Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4510_Библиотеки_им_академика_М_И_Перельмана.pdf
Percutaneous Tracheostomy Indications
andSurgical Technique
LucioPereira andCatherineLumley
Introduction
Tracheostomy is a procedure used to obtain a surgical airway. It has been performed
for over 3000 years. This operative technique was standardized by Chevalier
Jackson, but the modern era only started in the 1960s, when the surgical technique,
indications, and complications were better described.
The surgical airway can be temporary (in cases where the upper airway obstruction or
respiratory abnormality can be reversed) or permanent. The procedure is indicated for an
upper airway obstruction caused by tumors, infection, obstructive sleep apnea, or trauma;
and in cases of prolonged intubation, as an aid in handling secretions and to facilitate
ventilator support. A summary of the indications for tracheostomy can be seen in Table1.
Even though airway obstruction is the most dramatic indication for a surgical
airway, most procedures are performed for prolonged intubation in patients admitted to an intensive care unit (ICU). It is estimated that 20–38% of ICU beds are
lled with mechanically ventilated patients [1]. An average of 100,000 tracheostomies for this reason are performed each year in the USA [2].
Airway access for mechanical ventilation is initially provided by endotracheal
intubation. The perfect timing for tracheostomy in patients requiring mechanical
ventilation is still controversial. Some of the advantages of tracheostomy over endotracheal intubation include less trauma to the larynx, vocal cords, and arytenoids;
decreased airway resistance; and improvements in airway hygiene and patient comfort. Patients expected to require ventilation for less than 10 days are usually
L. Pereira, M.D. (*)
Department of Otolaryngology, Hofstra Northwell School of Medicine, Long Island Jewish
Medical Center, New Hyde Park, NY, USA
e-mail: pereiralucio@hotmail.com
C. Lumley, M.D.
Department of Otolaryngology–Head and Neck Surgery, Georgetown University, Washington,
DC, USA
© Springer International Publishing AG 2018
T.P. de Farias (ed.), Tracheostomy, https://doi.org/10.1007/978-3-319-67867-2_5
77
78
L. Pereira and C. Lumley
Table 1 Indications for
tracheostomy
Upper airway obstruction with any of the following:
Stridor
Air hunger
Retractions
Obstructive sleep apnea with documented arterial desaturations
Bilateral vocal cord paralysis
Previous neck surgery or throat trauma
Previous neck irradiation
Prolonged or expected prolonged intubation
Inability of patient to manage secretions, including the following:
Aspiration
Excessive bronchopulmonary secretions
Facilitation of ventilation support
Inability to intubate
Adjunct to manage head and neck surgery
Adjunct to manage signicant head and neck trauma
managed by endotracheal intubation alone. Tracheostomy is considered if the
patient will require intubation for more than 14–21days. The reported rate of stenosis following intubation ranges from 0.9% to 8.3% [3]. This is a result of injury due
to pressure at the level of the glottis and arytenoid cartilages by the endotracheal
tube. Despite the recognition of this problem and improvements in endotracheal
tube design and maintenance, prolonged intubation should still be avoided, and tracheostomy should be a solution in most cases.
Open tracheostomy is the gold-standard technique and can be done in a wide variety
of patient conditions and clinical scenarios. The surgical procedure is safe and has stood
the test of time. Although it can be done at the bedside, the vast majority of such procedures are done in the operating room (OR) and require a specialized surgical team, OR
time, and coordination between the ICU and surgical teams. Transportation of a critical
patient from the ICU to the OR needs to be taken into account as well, as it demands
coordination, and patients can become unstable on their way to the OR.
Percutaneous tracheostomy can be performed at the bedside, obviating the need
to transfer the patient to the OR, which can release OR resources. It also allows
physicians without surgical training to perform the procedure, making it easier to
schedule the procedure and allowing it to be performed in a more timely fashion.
Percutaneous Tracheostomy
In an attempt to nd an easier tracheostomy method that could be done at the bedside
and avoid transporting critically ill patients to the OR, several authors have described
alternative surgical techniques using a percutaneous method. A percutaneous technique
for tracheostomy was rst described in 1955 by Shelden etal. [4]. This was a blind
technique using a cutting trocar guided by a slotted needle to gain access to the trachea
(Fig. 1). This method was abandoned because it resulted in several complications,
Percutaneous Tracheostomy Indications andSurgical Technique
Fig. 1 Shelden technique.
The ball-tipped cutting
blade is passed through the
lateral opening and
advanced along the slot
79
A
including injury to the carotid and esophagus. Three decades later, Ciaglia etal. published their series using the Seldinger technique [5]. This method introduced the use
of beroptic bronchoscopy to visualize the tracheal puncture, making the procedure
safer. Other authors—such as Schachner (Rapitrach, 1989), Griggs et al. (1990),
Fantoni and Ripamonti (1997), and Frova and Quintel (2002)—developed their own
techniques for percutaneous tracheostomy. These techniques have been described
using a variation of the Seldinger technique [6]. In 1990, Griggs etal. dilated the trachea using curved forceps, which were passed over the guide wire in the trachea. The
forceps were then opened and provided force to dilate the trachea and anterior soft
tissue. The tracheostomy tube was then passed over the guide wire [7] (Fig.2). Fantoni
and Ripamonti reported a translaryngeal tracheostomy set in 1997 involving a unique
cannula to pass into and dilate the trachea retrograde from the lumen out to the skin.
