Percutaneous Tracheotomy

Percutaneous Tracheotomy

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Tracheotomy, as a means of airway access, is one of the oldest surgical procedures documented, dating back approximately 4000 years. However, it wasn’t until the early 20th century, when Chevalier Jackson introduced clear guidelines, that tracheotomy was 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, 2] 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. [3] Proponents of PCT purport smaller skin incisions, less tissue trauma, lower incidence of wound infection, and cost effectiveness. [4] Furthermore, a 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 Punthakee’s 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 in the procedure or at an institution where the procedure is performed infrequently. [5] 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.

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. [6] 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. [7] 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. [8] 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. [9] 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. [10]

In 2000, Byhahn et al introduced the Ciaglia Blue Rhino, which is a modified version of the Ciaglia technique. [11] In this technique, dilation of the stoma is formed in a single step by means of a hydrophilically coated, curved dilator—the 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. [12] 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.

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 Medscape Reference article Tracheostomy to review the main advantages of tracheotomy over prolonged translaryngeal intubation.

Airway obstruction due to the following:

Inflammatory disease

Congenital anomaly (eg, laryngeal hypoplasia, vascular web)

Foreign body that cannot be dislodged with Heimlich and basic cardiac life support (BCLS) maneuvers

Supraglottic or glottic pathologic condition (eg, neoplasm, bilateral vocal cord paralysis)

Laryngeal trauma or stenosis

Facial fractures that may lead to upper airway obstruction (eg, comminuted fractures of the midface and mandible)

Edema (eg, trauma, burns, infection, anaphylaxis)

Need for prolonged mechanical ventilation in cases of respiratory failure

Need for improved pulmonary toilet

Inadequate cough due to chronic pain or weakness

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

See Intraoperative details.

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, there have been several reports suggesting the safety and feasibility of performing PCT in patients with the previously described contraindications. [13, 14, 3, 15, 16, 17, 18]

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. [13] Tabaee et al demonstrated the safety of percutaneous dilational tracheotomy (PDT) in patients with short neck lengths in their prospective, randomized study. [17] PCT was found to be safe and feasible even in emergency trauma cases in a case series study by Ben-Nun (2004). [3] 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. [15] 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). [16]

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. [19]

Absolute contraindications are as follows:

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:

Hematoma

Tumor

Thyromegaly (second or third degree)

High innominate artery

The relative contraindications are as follows:

Patient obesity with short neck that obscures neck landmarks

Medically uncorrectable bleeding diatheses

Prothrombin time or activated partial thromboplastin time more than 1.5 times the reference range

Platelet count less than 50,000/µL

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

Ciaglia P, Firsching R, Syniec C. Elective percutaneous dilatational tracheostomy. A new simple bedside procedure; preliminary report. Chest. 1985 Jun. 87(6):715-9. [Medline].

Patel HH, Siltumens A, Bess L, Camacho F, Goldenberg D. The decline of tracheotomy among otolaryngologists: a 14-year review. Otolaryngol Head Neck Surg. 2015 Mar. 152 (3):465-9. [Medline].

Ben-Nun A, Altman E, Best LA. Emergency percutaneous tracheostomy in trauma patients: an early experience. Ann Thorac Surg. 2004 Mar. 77(3):1045-7. [Medline].

Freeman BD, Isabella K, Cobb JP, et al. A prospective, randomized study comparing percutaneous with surgical tracheostomy in critically ill patients. Crit Care Med. 2001 May. 29(5):926-30. [Medline].

Massick DD, Yao S, Powell DM, et al. Bedside tracheostomy in the intensive care unit: a prospective randomized trial comparing open surgical tracheostomy with endoscopically guided percutaneous dilational tracheotomy. Laryngoscope. 2001 Mar. 111(3):494-500. [Medline].

Shelden CH, Pudenz RH, Freshwater DB. A new method for tracheostomy. J Neurosurg. 1955. 12:428-31.

Toye FJ, Weinsten JD. A percutaneous tracheostomy device. Surgery. 1969. 65:384-9.

Schachner A, Ovil Y, Sidi J, et al. Percutaneous tracheostomy–a new method. Crit Care Med. 1989 Oct. 17(10):1052-6. [Medline].

Griggs WM, Worthley LI, Gilligan JE, et al. A simple percutaneous tracheostomy technique. Surg Gynecol Obstet. 1990 Jun. 170(6):543-5. [Medline].

Fantoni A, Ripamonti D. A non-derivative, non-surgical tracheostomy: the translaryngeal method. Intensive Care Med. 1997 Apr. 23(4):386-92. [Medline].

Byhahn C, Wilke HJ, Halbig S, et al. Percutaneous tracheostomy: ciaglia blue rhino versus the basic ciaglia technique of percutaneous dilational tracheostomy. Anesth Analg. 2000 Oct. 91(4):882-6. [Medline].

Frova G, Quintel M. A new simple method for percutaneous tracheostomy: controlled rotating dilation. A preliminary report. Intensive Care Med. 2002 Mar. 28(3):299-303. [Medline].

