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Percutaneous Tracheotomy

Author: Scott E Brietzke, MD, MPH; Chief Editor: Arlen D Meyers, MD, MBA http://emedicine.medscape.com/article/866567-overview

Background
Tracheotomy, as a means of airway access, is one of the oldest surgical procedures documented, dating back approximately 4000 years. However, it wasnt until the early 20th century, when Chevalier Jackson introduced clear guidelines, was tracheotomy deemed a safe and viable procedure. With advances in technology and increasing interest in minimally invasive procedures, variations of the standard open tracheotomy have evolved over the last half century. Since Ciaglia et al introduced the percutaneous dilatational tracheotomy (PDT) in 1985, percutaneous tracheotomy (PCT) has become increasingly popular and has gained widespread acceptance in many ICU and trauma centers as a viable alternative approach.[1] In some institutions, PCT has become the procedure of choice. A large number of studies have been published comparing several techniques of PCT with the open surgical tracheotomy over the last 2 decades. Most studies suggest either lower complications rates with PCT or no statistical significances between the 2 methods.[2] Proponents of PCT purport smaller skin incisions, less tissue trauma, lower incidence of wound infection and cost effectiveness.[3] Furthermore, a recent meta-analysis by Higgins and Punthakee demonstrated no significant difference when comparing overall complications, with a trend toward favoring percutaneous method. Despite its substantial popularity, PCT does have limitations and risks. In Higgins and Punthakees meta-analysis, the percutaneous method was associated with a higher incidence of decannulation and obstruction. Furthermore, some investigators have proposed a learning curve for PCT, and increased complications result for patients who are treated by a surgeon who is inexperienced with the procedure or at an institution where the procedure is performed infrequently.[4] Therefore, early experience with PCT should be obtained under controlled settings. All surgeons using this technique should be prepared to perform immediate standard open tracheotomy to minimize the potentially lethal complications of this elective procedure.

History of the Procedure


The percutaneous techniques developed not long after Seldinger described needle replacement over a guidewire for arterial catheterization in 1953. In 1955, Shelden et al reported the first attempt to perform PCT.[5] They gained airway access with a slotted needle that then was used to guide a cutting trocar into the trachea. Unfortunately, the method caused multiple complications, and fatalities were reported secondary to the trocar's laceration of vital structures adjacent to the airway.

Subsequently, percutaneous airway access methods have improved, and various techniques and refinements have been reported. In 1969, Toye et al reported a tracheotomy technique based on a single tapered dilator with a recessed cutting blade.[6] This dilator was advanced into the airway over a guiding catheter, and the recessed blade was designed to cut tissues under tension as the dilator was forced into the trachea. In 1985, Ciaglia et al described the percutaneous dilational tracheotomy (PDT), a method based on needle guidewire airway access followed by serial dilations with sequentially larger dilators.[1] Schachner et al reported the Rapitrach method in 1989.[7] This method consists of using a dilating forceps device with a beveled metal conus that is designed to advance forcibly over a wire into the airway. In 1990, Griggs and colleagues reported the guidewire dilating forceps (GWDF) method.[8] This method is based on a forceps similar to that of the Rapitrach method, except without a cutting edge on the tip of the instrument. 1997 Fantoni translaryngeal tracheotomy using a specially designed canula to dilate the trachea in a retrograde manner.[9] In 2000, Byhahn et al introduced the Ciaglia Blue Rhino, which is a modified version of the Ciaglia technique.[10] In this technique, dilation of the stoma is formed in a single step by means of a hydrophilically coated, curved dilatorthe Blue Rhino. Therefore, the risk of posterior tracheal wall injury and intraoperative bleeding is reduced, and the adverse effect on oxygenation during repeated airway obstruction by the dilators is reduced. In 2002, the latest variation of PCT was introduced as Frova introduced the PercuTwist technique.[11] This technique features a controlled rotating dilation using a single step dilator with a self-tapping screw. To date, little experience has been reported with this technique and thus it will not be considered in detail. Among the various PDT techniques developed, the CBR method is currently the most commonly used PDT procedure worldwide.

Indications
In the ICU, the most common indication for tracheotomy is a need for prolonged mechanical ventilation. This need may arise from pneumonia refractory to treatment, severe chronic obstructive pulmonary disease, acute respiratory distress syndrome, severe brain injury, or multiple organ system dysfunction. The Council on Critical Care of the American College of Chest Physicians recommends tracheotomy in patients who are expected to require mechanical ventilation for longer than 7 days. Indications for percutaneous tracheotomy (PCT) are the same as those for standard open tracheotomy. Please refer to the eMedicine article Tracheotomy to review the main advantages of tracheotomy over prolonged translaryngeal intubation.

