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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4510_Библиотеки_им_академика_М_И_Перельмана.pdf
Conventional or Percutaneous Tracheostomy?
LúcioNoleto, ThiagoPereiraDiniz,
andTerencePiresde Farias
Introduction
The term tracheostomy, of Greek origin, denes an opening in the trachea that
maintains communication with the exterior, usually by means of a cannula. It is one
of the most performed procedures in critically ill patients, especially in intensive
care units (ICUs). This procedure is one of the oldest in medicine, and is even
described in medical books of antiquity [1].
Galen, a renowned Greek physician at the time, performed a tracheostomy for
treatment of upper airway obstruction in the second century BC.The rst successful
tracheostomy, however, is credited to Antonio Brasalova in 1546, an Italian physician, in a patient with a laryngeal abscess [1].
A new technique, similar to percutaneous tracheostomy through blind tracheal
cannulation, was started in 1955 by Shelden etal. but, due to some accidents—
including fatal ones—this technique did not obtain good acceptance [2]. In 1969,
Toye and Weinstein developed a guide and dilator in order to facilitate the passage
L. Noleto, M.D., Ph.D. (*)
Department of Head and Neck Surgery, University of the State of Piaui, Piaui, Brazil
e-mail: lanoleto@yahoo.com.br
T.P. Diniz, M.D.
Department of General Surgery, University of the State of Piauí, Piauí, Brazil
T.P. de Farias, M.D., Ph.D., M.Sc., Researcher.
Department of Head and Neck Surgery, Brazilian National Cancer Institute—INCA,
Rio de Janeiro, RJ, Brazil
Department of Head and Neck Surgery, Pontical Catholic University,
Rio de Janeiro, RJ, Brazil
© Springer International Publishing AG 2018
T.P. de Farias (ed.), Tracheostomy, https://doi.org/10.1007/978-3-319-67867-2_7
119
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L. Noleto et al.
of the cannula [2]. In 1985, Ciaglia etal. described a modication of the open tracheostomy and introduced the Seldinger principle for the percutaneous approach
[3]. The rst percutaneous tracheostomy system utilized multiple, sequentially
larger dilators (Fig.1). However, in 1999, Ciaglia modied the original procedure
for the single progressive dilator method, known today as Blue Rhino (Cook Co.,
Bloomington, IN, USA) [3, 4]. Other methods of anterograde percutaneous tracheostomy were reported by Griggs (Figs.2 and 3) in 1990 using rounded-tip forceps
dilatation, by Frova and Quintel in 2002 using stomal dilatation with a single screw
dilation device (PercuTwist), and by Zgoda and Berger in 2005 and Cianchi etal. in
2010 using a modication of the Blue Rhino device, which employed balloon
dilatation [5–7].
Fig. 1 Passage of progressive dilators through the guide wire
Fig. 2 Griggs forceps. At
the end of the clamp there
is a hole through which the
thread will be inserted
ab
Conventional or Percutaneous Tracheostomy?
Fig. 3 Demonstration of guide wire passing through the Griggs clamp
121
Several trials have compared conventional (i.e., surgical) tracheostomy (CT) and
percutaneous tracheostomy (PT), and which is the best method is discussed in the
literature [8–10]. This chapter discusses general aspects of tracheostomies, such as
indications, complications, descriptions of techniques, paralleling the conventional
and percutaneous techniques.
Percutaneous Versus Conventional Tracheostomy:
Indications andContraindications
Tracheostomy is considered the airway of choice in patients requiring prolonged
ventilatory support or airway protection, as well as facilitating respiratory dynamics
and the weaning process of ventilatory support, when indicated [11]. There are basically two scenarios that culminate in the indication for a tracheostomy: elective
tracheostomy and emergency tracheostomy. The rst, in general, is a patient admitted to an ICU with a prolonged tracheal intubation time, while the second is indicated when there is a need to guarantee the airway in cases of acute respiratory
failure due to tracheal obstruction.
Tracheostomy has several advantages over translaryngeal intubation, including
better tolerability by the patient, less laryngeal irritation, facilitation of nursing care,
increased communication capacity, better breathing, and reduction of dead space.
