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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4510_Библиотеки_им_академика_М_И_Перельмана.pdf
108
M.Y. Nakai et al.
Fig. 20 Longitudinal view.
The double parallel
hyperechoic line corresponds to the anterior wall
of the endotracheal tube
(Tubo). In this case, for
better visualization of the
tube, the cuff was inated
with distilled water.
Cricoide cricoid, Glandula
Tireoide thyroid
Fig. 21 Use of ultrasound
to identify cervical
structures
Cuff
Cricoid
cartilage
Thyroid
gland
Endotracheal
Tube
The transducer is turned back to the transversal position, just next to the needle,
to guide the puncture on the midline of the trachea, which is shown by an acoustic
shadow. The needle must be inserted perpendicularly to the skin and, after that,
slightly turned caudally so that the guide wire can be introduced correctly (Fig.23).
After introduction of the guide wire, the technique specied for the available
PDT kit is followed.
Ultrasound evaluation for performing PDT allows:
• Identication of the thyroid isthmus, avoiding its puncture and consequent bleed-
ing [19]
• Identication of vascular structures, anatomical alteration, tracheal deviation
Percutaneous Tracheostomy: Pearls andPitfalls, andHow toCreate a“Hand-On”
Fig. 22 Ultrasound
transverse view to identify
cervical structures and the
depth of the tracheal lumen
(Luz Traqueal) from the
skin, and to measure the
tracheal diameter for the
tube selection. Tireoide
thyroid
Thyroid
gland
Tracheal
lumen
Fig. 23 Tracheal puncture
on the midline
109
Thyroid
gland
• Tracheal lumen measurement for better tube selection
• Positioning of the puncture on the midline between the tracheal rings
This way, the site of the puncture previously determined by the physical examination using palpation landmarks has changed 20–24% after the use of ultrasound,
according to some reports [20–22].
Studies comparing bronchoscopy-guided and ultrasound-guided PDT have not
shown statistically signicant differences between these techniques in terms of
mortality, number of punctures, bleeding, hypoxemia, and technical difculty [23].
However, the learning curve for the ultrasound-guided technique is steeper than that
for the bronchoscopy-guided technique. It is estimated that performance of 50
110
M.Y. Nakai et al.
ultrasound- guided PDTs are required to achieve expertise in the procedure, versus
only 20 for bronchoscopy-guided PDT [24].
Tracheostomy Complications andTheir Care
Conventional surgical tracheostomy and PDT are considered to be low-complexity
and easy procedures, frequently performed in mechanically ventilated patients
admitted to ICUs. However, complication rates between 5% and 40% are reported
in the literature, and when these procedures are performed in emergency situations,
critically ill patients, or small children, the complication rates are 2–5 times higher.
Although tracheostomy is considered easy and safe to perform, fatal events can
occur, with a mortality rate of almost 2% [25, 26].
In emergency situations when cricothyroidotomy or oral intubation are not possible (Goldenberg et al. [26] retrospectively analyzed 1130 patients, where this
occurred in 0.26%), performance of a tracheostomy can be challenging, with immediate and early complication rates of 12.2%, as reported by Costa etal. [27].
In our practice, in addition to emergency situations, cases such as low tracheal
stenosis are generally associated with major technical difculties in accessing the
trachea—also requiring consideration of the conditions of tension and stress to
which the surgical team is submitted. Carrying out the procedure under local anesthesia—sometimes in a situation where it is impossible for the patient to lie in a
supine position with neck extension, along with acute respiratory failure and
hypoxia—makes the procedure more difcult. Therefore, in this situation, a welltrained and experienced team may be important to reduce the risk of complications,
especially fatal ones.
Tracheostomy complications can be classied according to the severity. “Minor”
complications include bleeding with no hemodynamic instability; smaller cartilage
lesions; mucosal, skin, and soft tissue damage; pneumothorax or small pneumomediastinum without the need for treatment; intraoperative cardiac rhythm disorders;
postoperative hemorrhage arrestable by tamponade or fast surgical revision; subcutaneous emphysema; obstruction/failure or dislocation of the cannula without
hypoxia; local wound infection requiring systemic antibiotics and/or diagnosed as
an infected stoma; tracheitis; extended granulations; small atelectasis; and other
non-life-threatening complications.