This required a guide wire to be passed through a needle in the trachea out through the
mouth in order to load the specially designed cannula, which was then pulled back
through the oral cavity, larynx, and trachea to pierce through the skin of the neck [8]
(Fig.3). In 2002, Frova and Quintel described a new technique using a screw-like
dilator in order to decrease the need for increased pressure applied when introducing
the rst dilator and therefore decrease the risk of posterior tracheal wall lesion. This
was done under beroptic guidance and using transillumination. After successful
puncture of the trachea, the guide wire was inserted into the trachea. They then placed
a hydrophilically coated dilation screw with threads (PercuTwist, Rusch, Kernen,
Germany) into the incision, which was turned clockwise and advanced by rotation to
80
Fig. 2 (a) Griggs
technique. The trachea is
located by aspirating air,
using a 14-gauge cannula.
The guide wire is then
introduced into the trachea,
followed by a 14-French
dilator. Fully closed metal
tracheal dilating forceps
are passed over the guide
wire and opened just
enough to accept the
tracheostomy tube
Fig. 3 Fantoni’s
technique, with retrograde
dilation of the trachea from
the lumen to the skin
L. Pereira and C. Lumley
A
B
Percutaneous Tracheostomy Indications andSurgical Technique
81
dilate the trachea [9] (Fig.4). With all of these percutaneous tracheostomy methods,
there has been no evidence showing superiority of any one method.
Alvaro Sanabria [6] did a systematic review comparing different percutaneous
tracheostomy techniques. He reviewed studies comparing the Ciaglia Blue Rhino,
Ciaglia multiple dilator, Blue Dolphin, Griggs dilating forceps, and PercuTwist, but
could not nd statistically signicant differences in outcomes.
Percutaneous tracheostomy was initially viewed with skepticism by surgeons,
who were under the impression that it was associated with a higher rate of complications. Several hundred articles have been published on this subject, and many of
them have tried to compare open tracheostomy and the percutaneous technique.
Three meta-analyses have been performed and concluded that there is no clear difference in terms of complications [10–12]. Dulguerov etal., in their meta-analysis
from 1999, showed a higher incidence of perioperative complications associated
with percutaneous tracheostomy and a higher rate of postoperative complications
with open surgical tracheostomy [11]. Freeman etal. found that the percutaneous
technique is easier to perform and has low incidence rates of peristomal bleeding
and postoperative infection [12]. Higgins and Punthakee showed that percutaneous
tracheostomy is more cost effective and provides greater feasibility in terms of bedside capability and nonsurgical operation [10].
Fig. 4 PercuTwist
technique. Note the
presence of the dilation
screw with threads
C
82
L. Pereira and C. Lumley
The indications for percutaneous tracheostomy are the same as those for standard open tracheostomy (Table1).
Absolute contraindications to percutaneous tracheostomy include emergent
tracheostomy and tracheostomy in infants and children. Relative contraindications include local conditions that can distort the anatomy and the pathway from
the skin to the airway. Examples include patients with poor neck landmarks, a
large neck mass, a high innominate artery, previous neck surgery, limited neck
extension, an active infection over the tracheostomy site, a history of difcult
intubation, uncorrectable coagulopathy, and a positive end-expiratory pressure
(PEEP)>15cmH
O.
2
Procedure
Several percutaneous techniques are available in the market, such as Ciaglia, Griggs,
PercuTwist, Rapitrach, and others. The single-dilator technique is faster with no
signicant difference in the complication rate [13].
The Ciaglia technique is usually performed using the Cook Blue Rhino singledilator kit (Cook Medical, Bloomington, IN, USA). A exible bronchoscope should
be available to visualize the introduction and the dilation of the anterior tracheal
wall. An open tracheostomy set should also be in the room for use in the rare event
that this procedure needs to be converted into an open procedure. A second physician trained in exible bronchoscopy should be present in order to perform the
bronchoscopy.
The patient is sedated, and the neck is extended over a shoulder roll. Use of
muscle relaxants prevents the patient from moving and biting the bronchoscope. A
bite block can be used to facilitate introduction of the scope.
The patient is then prepped and draped in the standard fashion for a tracheostomy. The landmarks should be palpated, including the thyroid notch, cricothyroid
membrane, cricoid cartilage, trachea, and sternal notch. The skin is then injected
with 1% lidocaine with a 1:100,000 epinephrine solution.
