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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4510_Библиотеки_им_академика_М_И_Перельмана.pdf
98
Fig. 2 Stage 2—patient
preparation: patient
sedation, semi-Fowler’s
positioning (semi-seated
with cervical extension)
Fig. 3 Stage 3—ventilator
adjustment: fraction of
inspired oxygen (FiO
100%, controlled assisted
mode
)
2
M.Y. Nakai et al.
Percutaneous Dilatational Tracheostomy Kits
There are several different kits on the market for performing percutaneous tracheostomy. All of them involve an initial tracheal puncture, using the Seldinger technique, with guide wire placement and initial dilatation, followed by the main
dilatation and passage of the tracheostomy cannula.
The main kits available are described below.
Single Progressive Plastic Dilator (Ciaglia Blue Rhino®, Cook®)
This kit (see Fig. 15) represents an evolution of the kit initially developed by Ciaglia
when the percutaneous tracheostomy technique was described [13]. The previous
kit had multiple progressive plastic dilators and required multiple steps in the dilation process until the orice in the trachea reached the same size as the chosen
Percutaneous Tracheostomy: Pearls andPitfalls, andHow toCreate a“Hand-On”
Fig. 4 Stage 4—
monitoring: checking that
the patient is properly
monitored (oximeter,
cardioscope, Arterial Blood
Pressure)
99
Fig. 5 Stage 5—bronchoscopy: entry of the bronchoscope through the orotracheal tube and positioning of the cannula in the subglottic region
100
Fig. 6 Stage 6—kit preparation: kit opening, cannula choice (preferably no. 08), mounting of the
cannula on the guide rail
M.Y. Nakai et al.
Fig. 7 Stage 7: palpation of anatomical parameters (cricoid and furcula), local anesthesia with
xylocaine 2%, vertical incision 2cm between the cricoid and furcula
cannula. Through use of a unique blue plastic dilator with the shape of a rhinoceros
horn—hence the name given to the kit—the process became simpler, since after the
initial dilation, this dilator is introduced through the guide wire with another plastic
guide for reinforcement. As this dilator has a thin tip and a progressively larger caliber toward its base, the tracheal orice increases in size as the dilator is introduced.
It has black reference marks so the doctor knows how far to insert it (depending on
the chosen cannula), as well as a safety mark that represents the maximum safe dilation. After this step, three different cannula introducers (which engage the plastic
guide wire assembly) are available, depending on the size of the cannula chosen by
the surgeon. This kit is perhaps the most widely used nowadays due to its versatility,
since it allows the use of cannulae of different calibers and models. When compared
with the Portex
®
kit, it has the peculiarity of requiring a tracheal puncture on the
midline, since this type of dilator does not allow side compensation of the dilation.
Studies that have shown that up to 30% of tracheostomies done with this kit are
accompanied by tracheal ring fractures, but there seems to be no relation between
this fact and other complications such as tracheal stenosis [14].
Percutaneous Tracheostomy: Pearls andPitfalls, andHow toCreate a“Hand-On”
Fig. 8 Stage 8: Divulsion
of the subcutaneous tissue
immediately under the skin
in the midline of the neck,
visualization of the
bronchoscope light
between the second and
third tracheal rings
101
Fig. 9 Stage 9: puncture between the second and third rings on the midline
102
Fig. 10 Stage 10: guide wire path
M.Y. Nakai et al.
Fig. 11 Stage 11: dilatation with a 14-French dilatator
Dilation by Metallic Forceps (Griggs® Forceps, Portex®)
This kit (see Fig. 16) has metal dilator forceps with a hole in the tip. After puncture,
guide wire passage, and initial dilation, the forceps are connected to the guide wire
through the orice and can be led to the tracheal lumen. After the dilation performed
with clamp opening to the size of the chosen cannula, the cannula (which has its own
introducer and is included in the kit) is placed [15]. The introducer of the cannula is
Percutaneous Tracheostomy: Pearls andPitfalls, andHow toCreate a“Hand-On”
Fig. 12 Stage 12: dilatation with a progressive dilatator
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Fig. 13 Stage 13: removal of the progressive dilatator (keeping the guide wire), insertion of the
tracheostomy tube mounted in the guide rail
104
M.Y. Nakai et al.