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Airway obstruction due to the following: o Inflammatory disease o Congenital anomaly (eg, laryngeal hypoplasia, vascular web) o Foreign body that cannot be dislodged with Heimlich and basic cardiac life support (BCLS) maneuvers o Supraglottic or glottic pathologic condition (eg, neoplasm, bilateral vocal cord paralysis) o Laryngeal trauma or stenosis o Facial fractures that may lead to upper airway obstruction (eg, comminuted fractures of the midface and mandible) o Edema (eg, trauma, burns, infection, anaphylaxis) Need for prolonged mechanical ventilation in cases of respiratory failure Need for improved pulmonary toilet o Inadequate cough due to chronic pain or weakness o Aspiration and the inability to handle secretions (The cuffed tube allows the trachea to be sealed off from the esophagus and its refluxing contents. However, some argue that secretions can leak around the cuffed tube and reach the lower airway.) Prophylaxis (as in preparation for extensive head and neck procedures and the convalescent period) Severe sleep apnea not amendable to continuous positive airway pressure (CPAP) devices or other, less invasive surgery

Relevant Anatomy
See Intraoperative details.

Contraindications
What constitutes absolute and relative contraindications has become a matter of debate. Most published articles consider cervical injury, pediatric age, coagulopathy, and emergency airway necessity as absolute contraindications, whereas short, fat neck or obesity are relative contraindications. However, several reports suggesting safety and feasibility of performing PCT in patients with the previously described contraindications.[12, 13, 2, 14, 15, 16] A retrospective study by Blankenship suggests percutaneous tracheotomy (PCT) may be performed safely in the morbidly obese patient as long as anterior neck landmarks can be palpated and in the coagulopathic patient with platelets as low as 17,000 and International Normalized Ratio.[12] Tabaee et al demonstrated the safety of percutaneous dilational tracheotomy (PDT) in patients with short neck lengths in their prospective, randomized study.[16] PCT was found to be safe and feasible even in emergency trauma cases in a case series study by Ben-Nun (2004).[2] Gravvanis et al showed in their retrospective study that PCT can be safely and more rapidly performed in burned patients with associated inhalation injury at the bedside.[14] PCT was also found to be safe and feasible in patients with cervical spine fractures in a case series by Ben-Nun et al (2006).[15] Kornblith et al reviewed 1000 patients who underwent bedside percutaneous tracheotomy over 10 years and found it to be a safe procedure with minimal complications, even for high-risk patients.[17]

Absolute contraindications are as follows:


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Patient age younger than 8 years Necessity of emergency airway access because of acute airway compromise Gross distortion of the neck anatomy due to the following: o Hematoma o Tumor o Thyromegaly (second or third degree) o High innominate artery o The relative contraindications are as follows: Patient obesity with short neck that obscures neck landmarks Medically uncorrectable bleeding diatheses o Prothrombin time or activated partial thromboplastin time more than 1.5 times the reference range o Platelet count less than 50,000/L Bleeding time longer than 10 minutes Need for positive end-expiratory pressure (PEEP) of more than 20 cm of water Evidence of infection in the soft tissues of the neck at the prospective surgical site

Laboratory Studies
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Complete blood count: Platelet count must be more than 50,000/L. Coagulation profile: Prothrombin time or activated partial thromboplastin time must be less than 1.5 times the reference range. Bleeding time: Bleeding time should be checked if blood urea nitrogen is more than 40 mg/dL or if the creatinine level is above 4 mg/dL. Bleeding time must be less than 10 minutes.

Imaging Studies
A standard chest radiograph can provide information regarding the tracheal air column. Anteroposterior filtered tracheal views and lateral soft tissue views of the neck provide information regarding the glottic and subglottic air columns.

Surgical Therapy
Numerous investigative reports show that all techniques for percutaneous tracheotomy (PCT) (eg, guidewire dilating forceps [GWDF], Rapitrach, percutaneous dilational tracheotomy [PDT]) have similar success rates. All techniques are based on the use of a needle guidewire to gain airway access. However, each method requires unique equipment and follows a different intraoperative procedural sequence. For example, all techniques that are conducted by serial dilatations of the stoma with commercial dilatators could be classified under PDT.