A direct laryngoscopy is performed to ensure that there is no airway distortion
and that the cuff of the endotracheal tube is at the vocal cord level.
A horizontal 2cm incision is made immediately below the inferior border of the
cricoid cartilage, or between the cricoid and the sternal notch (Fig.5). Tonsil clamps
can be used to perform blunt dissection down to the level of the pretracheal fascia.
When present, the thyroid isthmus should be pushed down (inferiorly) during this
part of the procedure. Transillumination can be done using the bronchoscope to
indicate the best site to place the introducer needle.
The exible bronchoscope is withdrawn and protected by the endotracheal tube
prior to needle insertion. The needle is inserted at the inferior edge of the light
reex, which should correspond to the space between the rst and second or second
and third tracheal rings (Fig.6). The insertion is visualized through the scope and
directed inferiorly to avoid damage to the posterior tracheal wall. Insertion into the
Percutaneous Tracheostomy Indications andSurgical Technique
Fig. 5 Transverse incision
below the level of the
cricoid cartilage
83
Fig. 6 Placement of the introducer needle
trachea can also be veried by aspiration on the syringe, resulting in air bubble
return. The needle is withdrawn, and the cannula is kept in the tracheal lumen.
A J-tipped guide wire is passed through the cannula under direct visualization.
After conrmation of proper placement of the guide wire (Fig.7), the cannula can
be removed, leaving the wire in place. At this point, using the bronchoscope, one
should conrm that the wire is in the correct position, entering the anterior wall
between the 11and 1o’clock positions, and goes all the way to the carina without
passing through the endotracheal tube opening.
84
Fig. 7 The guidewire is placed into the trachea through the introducer
L. Pereira and C. Lumley
Fig. 8 Introduction of the 8-French dilator
After conrmation of proper placement of the guide wire, the tract is initially
dilated with a short 8-French or 11-French catheter (Fig.8). An 8-French guiding
catheter with a safety ridge, to avoid damage to the posterior tracheal wall, is introduced over the guide wire (Fig.9).
The dilator is used to further dilate the tract to the point where it will accommodate the tracheostomy cannula. The dilator is loaded onto the guide wire/guiding catheter complex. The tip of the dilator should be at the level of the safety
ridge. It should be carefully advanced, taking care not to pass the 40-French mark
below the level of the skin. While introducing the dilator, moving the complex in
Percutaneous Tracheostomy Indications andSurgical Technique
85
and out will help to accomplish good dilation of the soft tissues and anterior tracheal wall (Fig.10).
Once the tract is dilated, the next step is the placement of the tracheostomy tube.
The size of the tracheostomy tube will dictate which dilator will be used for this
step. A number6 cuffed Shiley tube will be used with a 26-French dilator, while a
Number 8 Shiley will require a 28-French dilator. The tracheostomy tube is mounted
on the appropriate dilator and loaded onto the guide catheter. Now it can be
Fig. 9 After removal of
the 8-French dilator, the
8-French guiding catheter
is placed into the trachea
Fig. 10 The dilator is
introduced. Note that the
40-French (40-Fr) mark is
not supposed to get below
the skin level
40-Fr Mark
86
Fig. 11 The tracheostomy
cannula/guiding catheter
complex is introduced into
the trachea
L. Pereira and C. Lumley
introduced into the trachea under direct visualization (Fig.11). The dilator, guide
wire, and guide catheter are removed, and the proper placement of the cannula is
conrmed by the presence of end-tidal CO2. The bronchoscope is removed from the
endotracheal tube and passed through the tracheostomy tube to make sure the tube
is in a good position. The tube is then secured in a standard fashion. This can be
done by using 2–0silk stitches on each side of the ange.
Another adjuvant that can be used to improve the safety of the procedure is ultrasound (US). By using US, the physician can visualize the path of the needle and the
insertion into the trachea, as well as the placement of the dilator and cannula in real
time. Vascular structures and the thyroid isthmus can also be visualized and avoided
using this technique, which can be particularly useful in obese patients. Identication
of landmarks can be difcult in these patients, and obesity is a relative contraindication to the procedure. US can guide the needle into the trachea; at the same time it
helps to avoid injury to vessels and the thyroid, making it safe to perform percutaneous tracheostomy in this population [14]. In a recent article, Gobatto et al. [15]
reviewed 60 percutaneous tracheostomies performed at their institution. Eleven procedures were done under bronchoscopy guidance and 49 were done using US guidance. The US-guided procedure was found to be quicker (12 versus 15 min,
p=0.028), and the complication rate was not signicantly different.
Postoperative Care
Care for a patient with a fresh percutaneous tracheostomy is similar to standard
open tracheostomy postoperative care. The tube needs to be secured to the skin to
avoid dislodgement, which can cause immediate respiratory distress and airway
obstruction. The obturator used to introduce the tracheostomy cannula should be at
the bedside in case of tube dislodgement and need for reinsertion. A postoperative
chest X-ray is still recommended, even though some studies show that the incidence