Blankenship DR, Kulbersh BD, Gourin CG, et al. High-risk tracheostomy: exploring the limits of the percutaneous tracheostomy. Laryngoscope. 2005 Jun. 115(6):987-9. [Medline].

Kluge S, Meyer A, Kuhnelt P, et al. Percutaneous tracheostomy is safe in patients with severe thrombocytopenia. Chest. 2004 Aug. 126(2):547-51. [Medline].

Gravvanis AI, Tsoutsos DA, Iconomou TG, et al. Percutaneous versus Conventional Tracheostomy in Burned Patients with Inhalation Injury. World J Surg. 2005 Dec. 29(12):1571-5. [Medline].

Ben Nun A, Orlovsky M, Best LA. Percutaneous tracheostomy in patients with cervical spine fractures–feasible and safe. Interact Cardiovasc Thorac Surg. 2006 Aug. 5(4):427-9. [Medline].

Tabaee A, Geng E, Lin J, Kakoullis S, McDonald B, Rodriguez H, et al. Impact of neck length on the safety of percutaneous and surgical tracheotomy: a prospective, randomized study. Laryngoscope. 2005 Sep. 115(9):1685-90. [Medline].

Kaese S, Zander MC, Lebiedz P. Successful Use of Early Percutaneous Dilatational Tracheotomy and the No Sedation Concept in Respiratory Failure in Critically Ill Obese Subjects. Respir Care. 2016 May. 61 (5):615-20. [Medline]. [Full Text].

Kornblith LZ, Burlew CC, Moore EE, et al. One thousand bedside percutaneous tracheostomies in the surgical intensive care unit: time to change the gold standard. J Am Coll Surg. 2011 Feb. 212(2):163-70. [Medline].

Deppe AC, Kuhn E, Scherner M, Slottosch I, Liakopoulos O, Langebartels G, et al. Coagulation disorders do not increase the risk for bleeding during percutaneous dilatational tracheotomy. Thorac Cardiovasc Surg. 2013 Apr. 61(3):234-9. [Medline].

Veelo DP, Vlaar AP, Dongelmans DA, Binnekade JM, Levi M, Paulus F, et al. Correction of subclinical coagulation disorders before percutaneous dilatational tracheotomy. Blood Transfus. 2012 Apr. 10(2):213-20. [Medline]. [Full Text].

Kost KM. Endoscopic percutaneous dilatational tracheotomy: a prospective evaluation of 500 consecutive cases. Laryngoscope. 2005 Oct. 115(10 Pt 2):1-30. [Medline].

Dulguerov P, Gysin C, Perneger TV, et al. Percutaneous or surgical tracheostomy: a meta-analysis. Crit Care Med. 1999 Aug. 27(8):1617-25. [Medline].

Cheng E, Fee WE Jr. Dilatational versus standard tracheostomy: a meta-analysis. Ann Otol Rhinol Laryngol. 2000 Sep. 109(9):803-7. [Medline].

Freeman BD, Isabella K, Lin N, et al. A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients. Chest. 2000 Nov. 118(5):1412-8. [Medline].

Higgins KM, Punthakee X. Meta-analysis comparison of open versus percutaneous tracheostomy. Laryngoscope. 2007 Mar. 117(3):447-54. [Medline].

Yurtseven N, Aydemir B, Karaca P, et al. PercuTwist: a new alternative to Griggs and Ciaglia’s techniques. Eur J Anaesthesiol. 2007 Jun. 24(6):492-7. [Medline].

Sheu CC, Tsai JR, Hung JY, et al. A simple modification of Ciaglia Blue Rhino technique for tracheostomy: using a guidewire dilating forceps for initial dilation. Eur J Cardiothorac Surg. 2007 Jan. 31(1):114-9. [Medline].

Decker S, Gottlieb J, Cruz DL, et al. Percutaneous dilatational tracheostomy (PDT) in trauma patients: a safe procedure. Eur J Trauma Emerg Surg. 2015 Oct 5. [Medline].

Klemm E, Nowak AK. Tracheotomy-Related Deaths. Dtsch Arztebl Int. 2017 Apr 21. 114 (16):273-9. [Medline]. [Full Text].

Ikegami Y, Iseki K, Nemoto C, Tsukada Y, Shimada J, Tase C. Patient questionnaire following closure of tracheotomy fistula: percutaneous vs. surgical approaches. J Intensive Care. 2014. 2 (1):17. [Medline].

Vargas M, Sutherasan Y, Brunetti I, et al. Mortality and long-term quality of life after percutaneous tracheotomy in Intensive Care Unit: a prospective observational study. Minerva Anestesiol. 2018 Jan 16. [Medline].

Nowak A, Kern P, Koscielny S, et al. Feasibility and safety of dilatational tracheotomy using the rigid endoscope: a multicenter study. BMC Anesthesiol. 2017 Jan 14. 17 (1):7. [Medline]. [Full Text].