Preoperative Details
Equipment
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PDT kit (Cook Critical Care Inc, Bloomington, IN): 22-gauge needle and syringe; 11-F short punch dilator; 1.32-mm guidewire; 8-F guiding catheter; 18-F, 21-F, 24-F, 28-F, 32-F, 36-F, and 38-F dilators; Shiley size 8 double-cannula tracheotomy tube; fiberoptic bronchoscope GWDF kit (Sims Portex): 14-gauge needle and syringe, guidewire (J-tipped Seldinger wire type), scalpel, Howard-Kelly forceps modified to produce a pair of GWDF (seen in the image below), Shiley size 8 double-cannula tracheotomy tube with curved obturator, fiberoptic bronchoscope

Guidewire dilator forceps (GWDF). Rapitrach kit (Fresenius, Runcorn, Cheshire, UK): 12-gauge needle and syringe, short guidewire, scalpel, Rapitrach PCT dilator (seen in the image below), standard Portex 8-mm tracheotomy

tube with curved obturator, fiberoptic bronchoscope Rapitrach dilating forceps. Ciaglia Blue Rhino kit (Cook Critical Care Inc, Bloomington, IN): 14-gauge catheter introducer needle and syringe, guidewire (J-tipped Seldinger wire type), guiding catheter, introducer dilator, loading dilators, single tapering Blue Rhino dilator, Shiley size 8 double-cannula tracheotomy tube with curved obturator; fiberoptic bronchoscope

Anesthesia
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Intravenous sedation with the type and dosage of medications dictated by the clinical needs of the patient Place the patient on 100% oxygen throughout the procedure. Hyperextend the patient's neck if no contraindications exist. Before preparation of the surgical area begins, withdrawal of the endotracheal tube under direct vision of bronchoscope is recommended to place the balloon just under the vocal cords. The respiratory therapist then protects the tube against any further movement during the procedure. Infiltrate the incision site with a solution of 1-2 2% lidocaine with 1:100,000 epinephrine.

Intraoperative Details
Percutaneous dilational tracheotomy technique
The neck is cleansed with antiseptic solution and properly draped. The cricoid cartilage is identified, and the skin is anesthetized with 1% lidocaine with 1:100,000 epinephrine below the cricoid cartilage. A 1.5- to 2-cm transverse skin incision is made on the level of the first and second tracheal rings. Then, the blunt dissection of the midline is performed. A 22-gauge needle is inserted between the first and second or the second and third tracheal rings. This is represented in the image below.

Percutaneous dilational tracheotomy (PDT technique). Needle access of airway after blunt dissection of pretracheal tissues.

When air is aspirated into the syringe, the guidewire is introduced. After the guidewire is protected, the dilators are introduced. All dilators are inserted in a sequential manner from small to large diameter. The tracheotomy tube is then introduced along the dilator and guidewire. The guidewire and dilator are removed, the cuff of the tracheotomy tube is inflated, and the breathing circuit is connected. The ET tube is removed. The procedure is represented in the images below.

Percutaneous dilational tracheotomy (PDT technique). After removing the needle and reaspirating to confirm catheter location in the airway, the guidewire is placed.

Percutaneous dilational tracheotomy (PDT technique). Serial dilations

are performed over the guidewire. Percutaneous dilational tracheotomy (PDT technique). A tracheotomy tube is inserted in the dilated passageway using a dilator as obturator over the guidewire.

Guidewire dilating forceps technique


The neck is cleansed with antiseptic solution and properly draped. The neck is palpated, and the cricoid cartilage is identified. The skin below this level is anesthetized with 1% lidocaine with 1:100,000 epinephrine solution. A 1.5- to 2-cm midline transverse cutaneous incision is made at this level. A 14-gauge IV needle with syringe is inserted in the midline of the incision. The needle is directed to pass between the first and second or the second and third tracheal rings. As soon as air begins to bubble into the syringe, the outer plastic cannula is advanced into the lumen of the trachea and the inner needle is removed. A J-tipped Seldinger wire is introduced into the trachea, and the plastic cannula is removed. The tip of the Seldinger wire is passed through the closed GWDF. The forceps are advanced through the soft tissues of the neck until resistance is felt. The GWDF are opened to dilate the soft tissues anterior to the trachea. The forceps are then closed and reinserted over the wire into the trachea. A slight loss of resistance occurs as the tracheal membrane is pierced. To prepare the stoma of the tracheotomy, the GWDF are opened to the same diameter as the skin incision. A tracheotomy tube with obturator is inserted over the guidewire and advanced into the trachea. The obturator and guidewire are removed, the cuff of the tracheotomy tube is inflated, and the appropriate breathing circuit is connected. The ET tube is removed. The procedure is represented in the images below.