Approximately 5–13% of patients using an orotracheal tube in ICUs will need to
spend more than 21days on mechanical ventilation (MV), i.e., prolonged MV.In
these patients, the intensive care team has to make a decision about when to perform
a tracheostomy. Currently, most intensivists agree that if a patient needs MV for
more than 10–14days, a tracheostomy is indicated and should be performed under
optimal conditions, either in the ICU, in a hospital room, or in a surgical center
[12–14]. What the advantages are of performing the procedure at the bedside or in
a surgical environment has been a divergent theme and the object of discussion in
several trials. Variables such as cost, complications, and other issues will be
described next.
122
Nowadays, tracheostomy is a standard and elective procedure in critically ill
patients, and its indications include relief of upper airway obstruction, prevention
of upper and laryngeal airway injuries due to prolonged tracheal intubation, the
need for easy and frequent access to the lower airway for aspiration and removal of
secretions, a decreased level of patient consciousness as well as protective airway
reexes, and severe changes in respiratory physiology. However, prolonged respiratory failure requiring long-term MV is probably the most common indication. In
emergency situations, the main indications are tracheal obstructions due to trauma
in the postoperative period of cervical surgery where there is inadvertent bilateral
recurrent laryngeal nerve damage by benign or malignant tumors, such as tumors
that cause extrinsic obstruction of the upper airways and endoluminal tumors—for
example, a laryngeal tumor. However, the indications, risks, benets, timing, and
technique of the conventional and percutaneous procedures remain controversial
and depend on the clinical condition of the patient—in particular, the respiratory
performance status [14].
Tracheostomy contraindications have changed over time. Some causes that
were absolute contraindications to the percutaneous method—such as distortion
of the anatomical references of the neck by a hematoma, tumor, or previous surgical scar; infection of soft parts of the neck; an obese or short neck making it
difcult to identify anatomical repairs; and inability to extend the neck—have
been increasingly considered only relative contraindications due to the increased
experience of teams with the method [15]. Also, according to DeLeyn etal. [15],
the only absolute contraindications to PT are the presence of a skin infection at
the puncture site and a large prior cervical surgery that completely obscures the
cervical anatomy.
L. Noleto et al.
Percutaneous Versus Conventional Tracheostomy: Surgical Approach
The anatomical and technical concepts that guide the performance of CT must be
respected in PT [16]. The sequence to be followed is practically the same in both
techniques, with some differences in the materials and kits used.
(a) Sedation, analgesia, and muscle blockade: Tracheostomy is performed under
general anesthesia or sedation, although it may be practiced under local anesthesia. If necessary, a muscle blocker may be used. It is important to be assisted
by a physician in the ICU or an anesthesiologist in the operating room. In
patients with high airway obstruction, for which endotracheal intubation is not
feasible, the tracheostomy is performed with local anesthesia and minimal
sedation.
(b) Positioning of the patient: There are similarities regarding the positioning
of the patient. In both techniques, the patient should be positioned in the
dorsal position with a cushion under the shoulders to extend the neck. This
Conventional or Percutaneous Tracheostomy?
123
maneuver provides greater exposure of the trachea. It is worth noting that
extension is not possible in cases of cervical spine fracture, cervical arthrosis, recent neck surgery, a short neck, kyphosis, sequelae of radiotherapy,
or other alterations.
(c) Incision and dissection by planes until the trachea is identied: The incision in
the skin can be transverse or longitudinal. The transverse incision is made about
2cm (one to two ngers) above the sternal furcula, with extension between 2
and 3cm; the aesthetic result is better. The vertical incision corresponds to the
tracheal plane, initiated just below the cricoid cartilage extending approximately 2cm in the caudal direction. In the conventional technique, in elective
situations, transverse incisions are preferred, while percutaneous transection is
generally performed longitudinally, with a smaller extension, as described
below. In PT, a longitudinal incision of 1.5cm in length and 1.5cm below the
cricoid cartilage is performed. The subcutaneous tissue and the supercial fascia are opened on the midline by divulsion with Kelly tweezers. The trachea is
palpated and the area to be punctured is released by digital blunt dissection to
avoid puncturing the isthmus of the thyroid. With the bronchoscope inserted
through the orotracheal intubation cannula, it is retracted into the subglottic
space. The trachea should be punctured on the midline between the second and
third tracheal rings.