Fig. 14 Stage 14: checking of the tracheostomy tube position, airway aspiration, glottic lesion
diagnosis caused by the orotracheal tube
unique because it has one orice and does not attach to other cannulae models, so the
doctor must use the cannula included in the kit or another one of the same brand that
also has this kind of introducer. It has the advantage of compensating the dilation to
one side, through the unequal opening of the clamp, allowing correction of a
paramedian puncture. In addition, the metal clamp can be reused after sterilization,
and the kit can be purchased without the tweezers, which may reduce costs.
Balloon Dilator Through Water Pressure (Dolphin BT®, Cook®)
More recently the percutaneous tracheostomy balloon kit (see Fig.17) was introduced, based on other types of dilatation systems used in other specialties. Unlike
other dilatation systems, it has controlled dilatation through pressure measurement inside the balloon, which is inated with saline during the procedure. Just
behind the balloon is the introducer attached to the cannula, which eliminates the
Percutaneous Tracheostomy: Pearls andPitfalls, andHow toCreate a“Hand-On”
Fig. 15 Ciaglia Blue
®
Rhino
(Cook®)
tracheostomy kit with a
single progressive dilator
in rhino horn format; note
the three introducers of
differently-sized cannulae
in the middle
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Fig. 16 Percutaneous
tracheostomy kit with
®
Griggs
forceps; note the
hole in the tip of the
forceps for guide wire
attachment
step of removing the dilator and introducing the cannula, making the process
easier.
Exactly as in the other kits, the procedure starts with a tracheal puncture (using the
Seldinger technique) followed by guide wire placement; initial dilatation; positioning
of the system with the balloon, introducer, and cannula; dilatation; and introduction of
the cannula. The procedure has been shown to be safe and has the advantages of a
more controlled dilation (although it is mechanical) independent of the surgeon
strength, and tamponade power of the compression made by the balloon [16].
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M.Y. Nakai et al.
Screw Rotating Plastic Dilator (PercuTwist®, Rush®)
The rotational dilator contained in this kit (see Fig.18) is introduced into the trachea after puncture using the Seldinger technique, as with other kits. Tracheal dilation is accomplished by progressively rotating the dilator until the tracheal aperture
Fig. 17 Dilator balloon kit connected to a manometer; the tracheostomy cannula is located just
behind the balloon
Fig. 18 PercuTwist® kit with a rotational screw dilator
Percutaneous Tracheostomy: Pearls andPitfalls, andHow toCreate a“Hand-On”
107
reaches the size of the chosen cannula. Some studies have shown that this kit may
cause more trauma than others and can lead more frequently to posterior tracheal
wall injuries [17].
Role ofUltrasound inPercutaneous Dilatational Tracheostomy
One of the challenges of performing PDT is to dene the right place to make the
puncture, in order to make the tracheostomy between the second and the fourth
tracheal rings. Due to edema and/or subcutaneous emphysema in ICU patients, palpation of landmarks for the puncture can be difcult. An abnormal physical examination such as the presence of a goiter, a short neck, tracheal deviation, or obesity
can also make palpation of the anatomical features difcult or even impossible.
To perform PDT, therefore, it is necessary to use ultrasound equipment with a
high-frequency linear transducer (10–14MHz), which allows an evaluation from
the supercial structures to 5cm deeper [18].
Cartilage appears hypoechoic (dark) on ultrasound. The anterior border of the
airway creates a hyperechoic (white) line, due to the acoustic impedance difference
between the soft tissue and the air, which produces an intense wave reection
(Figs.19 and 20). The posterior tracheal wall cannot be evaluated because the air
inside the tracheal lumen does not allow the return of the ultrasound wave. The use
of the Doppler function can also determine if there is any vessel in the path.
The transducer is initially applied in the transversal orientation to locate the airway and to identify possible risks and difculties (Figs.21 and 22). Then, over the
midline of the trachea, the transducer is turned to the longitudinal position, with the
directional indicator oriented toward the patient’s head. The thyroid isthmus is identied to avoid puncturing it, and the tracheal rings from the cricoid are counted
(Fig.19). At that moment, the endotracheal tube is searched for, which is shown as
a parallel hyperechoic line (Fig.20), and it is pulled so that the tube stays cephalad
to the puncture site.
Fig. 19 Longitudinal
ultrasound image. The
thyroid [Tireoide], cricoid
[Cricoide] and tracheal
rings [Anéis traqueais] are
shown as hypoechoic
(dark) structures. The air–
mucosal interface produces
the hyperechoic (white)
line
Thyroid
cartilage
Tracheal
rings
Cricoid
cartilage