Guidewire dilating forceps (GWDF) technique. The guidewire dilator forceps are advanced along the Seldinger wire into the long axis of the trachea.

Guidewire dilating forceps (GWDF) technique. The guidewire dilator forceps enlarge the hole between tracheal rings.

Rapitrach technique
The neck is cleansed with antiseptic solution and properly draped. The skin is anesthetized with 1% lidocaine with 1:100,000 epinephrine below the cricoid cartilage. A 1.5- to 2-cm skin incision is performed at the level of the first and second tracheal rings. Subcutaneous layers are then bluntly dissected with a pair of forceps. Blunt dissection is continued until the tracheal rings can be palpated with a finger. A 12-gauge needle is inserted into the trachea between the first and second or the second and third rings. A short, flexible guidewire is inserted into the trachea, and the needle is removed. The Rapitrach dilator is introduced into the trachea over the guidewire. The dilator is opened when its tip lies in the trachea. A tracheotomy tube with obturator is inserted through the dilator jaws to the trachea. The dilator and guidewire are removed, the cuff of the tracheotomy tube is inflated, and the breathing circuit is connected. The ET tube is removed. Bronchoscopic guidance of the gauge needle and the guidewire insertion is optional but strongly recommended, especially for less-experienced operators.[18] A large number of paratracheal cannula insertions and pneumothoraces can be avoided if endoscopic monitoring is employed. Bronchoscopic monitoring also allows patients with short, fat necks to undergo PCT. However, bronchoscopic guidance during PCT appears to be the most important factor responsible for the hypercarbia that develops during the procedure. Therefore, bronchoscopic guidance should be limited to initial dilatation steps only.

Ciaglia blue rhino technique

The neck is cleansed with antiseptic solution and properly draped. The cricoid cartilage is identified, and the skin is anesthetized with 1% lidocaine with 1:100,000 epinephrine below the cricoid cartilage. A 1-1.5 cm transverse skin incision is made on the level of the first and second tracheal rings. Then, the blunt dissection of the midline is performed. A 14-gauge angiocatheter is inserted between the first and second or the second and third tracheal rings. When air is aspirated into the syringe, the guidewire is introduced. After the guidewire is protected, the Blue Rhino single tapering dilator is introduced over the guidewire until the stoma is dilated to an adequate diameter (36-F to 38-F). Once dilation is achieved, the tracheotomy cannula is assembled with 1 of the 3 intermediate dilators. Once assembled, it is advanced over the guidewire until the cannula is in place within the tracheal lumen. The intermediate dilator and guidewire is removed, the cuff of the tracheotomy tube is inflated, and the breathing circuit is connected.

Postoperative Details
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Air entry into the lungs is checked by chest auscultation and respiratory plethysmography. Excess secretions or blood should be suctioned to prevent a drop in oxygen saturation and to provide good bronchopulmonary hygiene. Everyday antiseptic wound care must be provided. A tracheotomy tube with an inner cannula facilitates care and hygiene and ensures added safety (due to easy removal) if obstruction from secretions occurs. In the event of accidental decannulation within 5-7 days of the procedure, the patient may need to be reintubated orally if the tracheotomy tube cannot be immediately reinserted because the tracheotomy tract is still relatively immature.

Follow-up
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Monitor the patient to prevent dislodgment of the tracheotomy tube. Deliver oxygen and/or mechanical ventilation as needed to maintain the patient's oxygen saturation and maintain appropriate ventilation. If using a cuffed tracheotomy tube, monitor cuff pressure carefully because prolonged inflation and/or overinflation can lead to tracheal mucosal injury. Clean the inner cannula as much as needed to clear secretions at least once every 8 hours. Suction the trachea as needed.

Complications
Numerous articles have been published comparing several techniques of percutaneous tracheotomy (PCT) with open surgical tracheotomy, as well as with one another. In general, most have shown similar complication rates. Four meta-analysis studies have been published in the last decade comparing percutaneous and open tracheotomy methods. In a meta-analysis of studies (1985-1996), Dulguerov et al found more frequent perioperative complications in the percutaneous cohort (10% vs 3%) but more postoperative complications with the surgical approach (10% vs 7%).[19] Also noted was a higher incidence of perioperative

