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CHAPTER 17 Medical Thoracoscopy
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187
bronchoscope, thoracoscope, or needle (nCLE), and
directed to the area of interest where it illuminates the
tissue with laser light (488 nm). Reected light in focus
will pass through the pinhole, resulting in high-resolution images. Moving the laser beam vertically or horizontally enables reconstruction of 3D images by special
soware.
Both pCLE and nCLE have been used to assess pleu-
50
ral lesions. Bonhomme and colleagues
showed pCLE
images of normal pleura, non–small cell lung cancer
pleural metastasis, and mesothelioma. pCLE was able
to dierentiate normal from malignant involvement of
pleura. A subsequent study was undertaken demonstrating that pCLE and nCLE could dierentiate malignant
mesothelioma from pleural brosis to guide biopsy.
51
Another ex vivo study has found high sensitivity and
specicity for pleural malignancy with pCLE in pleural
eusion.
52
Lung Cancer
Cancer-related pleural eusions occur due to direct
invasion, tumor embolization to visceral pleura with
secondary seeding of the parietal pleura, hematogenous, or lymphangitic spread. Elastin staining and careful examination for invasion beyond the elastic layer of
the visceral pleura should be carried out for lung cancer
resections as visceral pleural invasion is important for
staging in the absence of nodal involvement. It is rare to
nd resectable lung cancer in the setting of an exudative
pleural eusion despite negative cytologic examination.
MT can assess surgical operability by determining if the
pleural eusion is paramalignant or due to metastases.
25
If pleural metastases are found they denote disseminated disease with reduced life expectancy and talc poudrage or tunneled pleural catheter can be performed at
the same setting.
53
Malignant Mesothelioma
e average survival of a patient diagnosed with malignant mesothelioma is 6 to 18 months, and death occurs
from respiratory failure.
suspected in a patient with asbestos exposure and characteristic CXR of a pleural eusion without contralateral
mediastinal shi. Diagnosis by pleural uid cytology,
even with closed pleural biopsy, is dicult, which
prompts some physicians to advocate open biopsy by
mini or lateral thoracotomy in order to obtain specimens
of sucient size and quantity for immunohistochemical
53
Malignant mesothelioma is
54
stains.
Pleural uid mesothelin (>2 nmol/L) and
megakaryocyte potentiating factor (MPF, >12.4 ng/mL),
which originate from a common precursor protein, have
shown 65% sensitivity and 95% specicity for pleural
mesothelioma in a large study of 507 patients.
55
MT is favored over thoracotomy as the pleural spec-
imens obtained with 5- or 7-mm rigid forceps are com-
56
parable with open biopsies.
MT allows staging to be
performed in a minimally invasive manner with good
sensitivity. 5-ALA-uorescence VATS should be viewed
as experimental but may be able to improve staging
49
accuracy.
Adequacy of tissue sampling obtained with
the exible forceps is a concern in cases of mesothelioma, so biopsy with the rigid 5-mm optical forceps, IT
knife, or cryobiopsy is recommended to establish the
diagnosis.
21,22,55–57
Since mesothelioma is notorious for
seeding, biopsy, MT, and chest tube sites should be chosen carefully to avoid tumor involvement and seeding.
Boutin and colleagues recommended prophylactic irradiation of 7Gy for three consecutive days within 2 weeks
58
of MT
; however, a recent randomized trial comparing
immediate drain site radiotherapy (21 Gy in three fractions) to best supportive care in 61 patients failed to show
any dierence in the occurrence of tract metastases.
59
us prophylactic radiotherapy to MT and drain sites
60
remains controversial.
able for curative surgery,
As only 5% of patients are suit-
61
a palliative approach toward
aggressive relief of dyspnea by removing pleural uid,
talc poudrage, pain control, and prophylactic irradiation
of incision sites has conferred good symptom control.
62
In recurrent symptomatic pleural eusions, tunneled
pleural catheters may represent a viable option.
