Modified Technique of Percutaneous Dilational Tracheostomy in 600 Cases

Abstract

Tracheostomy is frequently required for the treatment of critically ill patients to prevent the complications with prolonged translaryngeal intubation. It may facilitate airway suctioning and improve patient comfort during the process of weaning. The purpose of the study was to introduce a new modified technique for percutaneous dilational tracheostomy (MPDT) and assess its advantages. From November 1997 through December 2000, a series of 600 patients (350 men, 250 women; mean age 44.5 years) underwent MPDT in our department. The technique we used is a combination of the Seldinger and Schachner techniques with an incision of 2 to 3 cm between the cricoid cartilage and the notch. Using a small automatic retractor, the thyroid muscles were dissected with the help of a curved mosquito clamp. This gave us the opportunity to control the isthmus and offered the possibility of ligation when the thyroid was large, providing a good operative field directly on the trachea. Hence we avoided traumatizing the isthmus, which is the main source of hemorrhage during this procedure. The mean operating time was 4.5 minutes. The morbidity rate was 0.04%. One patient developed a subcutaneous emphysema and in three cases we had to ligate the external jugular vein. The surgical incision was completely healed within 3 to 4 days after removing the tracheostoma. No tracheal stenoses were observed during the follow-up. MPDT is a safe, applicable technique that can be performed quickly even by a nonsurgeon in the intensive care unit and emergency department, with a low risk of complications because there is a direct view of the trachea and minimal trauma.

An appraisal on emergency tracheostomy

“…The vertical skin incision would have given more space for manoeuvring and is known to make the procedure safer, easier and faster. OST, by the very nature of the procedure, allows the tracheotomy to be easily targeted in the most optimal site on the membrane between the second and third tracheal rings without unduly damage to the adjacent cartilaginous rings and to be fashioned for a perfectly 348 F.G. Bonanno 1,3,5,7,8 The site and the centrality of the initial needle puncture/tracheotomy are crucial in avoiding complications: a plane of dissection not strictly on the midline, a high/very high tracheotomy for its proximity to the larynx, a low tracheotomy for the decubitus of the cannula on the trachea on neck flexion/extention movements, a not central ostomy with lateral decubitus of the cannula, an erroneous estimation of the depth of the trachea during manouvring with risk of posterior wall damage, are the five mechanisms accounting for the complications of the technique. 2,4,10 The open procedure, finally, represents the only possible treatment for life-threatening CTYand PCT intraoperative complications.…”

Percutaneous Tracheotomy

“…Leptidis et al ( 16) introduced a new modified technique for percutaneous dilational tracheotomy that can be performed quickly even by a non-surgeon in the intensive care unit (ICU) or emergency department. This technique is a combination of the techniques of Seldinger ( 17) and Schachner et al ( 11 ), which uses a 2-3-cm incision between the cricoid cartilage and the notch.…”

“…A number of complications have been associated with percutaneous tracheotomy, including hemorrhage, loss of airway, subcutaneous emphysema, mediastinal emphysema, pneumothorax, laryngotracheal stenosis, collapse of the tracheal lumen (due to force applied to the anterior tracheal wall), wound infections, stomal cellulitis, fracture of tracheal rings, fracture of the cricoid, poor placement of the tracheotomy tube, posterior tracheal wall injury, esophageal perforation, cardiopulmonary arrest, bronchospasm and death ( 1,15,16,18,19,.…”

Issues of critical airway management (Which anesthesia; which surgical airway?)

“…[37] SOT offers the best option in cases of cervical spine injury (CSI) with impalpable trachea. SOT requires less dissection, though at risk of not being able to control the occurrence of intraoperative complications,[8] and often the help of hookers and traction stitches, but it obviates to hazardous head/neck manipulations.…”