death (0.44 vs 0.03%) and serious cardiorespiratory events (0.33% vs 0.06%) in the percutaneous group. Cheng and Fee (2000) analyzed 4 studies showing PCT required shorter operative times (8 minutes vs 20.9 minutes for the ST group), produced less intraoperative minor bleeding (9% vs 25%), and postoperative bleeding (7% vs 18%), and resulted in fewer overall postoperative complications (14% vs 60%), which included stomal infection (4% vs 29%), pneumothorax (1% vs 4%), and death (0% vs 3%).[20] Freeman et al (2000) analyzed 5 studies (n=236 patients) and found that percutaneous method was associated with shorter operative time (absolute difference 9.84 minutes), less perioperative bleeding (OR with 95% CI, 0.14), lower overall postoperative complication rate (OR 0.14), and lower postoperative incidence of bleeding (OR 0.39) and stomal infection (OR 0.02).[21] No difference was identified in overall operative complications, days intubated prior to tracheotomy, or death. Higgins and Punthakee (2007) recently published a meta-analysis comparing complication rates in 15 prospective, randomized-controlled trials involving 973 patients (490 percutaneous, 483 open).[22] See the table below for a summary of the results. This meta-analysis showed no significant difference when comparing overall complications, with a trend toward favoring percutaneous method. However, the more serious and life-threatening complication of decannulation/obstruction was more likely to occur with the percutaneous technique and false passage trended toward favoring the open procedure. Nevertheless, no significant difference was shown between the 2 methods in regards to death. As PCT gains more widespread exposure, studies comparing complications of the various PCT techniques have appeared. In a recent study comparing PercuTwist to PDT and guidewire dilating forceps (GWDF) techniques, the PercuTwist was found to require shorter procedure times (5.4 minutes +/- 1.2 minutes vs 9.9+/-1.1 and 6.2+/-1.4, respectively) and similarly acceptable complication rates.[23] Sheu et al reported a modification of the Ciaglia Blue Rhino (CBR) technique using a guidewire dilating forceps (GWDF) for initial dilation.[24] In their case series comparing GWDF-CBR (n=114) with standard CBR (n=120), they found shorter procedure times (4.5 +/- 1.6 minutes vs 5.7 +/- 3.0 minutes, P< 0.001), as well as fewer overall procedure-related complications (13.1% vs 27.5%, P=0.006). As time goes on, similar comparative studies will be performed, perhaps better elucidating optimal methods of PCT. Summary of comparative studies results (Open Table in a new window)
Complication Decannulation/obstruction False passage Minor hemorrhage Pooled OR 95% CI P value 2.79 2.70 1.09 1.29-6.03 0.009 0.89-8.22 0.08 0.61-1.97 0.77

Major hemorrhage Wound infection Unfavorable scarring Subglottic stenosis Death Overall complications

0.60 0.37 0.44 0.59 0.70 0.75

0.28-1.26 0.17 0.22-0.62 0.0002 0.23-0.83 0.01 0.27-1.29 0.19 0.24-2.01 0.50 0.56-1.00 0.05

When comparing costs, procedure time, and personnel involved, the percutaneous method appears to have the advantage ($461 USD less, 4.59 minutes less, 1 individual less). The decreased amount of time and personnel required for the percutaneous method is possibly because it is more likely to be performed by more experienced personnel, while trainees were more likely to perform the open technique.

Outcome and Prognosis


Because percutaneous tracheotomy (PCT) is performed in critically ill patients, late outcome of the procedure is difficult to describe. The mortality rate is high, but this high rate related to medical problems other than PCT. Mortality because of PCT or related complications is relatively rare. Conditions after PCT that significantly affect patients' lives and everyday activities are few. Symptomatic tracheal stenosis, the most difficult long-term complication to manage that requires operative correction, is relatively rare (1.9%). Hoarseness and temporary voice changes were reported by a significant number of patients (with a prevalence of up to 50%). In most cases, however, these changes are related to previous translaryngeal intubation. Direct injuries to the vocal cords or recurrent laryngeal nerve are extremely rare. Small skin incisions and few adjacent anatomical structure injuries due to blunt tissue dissection lead to favorable cosmetic results in stomal wound healing.

Future and Controversies


Percutaneous tracheotomy (PCT) has undergone and continues to undergo rigorous evaluation regarding its safety and the simplicity of its techniques. New percutaneous methods as well as modifications of the currently popular techniques have continued to develop. As new methods are introduced, future prospective randomized clinical studies would be helpful. PCT has been shown to be a safe and viable alternative to the standard open tracheotomy technique. However, this method has drawbacks and contraindications, and the surgeon performing PCT should be aware of them when making the decision as to which approach to use.

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