60
Tuberculous Pleural Effusion
e diagnostic yield of closed pleural biopsy in tuberculous pleural eusions is variable. In a prospective study
of 100 tuberculous eusions in Germany, an immediate
histologic diagnosis was established in 94% by MT compared with 38% by closed pleural biopsy (Fig. 17.7). A
positive yield from tissue cultures was also higher with
MT-guided biopsies than with closed pleural biopsy tissue and pleural uid combined.
reported by another study performed in a tuberculosis
(TB) endemic country, where MT-guided pleural biopsies achieved superior yield over closed pleural biopsy
with Abrams needle (98% vs. 80%). On balance, it
appears that MT is superior to closed pleural biopsy for
TB diagnosis, and can be the rst choice if drug-resistant
63
Similar results were
188
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Fig. 17.7 (A) Sago nodules and (B) brinous adhesions in tuberculous effusion.
SECTION 3 Pleural Disease
TB is a concern as large quantities of pleural tissue can
be obtained via MT for culture. In addition, adhesiolysis can also be performed to promote drainage of uid
loculations.
64
S U MM A RY
Diagnostic MT is eective in the evaluation of pleural
and pulmonary diseases when routine uid analysis
and cytology fail. In many institutions where facilities
for MT are available, it is used aer a rst thoracentesis
fails to establish a diagnosis and demonstrates an exudative eusion of unknown etiology. MT can also be used
to break down loculations in complicated parapneumonic eusions. For patients with recurrent MPEs, MT
combined with talc poudrage can be used to eectively
drain the eusion and establish pleurodesis. is is also
useful in cases of pneumothorax when pleurodesis is
warranted.
Training in MT is required; the American College
of Chest Physicians recommend 20 supervised procedures before operators are considered competent
and 10 each year to maintain competency.
rigid pleuroscope is a signicant invention in the era
of minimally invasive pleural procedures and is likely
to replace traditional biopsy methods.
MT will dene “when and how” to apply ex-rigid and
rigid instruments for the evaluation of pleuropulmonary diseases.
65
e ex-
66
e future of
REFERENCES
1. McKenna Jr. RJ. oracoscopic evaluation and treatment of pulmonary disease. Surg Clin North Am.
2002;80:1543–1553.
2. Yim AP, Lee TW, Izzat MB, Wan S. Place of videothoracoscopy in thoracic surgical practice. World J Surg.
2001;25:157–161.
3. Lee P, Mathur PN, Colt HG. Advances in thoracoscopy:
100 years since Jacobaeus. Respiration. 2010;79:177–186.
4. Tassi GF, Davies RJ, Noppen M. Advanced techniques in
medical thoracoscopy. Eur Respir J. 2006;28:1051–1059.
5. Moisiuc FV, Colt HG. oracoscopy: origins revisited.
Respiration. 2007;74:344–355.
6. Jacobaeus HC. Uber die Möglichkeit, die Zystoskopie
bei Untersuchungen seröser Höhlungen anzuwenden.
MunchMed Wschr. 1910;40:2090–2092.
7. Jacobaeus HC. e practical importance of thoracoscopy in surgery of the chest. Surg Gynecol Obstet.
1922;34:289–296.
8. Loddenkemper R. oracoscopy-state of the art. Eur
Respir J. 1998;11:213–221.
9. Rodriguez-Panadero F, Janssen JP, Astoul P. oracoscopy: general overview and place in the diagnosis
and management of pleural eusion. Eur Respir J.
2006;28:409–421.
10. Tassi G, Marchetti G. Minithoracoscopy: a less invasive
approach to thoracoscopy- minimally invasive techniques. Chest. 2003;124:1975–1977.
11. Munavvar M, Khan MA, Edwards J, Waqaruddin Z,
Mills J. e autoclavable semi-rigid thoracoscope:
the way forward in pleural disease? Eur Respir J.
2007;29:571–574.
CHAPTER 17 Medical Thoracoscopy
https://t.me/medicina_free
189
12. Lee P, Hsu A, Lo C, Colt HG. Prospective evaluation of
ex-rigid pleuroscopy for indeterminate pleural eusion:
accuracy, safety and outcome. Respirology. 2007;12:
881–886.