Alansari M, Alotair H, Al Aseri Z, Elhoseny MA. Use of ultrasound guidance to improve the safety of percutaneous dilatational tracheostomy: a literature review. Crit Care. 2015 May 18. 19:229. [Medline]. [Full Text].

Complication

Pooled OR

95% CI

P value

Decannulation/obstruction

2.79

1.29-6.03

0.009

False passage

2.70

0.89-8.22

0.08

Minor hemorrhage

1.09

0.61-1.97

0.77

Major hemorrhage

0.60

0.28-1.26

0.17

Wound infection

0.37

0.22-0.62

0.0002

Unfavorable scarring

0.44

0.23-0.83

0.01

Subglottic stenosis

0.59

0.27-1.29

0.19

Death

0.70

0.24-2.01

0.50

Overall complications

0.75

0.56-1.00

0.05

Michael Omidi, MD, FACS 

Michael Omidi, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Ronnie A Pezeshk, MD Clinical Research Fellow in Plastic and Reconstructive Surgery, University of Texas Southwestern Medical Center

Disclosure: Nothing to disclose.

Sammy D D Eghbalieh, MD Fellow in Vascular Surgery, Division of Vascular Surgery, Albany Medical College

Sammy D D Eghbalieh, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, American Medical Association, California Medical Association, Physicians for Social Responsibility, Society for Vascular Surgery, Vascular and Endovascular Surgery Society

Disclosure: Nothing to disclose.

Evelyne Kalyoussef, MD, FACS Assistant Professor, Otolaryngology Residency Program Director, Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School; Attending Otolaryngologist and Head and Neck Surgeon, Department of Otolaryngology-Head and Neck Surgery, The University Hospital, Hackensack UMC-Mountainside Hospital, and Trinitas Hospital

Evelyne Kalyoussef, MD, FACS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Rhinologic Society, Association of Women Surgeons, European Rhinologic Society, North American Skull Base Society, Women in Otolaryngology (WIO) Section, American Academy of Otolarynoglogy-Head and Neck Surgery

Disclosure: Nothing to disclose.

Soly Baredes, MD Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School; Director of Otolaryngology-Head and Neck Surgery, University Hospital

Soly Baredes, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, American Laryngological Association, The Triological Society, American Medical Association, North American Skull Base Society, Society of University Otolaryngologists-Head and Neck Surgeons, Triological Society, New York Head and Neck Society, New York Laryngological Society, New Jersey Academy of Otolaryngology-Head and Neck Surgery, The New Jersey Academy of Facial Plastic Surgery, International Skull Base Society

Disclosure: Nothing to disclose.

Mark S Granick, MD, FACS Professor of Surgery, Chief, Division of Plastic Surgery, Rutgers New Jersey Medical School

Mark S Granick, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society of Plastic Surgeons, New Jersey Society of Plastic Surgeons, Northeastern Society of Plastic Surgeons, Phi Beta Kappa, Wound Healing Society

Disclosure: medical consultant and speaker for: Misonix, Inc, medical consultant; Cytori, medical consultant; PolarityTE.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;Preacute Population Health Management;The Physicians Edge<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; for: Rxblockchain;Bridge Health.

Lanny Garth Close, MD Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, Columbia University College of Physicians and Surgeons

Lanny Garth Close, MD is a member of the following medical societies: Alpha Omega Alpha, American Head and Neck Society, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physicians, American Laryngological Association, New York Academy of Medicine

Disclosure: Nothing to disclose.

Soly Baredes, MD Professor of Otolaryngology-Head and Neck Surgery, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Soly Baredes, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Laryngological Association, American Laryngological Rhinological and Otological Society, American Medical Association, American Society for Head and Neck Surgery, New York Head and Neck Society, North American Skull Base Society, Society of UniversityOtolaryngologists-Head and Neck Surgeons, and Triological Society

Disclosure: Nothing to disclose. Darius Bliznikas, MD Staff Physician, Department of Otolaryngology, Wayne State University School of Medicine

Darius Bliznikas, MD is a member of the following medical societies: Sigma Xi

Disclosure: Nothing to disclose.

Scott E Brietzke, MD, MPH Assistant Professor of Surgery, Uniformed Services University of the Health Sciences; Director, Pediatric Otolaryngology, Department of Surgery, Otolaryngology Service, Walter Reed Army Medical Center; Associate Program Director, National Capital Consortium Residency in Otolaryngology

Scott E Brietzke, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, and American Academy of Sleep Medicine

Disclosure: Nothing to disclose.

Michael S Kong, MD Resident Physician, Department of Otolaryngology, National Capital Consortium

Michael S Kong, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Physicians, American Medical Association, and Association of Military Surgeons of the US

Disclosure: Nothing to disclose.

Joshua S Schindler, MD Assistant Professor, Department of Otolaryngology, Oregon Health and Science University

Joshua S Schindler, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: Nothing to disclose.

Percutaneous Tracheotomy

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