Ultrasound-guided percutaneous dilatational tracheostomy: a safe method to avoid cranial misplacement of the tracheostomy tube

Abstract

The aim of this investigation was to evaluate the role of ultrasonography in avoiding cranial misplacement of the tracheostomy tube and tracheal ring fractures during percutaneous dilatational tracheostomy (PDT). The tracheas of 26 consecutive ICU patients who had undergone PDT but who later died were removed en bloc at autopsy. The tracheas were opened along the membranous portion and the condition of tracheal rings and the site of tracheostomy macroscopically evaluated. The patients were divided in two groups: group A with 15 patients who underwent "blind" PDT and group B with 11 patients who underwent ultrasound-guided PDT. In five (33%) patients from group A, autopsy revealed that the tracheostomy tube was placed between the cricoid cartilage and the first tracheal ring (cranial misplacement) and in six (43%) patients a fracture of one tracheal ring was found. Cranial misplacement of the tracheostomy tube in patients from group B was not found (P < 0.05) and four (36%) patients had a broken tracheal ring (P = NS). The authors maintain that by using ultrasound-guided PDT cranial misplacement of the tracheostomy tube may be entirely avoided.

Ultrasound-guided percutaneous dilatational tracheostomy with laryngeal mask airway control in a morbidly obese patient

“…Ultrasonography allows optimal selection of the intercartilaginous space for the tracheostomy tube placement, avoiding eventual cranial misplacement. 5,8 Moreover, it has been recently demonstrated that ultrasound-guided PDT, in contrast to endoscopic guidance, is not accompanied by significant hypercarbia or elevation of intracranial pressure, conditions that could be detrimental in neurosurgical patients. 11,12 Endotracheal tube cuff puncture, or even puncture of the Murphy eye, are well known and reported complications of PDT.…”

“…1-3 However, the "blind" technique is burdened with potential complications and relative and absolute contraindications. [2][3][4] To diminish those problems, bronchoscopically or ultrasonically guided PDT is suggested and airway control maintained with LMA during the PDT 5,6,8,10 . A short, bull neck without clear anatomical landmarks in morbidly obese patients presents a relative contraindication for PDT 3,4 .…”

“…The ultrasound-guided PDT was performed as we have previously described. 8 With a sterile linear ultrasonography transducer (vascular probe, 7.5 MHz; Hitachi EUB 525, Tokyo, Japan) the trachea is viewed by vertical medial section (Figure 1). Following clear verification of thyroid and cricoid cartilage and tracheal rings, the site of puncture was determined as between the second and third tracheal ring.…”

Bilateral Pneumothorax as a Complication of Percutaneous Tracheostomy: Case Report

“…Prior to performing the procedure with the patient already positioned and the neck extended, we usually used ultrasound to identify the structures such as blood vessels close to the intended site of tracheostomy, the thyroid and cricoid cartilages, and the first three tracheal rings. Although the literature does not convincingly support using ultrasound routinely, but rather as an adjunct in selected patients, several studies and our personal experience have shown that ultrasound performed prior to percutaneous tracheostomy may be useful in avoiding injury to pretracheal vascular structures and in avoiding high placement of the tube 14,15 . Ultrasound examination performed before the procedure and fiberoptic bronchoscopy during the procedure can decrease complication rates and improve the safety of PDT 15 .…”

Pneumothorax during percutaneous tracheostomy ― a brief review of literature on attributable causes and preventable strategies

“…One must ensure adequate sedation and analgesia, preferably with a neuromuscular blockade using a short-acting intravenous paralytic agent in order to minimize coughing, biting and motion of the neck and trachea during the procedure. Although the literature does not convincingly support using ultrasound (US) routinely, but rather as an adjunct in selected patients, several studies have shown that ultrasound performed prior to PT may be useful in avoiding injury to pretracheal vascular structures and in avoiding high placement of the tube [24].…”