, Sadagopan S, Levine H, et al: Factors influencing choice between tracheostomy and prolonged endotracheal intubation in acute respiratory failure: a prospective study. Anesth Analg 55:195, Niederman MS, Ferranti RD, Zeigler A, et al: Respiratory infection complicating long-term tracheostomy: the implication of persistent gram-negative tracheobronchial colonization. Chest 85:39, Snow N, Richardson ID, Flint LM: Management of necrotizing tracheostomy infections. J Thorac Cardiovasc Surg 81:341, Waddell G: Movement of critically ill patients within hospital. Br Med J 2:417, 1975

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