(d) Guide wire passage, dilatation, and passage of the tracheal cannula: The guide
wire is then passed through the needle and directed distally. With the thread in
position, the dilation of the path with the dilator begins. From this point, the PT
technique will differ depending on the materials or set of dilators used. There
are basically two techniques, using either the Blue Rhino set or the Portex set.
In the Blue Rhino technique, the guide catheter should be placed on the guide
wire to increase its gauge and improve the conduction of the dilator to the tracheal lumen. Thereafter, the trachea is dilated with a single dilator. As soon as
the dilation is completed, a tracheostomy cannula placed over a dilator is introduced by the path into the trachea. When the bronchoscopist conrms that the
cannula is well positioned, the dilator with the guide catheter and guide wire are
withdrawn, the cannula cuff is inated, and the extension of the respirator is
connected to the tracheostomy cannula to ventilate the patient. The incision can
be closed with a surgical stitch and the cannula is attached to the neck. In the
Portex technique (also called the Griggs technique), the dilatation of the trachea
is performed with a metal clamp that has a groove between its rods, such that
the clamp slides around the guide wire. Once in the tracheal lumen, the surgeon
opens the forceps by dilating the bronchial-guided path. Thereafter, a tracheostomy cannula, which forms part of the kit—the obturator of which is pierced,
allowing passage of the guide wire—is introduced into the tracheal lumen. The
bronchoscopist performs aspiration of secretions through the tracheostomy cannula and checks for proximal hemostasis through laryngoscopy using the
orotracheal intubation cannula as a guide for the beroptic bronchoscope, as
shown in Figs.5 and 6.
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L. Noleto et al.
Percutaneous Versus Conventional Tracheostomy:
Complications andOther Issues
As early as 1992, a prospective study on PT concluded that it was a risky procedure
with potential for potentially serious complications—namely, severe hemorrhage, a
false tracheostomy tube pathway, and death [17]. Since then, the number of studies
published in this area has been increasing every year.
Massick etal. [18] demonstrated the existence of an important learning curve in
the development of PT, especially in the rst 20 patients, with the majority of complications occurring during initial contact with the technique. The complications of
PT are classically divided into early and late complications, and some result from
the injury of anatomical structures that are in the vicinity of the tracheostomy site.
Early complications include hemorrhage, infection, pneumothorax, pneumomediastinum, subcutaneous emphysema, paratracheal insertion of the tracheostomy
tube, laceration of the posterolateral wall of the trachea, technical failures, and perioperative hypoxia due to tube obstruction or accidental decannulation [19].
Late complications include development of granulation tissue with consequent
tracheal stenosis, difculty in decannulation, obstruction of the upper airway with
respiratory insufciency after decannulation, tracheoesophageal stula, tracheomalacia, tracheal–innominate artery stula, pneumonia, and aspiration [20, 21].
Bleeding is probably the most common perioperative complication, most of which is
insignicant due to minimal tissue disruption, the tamponade effect of the tracheostomy tube, and the vasoconstrictive effect of adrenaline when used as a local anesthetic [22, 23].
Among late complications, tracheal stenosis is the most feared and, at the same
time, the most difcult to quantify because many patients undergoing PT are
severely ill and may die or be discharged before being decannulated. Although there
is no ideal method of postoperative evaluation to determine the incidence of late
complications after PT, recent studies have used a number of methods, including
questionnaires, radiography and tracheal tomography, magnetic resonance imaging,
laryngotracheoscopy, and pulmonary function tests [24].
A trial using laryngotracheoscopy and high-resolution computed tomography to
assess the incidence of tracheal stenosis in 48 patients undergoing PT revealed a
global incidence of tracheal stenosis of 31%, with only 20% of these patients being
symptomatic, with a symptomatic tracheal stenosis index of 6%. For comparison
with the conventional technique, Anthony Delaney etal. performed a meta-analysis
in 2006, surveying 17 studies comparing PT and CT in critically ill patients in the
ICU, and concluded that there was in fact a greater tendency, although not signicant, toward tracheal stenosis in patients undergoing CT [25].