“Major” complications include bleeding with hemodynamic instability treated
only with surgical site exploration and/or causing a signicant fall in hemoglobin;
cartilage damage discovered postoperatively; perforation or ssure of the posterior tracheal wall; bilateral recurrent laryngeal nerve injury; pneumothorax or
pneumomediastinum requiring surgical drainage; aspiration of blood with
extensive atelectasis or decreased oxygen saturation levels; tracheoaortal ssure;
respiratory and/or cardiac arrest; and mediastinitis. In the immediate postoperative period, obstruction/failure and/or dislocation of the cannula with loss of airway control are serious problems and relatively common. In the late postoperative
period, laryngeal and/or tracheal stenosis are severe complications to be resolved.
Percutaneous Tracheostomy: Pearls andPitfalls, andHow toCreate a“Hand-On”
111
In recent years, routine use of low-pressure tracheostomy tubes has minimized
this adverse effect.
Another classication is related to the timing of occurrence: “immediate complications” occurring during the surgical procedure until its end (intraoperative);
“intermediate complications” (early postoperative) occurring until the rst postoperative week; and “late complications.” “Immediate complications” such as signicant bleeding during tracheostomy are unusual, being more frequent when the
procedure is performed in an emergency situation, with an incidence of up to 4%;
the vascular structures most commonly involved are the anterior jugular veins, the
vessels to the thyroid isthmus, and vascular variants such as the thyroid ima artery.
Incorrect positioning of the tracheostomy tube or electrocautery-induced intraoperative burns to tracheal and adjacent structures are other possible complications;
the latter is usually related to an incorrect surgical technique. For instance, esophageal lesions may occur during careless opening of the trachea, just as a dissection
that deviates from the midline can lead to lesions of the recurrent laryngeal nerve
and the cupola of the lung, especially in children. Moreover, fracture of the cricoid
cartilage may occur when the tracheostomy is performed in a very high position
[26] between the cricoid and the rst tracheal ring.
In early complications a hemorrhage may also occur later after the intraoperative
time, specially if the tracheostomy has been performed in patients with low blood
pressure or increase of venous pressure (coughing or vomiting) may cause subsequent bleeding. Nevertheless, most cases can be treated with a compressive dressing, with a small percentage of patients (0.61% in the series reported by Goldenberg
etal. [26]) requiring surgical exploration for hemostasis. Severe infections associated with tracheostomy—such as necrotizing fasciitis, mediastinitis, and clavicular
osteomyelitis—are rare but require immediate and aggressive treatment. Transient
peristomal tracheitis and cellulitis may also occur and cause mucosal damage,
which would increase the likelihood of subglottic stenosis, thus reinforcing the need
for adequate local wound care. However, Goldenberg etal. [26] suggest that this
occurrence is more related to tracheal damage previously caused by prolonged intubation than damage caused by the tracheostomy itself. Pneumonia and pulmonary
abscess after tracheostomy are related to aspiration of infected secretions.
Additionally, among early complications, pneumomediastinum, pneumothorax,
and subcutaneous emphysema may occur due to excessive dissection during the
surgical procedure with tracheal or pleural lesion, or to blockage of the tracheostomy tube by a blood clot, displacement of the tube, the cannula tip touching the
posterior wall of the trachea, or a mucus plug or granulation tissue in a later period.
Elevated endotracheal pressure in assisted ventilation is another cause of air dissection along the pretracheal fascia. In adults the incidence of pneumothorax is 0–4%
and the incidence of subcutaneous emphysema is 0–9%, but in children the incidence
of pneumothorax associated with tracheostomy is higher (10–17%) and it is an
important cause of death. In these conditions, tight closure of the surgical wound
around the tracheostomy tube should be avoided.