13. Marchetti G, Valsecchi A, Indellicati D, Arondi S,
Trigiani M, Pinelli V. Ultrasound-guided medical
thoracoscopy in the absence of pleural eusion. Chest.
2015;147:1008–1012.
14. Medford AR, Agarwal S, Bennett JA, Free CM, Entwisle
JJ. oracic ultrasound prior to medical thoracoscopy
improves pleural access and predicts brous septation.
Respirology. 2010;15:804–808.
15. Migliore M, Giuliano R, Aziz T, Saad RA, Sgalambro F.
Four-step local anesthesia and sedation for thoracoscopic
diagnosis and management of pleural diseases. Chest.
2002;121:2032–2035.
16. Tschopp JM, Purek L, Frey JG, etal. Titrated sedation
with propofol for medical thoracoscopy: a feasibility and
safety study. Respiration. 2011;82:451–457.
17. Grendelmeier P, Tamm M, Jahn K, Pimlin E, StolzD.
Propofol versus midazolam in medical thoracoscopy:
a randomized, noninferiority trial. Respiration.
2014;88:126–136.
18. Lee P, Colt HG. A spray catheter technique for pleural
anesthesia: a novel method for pain control before talc
poudrage. Anesth Analg. 2007;104:198–200.
19. DePew ZS, Wigle D, Mullon JJ, Nichols FC, DeschampsC,
Maldonado F. Feasibility and safety of outpatient medical
thoracoscopy at a large tertiary medical center: a collaborative medical-surgical initiative. Chest. 2014;146:
398–405.
20. Rozman A, Camlek L, Marc-Malovrh M, Triller N, KernI.
Rigid versus semi-rigid thoracoscopy for the diagnosis
of pleural disease: a randomized pilot study. Respirology.
2013;18:704–710.
21. Dhooria S, Singh N, Aggarwal AN, Gupta D, AgarwalR.
A randomized trial comparing the diagnostic yield of
rigid and semirigid thoracoscopy in undiagnosed pleural
eusions. Respir Care. 2014;59:756–764.
22. Sasada S, Kawahara K, Kusunoki Y, etal. A new electrocautery pleural biopsy technique using an insulated-tip
diathermic knife during semirigid pleuroscopy. Surg
Endosc. 2009;23:1901–1907.
23. Shaq M, Sethi J, Ali MS, Ghori UK, Saghaie T, Folch E.
Pleural cryobiopsy: a systematic review and meta-analysis. Chest. 2020;157(1):223–230.
24. Viskum K, Enk B. Complications of thoracoscopy.
Poumon-Coeur. 1981;37:25–28.
25. Rahman NM, Ali NJ, Brown G, etal. Local anaesthetic
thoracoscopy: British oracic Society Pleural Disease
Guideline 2010. orax. 2010;65(Suppl 2):ii54–ii60.
26. Colt HG. oracoscopy: a prospective study of safety and
outcome. Chest. 1995;108:324–329.
27. Kindler HL, Ismaila N, Armato 3rd SG, etal. Treatment
of malignant pleural mesothelioma: American Society
of Clinical Oncology Clinical Practice Guideline. J Clin
Oncol. 2018;36(13):1343–1373.
28. Agarwal R, Aggarwal AN, Gupta D. Diagnostic accuracy
and safety of semirigid thoracoscopy in exudative pleural
eusions: a meta-analysis. Chest. 2013;144:1857–1867.
29. Hsu C. Cytologic detection of malignancy in pleural
eusion: a review of 5, 255 samples from 3, 811 patients.
Diag Cytopathol. 1987;3:8–12.
30. Hooper C, Lee YC, Maskell N, BTS Pleural Guideline
Group Investigation of a unilateral pleural eusion in
adults: British oracic Society Pleural Disease Guideline 2010. orax. 2010;65(Suppl 2):ii4–ii17.
31. Renshaw AA, Dean BR, Antman KH, Sugarbaker DJ,
Cibas ES. e role of cytologic evaluation of pleural
uid in the diagnosis of malignant mesothelioma. Chest.
1997;111:106–109.
