Real-time ultrasound-guided percutaneous dilatational tracheostomy: a feasibility study

Abstract

IntroductionUltrasound (US) performed prior to percutaneous tracheostomy (PT) may be useful in avoiding injury to pretracheal vascular structures and in avoiding high placement of the tube. Bedside real-time US guidance with visualization of needle path is routinely utilized for other procedures such as central venous catheterization, and may enhance the safety and accuracy of PT without causing airway occlusion or hypercarbia. Our objective was to demonstrate that PT performed under real-time US guidance with visualization of needle path during tracheal puncture is feasible, including in patients with features that increase the technical difficulty of PT.MethodsMechanically ventilated patients with acute brain injury requiring tracheostomy underwent US guided PT. The orotracheal tube was withdrawn using direct laryngoscopy. The trachea was punctured under real-time US guidance (with visualization of the needle path) while using the acoustic shadows of the cricoid and the tracheal rings to identify the level of puncture. After guidewire passage the site and level of entry was verified using the bronchoscope, which was then withdrawn. Following dilatation and tube placement, placement in the airway was confirmed using auscultation and the "lung sliding" sign on US. Bronchoscopy and chest X-ray were then performed to identify any complications.ResultsThirteen patients successfully underwent US guided PT. Three patients were morbidly obese, two were in cervical spine precautions and one had a previous tracheostomy. In all 13 patients bronchoscopy confirmed that guidewire entry was through the anterior wall and between the first and fifth tracheal rings. There was no case of tube misplacement, pneumothorax, posterior wall injury, significant bleeding or other complication during the procedure.ConclusionsPercutaneous tracheostomy performed under real-time ultrasound guidance is feasible and appears accurate and safe, including in patients with morbid obesity and cervical spine precautions. Larger studies are required to further define the safety and relative benefits of this technique.Trial registrationUMIN Clinical Trials Registry, UMIN000005023.

Real time ultrasound-guided percutaneous tracheostomy: Is it a better option than bronchoscopic guided percutaneous tracheostomy?

“…9 Recently, Rajajee et al demonstrated the feasibility of US guidance during the implementation of PCT in a population of neuro-intensive care patients. 10 USPCT has many potential advantages over other techniques of PCT. The first is the ability to consistently place the tracheostomy tube below the first tracheal ring.…”

“…Placement of the tracheal tube above the first tracheal ring may increase the risk of late sub-glottic cicatrization and stenosis. 7,9,10 In one study of patients who underwent autopsy following PCT, 5 of 15 patients had the tracheal tube placed above the first tracheal ring when the tube was placed blindly vs zero of 11 patients when PT was performed with ultrasound guidance.…”

Percutaneous tracheostomy: a comprehensive review

“…The use of ultrasound in PT can be advantageous especially in select patient groups, such as those who are morbidly obese or have difficult neck anatomy (68)(69)(70). Bedside ultrasound screening allows for easy identification of pretracheal vascular structures that might pose a hemorrhage risk during PT (71).…”

Tracheostomy: Epidemiology, Indications, Timing, Technique, and OutcomesDiscussion

“…There was no case of tube misplacement, pneumothorax, posterior wall injury, significant bleeding, or other complications. 96 Although ultrasound may not be required in all patients undergoing PDT, real-time ultrasound should be considered in obese patients in whom surface landmarks are difficult to discern, in patients with altered cervical anatomy, and for difficult tracheostomy procedures such as repeat tracheostomy. 97 Another prospective study of 50 consecutive subjects in 2 surgical and critical care medicine departments in France demonstrated that ultrasound-guided percutaneous tracheostomy was feasible and safe in obese patients (median body mass index of 34 kg/m 2 , range of 32-38) with a low complication rate.…”