Displacement of the tracheostomy tube out of the airway site has an incidence of
0–7% and can be a fatal event, and factors such as short length of the tube, neck
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M.Y. Nakai et al.
thickness (obesity), tracheostomy position (the level at which it was performed),
technique (attachment of the tracheostomy edges to the skin or not), and the tracheostomy tube xation method may contribute to its occurrence [26].
In “late complications” bleeding may occur; however, this may be due to excessive tracheostomy tube traction on granulation tissue or injury of important blood
vessels such as the brachiocephalic artery or, more rarely, an anomalous carotid
artery. The incidence of tracheobrachiocephalic artery stula is 0.4–0.6%, and sudden massive bleeding can occur 3days to 3weeks after the occurrence of “sentinel
bleeding,” with a high mortality rate (80–90%). The main cause of this complication
is excessive ination of the tube cuff for a prolonged period of time and consequent
necrosis and erosion of the tracheal cartilage and vessel wall, or compression and
necrosis of the tracheal wall induced by the tip of the tracheostomy tube at the level
of the brachiocephalic artery, which may occur due to the tracheostomy being performed too low (below the third tracheal ring) or by a high position of the artery,
which is commonly observed in elderly patients.
Another late complication is tracheoesophageal stula, which is rare and occurs
due to injury to the posterior wall of the trachea during the tracheostomy procedure,
or as a consequence of an overinated and malpositioned tracheostomy tube cuff,
promoting excessive pressure on the posterior wall of the trachea; this, associated
with the nasogastric tube in the esophagus, may cause tissue ischemia and necrosis
and consequent tracheal and esophagus wall erosion. The incidence of tracheoesophageal stula is 0.01–1%; however, signicant related mortality rate of 70–80%
[26] is reported.
Subglottic and tracheal stenosis are severe complications associated with previous endotracheal intubation, high tracheostomy or cricothyroidotomy, and trauma
to the airway. Children and head trauma patients are at increased risk for stenosis.
The mechanism for this damage is excessive insufation of the tube cuff associated
with long-term tracheal intubation, which promotes ischemia and ulceration of the
mucosa, exposing the tracheal cartilage. Stenosis at the level of the stoma may be
caused by excessive tube traction or a large stoma, and occurred in 1.86% in the
study by Goldenberg et al. [26]; however, these instances were correlated with
prolonged tracheal intubation (all patients with stenosis were intubated more than
12days before the procedure).
Tracheocutaneous stula is another late complication, caused by epithelialization of the stomal tract in patient with long-term use of a tracheostomy tube, and
occurs in 0.53% of patients [26]. It may lead to persistent tracheal secretion with
consequent irritation of adjacent skin, disturbances in phonation, and frequent
infections.
With regard to improvement and wide performance of the PDT technique, the
systematic review and risk factor analysis published by Simon etal. [11] selected 45
publications that described 65 events related to the procedure (including cases from
their own institution), analyzing a total of 71 cases, with an incidence of lethal complications of 0.17%. Among the main complications related to death, bleeding and
Percutaneous Tracheostomy: Pearls andPitfalls, andHow toCreate a“Hand-On”
113
airway complications were the most important, accounting for 38% and 29.6%,
respectively. Most bleeding (75%) occurred 1–30 days after tracheostomy (at a
mean of 5 days); 59.3% of cases were related to arterial bleeding and, of these,
almost 70% originated from a tracheobrachiocephalic artery stula (tracheoinnominate artery stula). The potential risk factors for bleeding and subsequent death
were nonuse of bronchoscopic guidance during the procedure, a low tracheostomy
site, coagulopathy, previous surgery on the neck, previous radiotherapy, obesity,
anatomical abnormality, paratracheal misplacement of the tracheostomy tube, a
malpositioned tube tip, high cuff pressure, and excessive movement of the neck
associated with prolonged intubation.