There are some parameters on which there is agreement in the literature, favoring
the percutaneous or surgical technique, as well as indifferent results. It is also worth
noting that the indication for the best method should take into account the expertise
and experience of the team and the availability of appropriate materials for the
procedure.
Conventional or Percutaneous Tracheostomy?
125
Time Required toPerform theProcedure
Regarding the procedure time, most trials show a shorter percutaneous execution
time, although in some cases there may be technical difculties, such as difculty
in performing the tracheal puncture, failure of the thread progression guide, and
difculty in introducing the cannula and positioning the puncture centrally and in
an adequate tracheal space. In these cases, it seems obvious that there is an
increase in the procedure time, thus indicating an advantage of conventional surgery [26].
In a large, prospective, randomized trial, Siamak Yaghoobi and colleagues compared the results of PT and CT in ICU patients. After 4years of data collection and
application of exclusion criteria, 40 patients were allocated to each group. The procedure times—dened by the time interval from the rst puncture of the trachea to
the end of successful insertion of the tracheostomy tube and connection to the ventilator—were 10.01±2.42min in the PT group and 15.08±3.16min in the CT
group.
Coagulation Pitfalls
The first measure to be taken before the tracheostomy, as in any other surgical
procedure, is to correct coagulopathies. Usually these patients undergo tracheostomy in the operating room. Auzinger etal. published an important prospective study in 60 patients with severe coagulopathy and liver disease, who
underwent the percutaneous technique in the ICU, and only one patient experienced significant bleeding, which ceased after the insertion of the cannula. The
experience of the team and the correction of blood dyscrasias are determinants
of success. It must be emphasized that all of the materials available in the surgical center should be available in the ICU to perform the procedure—for
example, electrocautery and surgical wires, which are essential for regular
hemostasis [23].
McCormick and Manara [27], in their case report article, showed that although
massive hemorrhage during PT occurs only rarely, it can be fatal. One patient
died during the procedure due to uncontrollable hemorrhage of the innominate
vein. This patient had a prior history of right breast carcinoma treated with mastectomy and radiotherapy, which resulted in extensive brosis of the tissues adjacent to the left innominate vein, distorting the normal anatomy. Two other
patients did not survive late hemorrhagic complications, which were caused by
erosion of the aorta through the tracheostomy tube in one case and were caused
by erosion of the innominate vein in the other case. In the postmortem evaluation
of both patients, it was pointed out that the unexpectedly low location of the
tracheal stoma may have contributed to the event. So, what is the lower limit for
performing the puncture or incision? Ideally, it should never be performed below
the fourth tracheal ring [28].
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L. Noleto et al.
Urgent Tracheostomy
Initially considered an absolute contraindication to the percutaneous method, urgent
tracheostomy is currently advocated for its safety in obtaining an emergency airway.
According to Klein etal., this procedure can be performed in emergency situations,
provided it is done by an experienced team. Still speaking of critical patients, individuals with severe respiratory insufciency and a very unfavorable ventilatory status (positive end-expiratory pressure (PEEP) >10mmHg and fraction of inspired
oxygen (FiO
)<70%) traditionally undergo the conventional technique. This fact is
2
explained by the possible hypoxemia that may occur during manipulation with the
bronchoscope, in which the orotracheal tube is drawn. There has been a report of PT
without major problems under these conditions [29].
Morbid Obesity
Patients with morbid obesity undergoing PT present a 2.7-fold higher risk of perioperative complications and a 4.9-fold risk of severe morbidities. For these patients,
blunt dissection of the pretracheal tissues is recommended, allowing tracheal palpation. Once PT is chosen, it is important that the neck is extended so that there is
palpation of a repair point [30].
