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

Abstract

Ultrasound Bronchoscopic a b s t r a c tBackground: The purpose of this study was to evaluate the efficacy of ultrasound guided percutaneous tracheostomy (USPCT) and bronchoscopic guided percutaneous tracheostomy (BPCT) and the incidence of complications in critically ill, obese patients. Methods: Seventy four consecutive patients were included in a prospective study and randomly divided into USPCT and BPCT. Incidence of complications, ease and efficacy were compared in obese USPCT (n ¼ 38)and BPCT (n ¼ 36). Results are expressed as the median (25the75th percentile) or number (percentage). Results: The median times for tracheostomy were 12 min (9e14) in USPCT patients and 18 min (12e21.5) in BPCT (p ¼ 0.05). The overall complication rate was higher in BPCT than USPCT patient group (75% vs. 321%, p < 0.05). Most complications were minor (hypotension, desaturation, tracheal cuff puncture and minor bleeding) and of higher number in the BPCT. Ultrasound-guided PCT was possible in all enrolled patients and there were no surgical conversions or deaths. Conclusions: This study demonstrated that real US-guided PCT is a favourable alternative to BPCT with a low complication rate and ease, thus proving more efficacious. A US examination provides information on cervical anatomy, vasculature etc. and hence modifies and guides choice of the PCT puncture site.

Awake percutaneous tracheostomy as an alternative to open emergency tracheostomy in a threatened airway

“…A learning curve is to be expected before the technique can be adopted in routine use. 13,16 In this case, ultrasound revealed the optimal location for tracheostomy, substantially lateral to the conventional tracheostomy site. The ENT surgeons were concerned about…”

“…5,14,17 This modality may provide important information less evident on clinical examination, especially in challenging cases (obesity, unfavourable anatomy/obscured landmarks, cervical spine precautions). 13,14 These factors most likely prompted the recent recommendation of ultrasound in both the Australian/New Zealand and Danish intensive care practice guidelines as a means of improving the safety of the technique. 18,19 Observational data suggests a 10 times higher incidence of complications in conventional groups when compared with ultrasound guidance.…”

“…Limitations of bronchoscopy include the possibility of complete airway obstruction prior to airway control and inability to assess overlying vascular or anatomical structures like the thyroid gland and thus the inability to predict or pre-empt procedural trauma to these structures. [13][14][15] It may also cause acute increases in intracranial pressure, which is undesirable in certain patient groups (neurosurgical). placing a tracheostomy in an infected neck but were reassured by the superficial location of the trachea and the absence of pus loculations in the vicinity of the planned stoma.…”

“…13 Most recently, the Trachus study, a single-centre open-label, parallel, non-inferiority RCT involving 118 patients (60 patients ultrasound group and 58 patients bronchoscopy) in eight ICUs found procedural ultrasound-guided PT to be non-inferior to bronchoscopy-guided PT. They showed no significant difference in a primary composite outcome (conversion to surgical tracheostomy, switching groups or major complication) with similar subjective procedural difficulty, similar procedure durations and ultrasound information effecting a change of puncture site in 23.3% of patients.…”

“…The combination of ultrasound alongside bronchoscopy can improve efficacy and safety. 13,14,16 Ultrasound is a non-invasive, repeatable and increasingly available tool that has shown promise in both simulated scenarios and clinical application. The small amount of emerging literature suggests that ultrasound-guided PT is safe and offers a potential benefit over the traditional landmark-guided technique, with specific relevance for certain patient groups, such as those with increased BMI and obscured surface landmarks.…”