As for airway complications related to fatal events, tracheal tube displacement
(52.4%), airway loss during the procedure (19%), and paratracheal misplacement of
the tube (14.3%) were the most common, and the risk factors associated with them
were nonuse of bronchoscopy, inexperience of the surgical team in the percutaneous
technique, patient obesity, patients with a difcult airway, not stitching the tracheal
tube, tracheostomy tube replacement in the early postoperative period, and postoperative care by an inexperienced team.
Other fatal complications were described in the study as tracheal perforation
(15.5%), pneumothorax (5.6%), severe bronchospasm (4.4%), cardiac arrest and
arrhythmia during the procedure related to clinical cardiac comorbidities (4.4%),
and sepsis secondary to mediastinitis (1.5%).
Thus, based on their study, Simon etal. [11] suggested measures to improve the
safety of PDT, always considering contraindications for the procedure (anatomic
distortion of the neck, the presence of a difcult airway, severe acute respiratory
distress syndrome, nontreated coagulopathy, and the presence of an unstable cervical spine), depending on the skill and experience of the surgical team in the percutaneous technique; use of bronchoscopy to guide the entire procedure; avoidance of
performing low tracheostomy (below the third tracheal ring); not allowing guide
wire folds (thereby avoiding the possibility of perforation of the tracheal wall and
adjacent structures, especially the esophagus); and routine use of outer ange tracheal tube sutures to the skin.
In conclusion, tracheostomy is a procedure with a low incidence of complications, especially when performed electively; however, fatal events can occur, above
all related to lesions of large vessels and obstructions of the airway.
Therefore, measures that may reduce the occurrence of severe and fatal complications [23, 26] are institution of a surgical training program for improvement of the
technique to ensure careful dissection on the midline and performance of the tracheostomy or puncture at the appropriate level (ideally between the rst and second or
second and third tracheal rings), routine use of bronchoscopy or ultrasound in percutaneous tracheostomy, xation of the tracheostomy tube outer ange with sutures,
and adequate postoperative tracheostomy care by nursing staff who are well trained
in manipulation of the tracheostomy tube.
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M.Y. Nakai et al.
Hands-On Percutaneous Dilatational Tracheostomy Training Program Course
Based on technical and practical experience in teaching residents in head and neck
and general surgery, the Head and Neck Service of Santa Casa de São Paulo has
developed a percutaneous tracheostomy training program.
This program has been transformed into a training course, with emphasis on handson management of bronchoscopy-guided and ultrasound-guided percutaneous tracheostomy. The course started in 2015 and is given in our Experimental Surgery Laboratory
Center, with approval from the Ethics Committee on Experimental Animals.
This 9-hour course basically consists of expositive and participatory classes, in
which the theoretical content represents 40%, with emphasis on practice in percutaneous tracheostomy in experimental and animal training (porcine) models.
The theoretical part of the course presents the historical evolution of the tracheostomy technique, from its creation as the conventional procedure to the development of the percutaneous puncture and dilation system by Ciaglia, with all variants
of percutaneous kits available, and also the indications, contraindications, and complications. Also, there is a video session for step-by-step operation of percutaneous
tracheostomy in an intensive care unit environment, performed in the surgeon’s day
practice.
In the hands-on scenario, there are six simulated workstations available: four
with full endoscopic facilities, one with an experimental model device, and one with
an ultrasound guidance facility. A maximum of two participants and a devoted tutor
are allocated to each workstation. Twelve participants can attend the course.
In the 4-hour training workstation sessions, the student performs the PDT technique, divided into the sequence shown in Figs.24, 25, 26, and 27:
Fig. 24 Presentation of available percutaneous tracheostomy kits
Percutaneous Tracheostomy: Pearls andPitfalls, andHow toCreate a“Hand-On”
115
Fig. 25 Operation on the experimental model
Fig. 26 Workstation training on the animal model (porcine) with endoscopy guidance
116
Fig. 27 Ultrasound-guided operation performed on the porcine model
M.Y. Nakai et al.
This course has already qualied several surgeons in the practice of the PDT
technique.
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