Bulky Thyroid Goiter
The presence of a thyroid goiter may make it difcult to palpate and identify cervical structures, but it is not a contraindication to the procedure, especially via the
percutaneous method, where there is a greater controversy. Proper cervical extension, puncture at the level of the rst tracheal ring, or cervical ultrasonography
(USG) aid make PT possible. Even when a transthyroid procedure is performed,
dissection is minimal and bleeding is usually self-limited [31].
Cervical Immobility
As a rule, inability to perform cervical hyperextension is considered a contraindication to performance of PT.In the postoperative period of arthrodesis of the cervical
spine, it is considered safe to perform the procedure from the seventh postoperative
day [10, 11]. In a clinical review, Al-Ansari MA and Hijazi MH [9] reported a 96%
success rate and a 7.1% complication rate in patients who did not have the possibility of adequate cervical extension.
Conventional or Percutaneous Tracheostomy?
127
Previous Tracheostomy or Cervical Scar
Historically, the presence of a previous tracheostomy has been a relative contraindication to performance of PT.On the other hand, the presence of a previous scar, in
a certain way, directs the puncture and possibly there are fewer pretracheal tissues,
which would facilitate the procedure. Meyer etal. [32] reported a case series of 14
patients with previous tracheostomy, where the method was successfully performed.
Using either technique, one can always nd local brosis and difculty opening the
tracheal rings, which makes the technique difcult [32].
Costs andEnvironment fortheProcedure
When performed in a hospital room, as long as there is all of the necessary equipment, PT a viable procedure when carried out by a trained surgical team, besides
presenting the lowest cost among the alternatives for performing this surgery [14].
When tracheostomy is performed in the operating room, the costs increase signicantly due to the time of occupation of the room and the need for a team of professionals to transport the patient, in addition to the presence of the anesthesiologist
and any drugs used. Those who defend it cite the advantage of having everything
available for cases in which there are operative complications. Those that oppose it,
in addition to citing the cost, draw attention to the risk of transporting a critical
patient from one sector to another within the hospital [33]. PT appears to be an
alternative, facilitating a low-risk bedside procedure with results similar to those
obtained with the traditional technique. A trial conducted by Cantais, Kaiser,
Le-Goff, and Palmier [41] also demonstrated that PT is a safe procedure to perform
at the bedside. In general it seems to be a less traumatic procedure and the cutaneous
incision required is less than in the surgical procedure. In addition, the former
requires tracheal opening by dilation of the soft tissue space between the tracheal
rings rather than a direct cut of a cartilaginous ring. Therefore, a lower incidence of
tracheal stenosis at the stoma site would be expected. Several studies have shown
signicant cost savings in Western countries; however, usually the main limitation
is still the high cost of the commercial set, especially in developing countries.
Bacchetta etal. studied 86 patients undergoing tracheostomy after cardiac surgery. The authors concluded that there was no difference in clinical outcomes or
complications, but there was a signicant reduction in the costs for patients undergoing PT.Although this was a remarkable trial, with socioeconomic reality diverging among different nations, these data should be considered until individualized
studies are performed. The percutaneous technique requires the availability of a
greater quantity of materials and kits suitable for such a procedure—a fact not
observed with the conventional technique, which depends basically on availability
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L. Noleto et al.
of the cannula. Regarding the costs of the procedure, the average cost of the procedure when performed in the ICU is US$1569, compared with US$3172 when performed in the operating room.
Cervical Bronchoscopy andUltrasonography
Another divergent point in the literature is performance of tracheostomy with bronchoscopy and cervical USG.In an attempt to reduce the incidence of complications,
it is possible to use bronchoscopy and cervical USG as ancillary methods in
PT.While bronchoscopy (Figs.4 and 5) may, for example, ensure that the tracheal
puncture is made on the midline and at the desired level to help control all steps of
the procedure [2], USG allows optimal selection of the intercartilaginous space for
insertion of the tracheostomy tube and may also help to dene the pre and paratracheal anatomy in order to avoid lesion of pretracheal vascular structures [34]. These
Fig. 4 Bronchoscopic image of guide wire passing during percutaneous tracheostomy
Fig. 5 Introduction of videobronchoscopy through the tracheostomy cannula and verication of
the positioning of the cannula. The positioning of the cannula is observed just above the carina