32. Abouzgheib W, Bartter T, Dagher H, Pratter M, KlumpW.
A prospective study of the volume of pleural uid
required for accurate diagnosis of malignant pleural
eusion. Chest. 2009;135:999–1001.
33. Canto A, Ferrer G, Ramagosa V, Moya J, Bernat R. Lung
cancer and pleural eusion: clinical signicance and
study of pleural metastatic locations. Chest. 1985;87:
649–651.
34. Whitaker D, Shilkin KB. Diagnosis of pleural malignant
mesothelioma in life: a practical approach. J Pathol.
1984;143:147–175.
35. Leung AN, Müller NL, Miller RR. CT in dierential
diagnosis of diuse pleural disease. AJR Am J Roentgenol.
1990;154:487–492.
36. Traill ZC, Davies RJ, Gleeson FV. oracic computed
tomography in patients with suspected malignant pleural
eusions. Clin Radiol. 2001;56:193–196.
37. Qureshi NR, Rahman NM, Gleeson FV. oracic ultrasound in the diagnosis of malignant pleural eusion.
orax. 2009;64:139–143.
38. Chian CF, Su WL, Soh LH, Yan HC, Perng WC, Wu CP.
Echogenic swirling pattern as a predictor of malignant
pleural eusions in patients with malignancies. Chest.
2004;126:129–134.
39. Maskell NA, Gleeson FV, Davies RJ. Standard pleural
biopsy versus CT-guided cutting-needle biopsy for
diagnosis of malignant disease in pleural eusions: a randomised controlled trial. Lancet. 2003;361:1326–1330.
40. Diacon AH, Schuurmans MM, eron J, Schubert
PT, Wright CA, Bolliger CT. Safety and yield of
ultrasound-assisted transthoracic biopsy performed by
pulmonologists. Respiration. 2004;71:519–522.
41. Tombesi P, Nielsen I, Tassinari D, Trevisani L, Abbasciano V, Sartori S. Transthoracic ultrasonographyguided core needle biopsy of pleural-based lung lesions:
190
https://t.me/medicina_free
SECTION 3 Pleural Disease
prospective randomized comparison between a
Tru-Cut-type needle and a modied Menghini-type
needle. Ultraschall Med. 2009;30:390–395.
42. Koegelenberg CF, Bolliger CT, eron J, etal. Direct
comparison of the diagnostic yield of ultrasound-assisted
Abrams and Tru-Cut needle biopsies for pleural tuberculosis. orax. 2010;65:857–862.
43. Hallifax RJ, Haris M, Corcoran JP, etal. Role of CT in
assessing pleural malignancy prior to thoracoscopy.
orax. 2015;70:192–193.
44. Dixon G, de Fonseka D, Maskell N. Pleural controversies:
image guided biopsy vs. thoracoscopy for undiagnosed
pleural eusions? J orac Dis. 2015;7:1041–1051.
45. Boutin C, Cargnino P, Viallat JR. oracoscopy in the
early diagnosis of malignant pleural eusions. Endoscopy.
1980;12:155–160.
46. Weissberg D, Kaufman M, Zurkowski Z. Pleuroscopy in
patients with pleural eusion and pleural masses. Ann
orac Surg. 1980;29:205–208.
47. Chrysanthidis MG, Janssen JP. Autouorescence videothoracoscopy in exudative pleural eusions: preliminary
results. Eur Respir J. 2005;26:989–992.
48. Schönfeld N, Schwarz C, Kollmeier J, Blum T, BauerTT,
Ott S. Narrow band imaging (NBI) during medical
thoracoscopy: rst impressions. J Occup Med Toxicol.
2009;4:24–28.
49. Baas P, Triesscheijn M, Burgers S, van Pel R, Stewart F,
Aalders M. Fluorescence detection of pleural malignancies using 5-aminolaevulinic acid. Chest. 2006;129:
718–724.
50. Bonhomme O, Duysinx B, Heinen V, Detrembleur N,
Corhay JL, Louis R. First report of probe based confocal
laser endomicroscopy during medical thoracoscopy.
Respir Med. 2019;147:72–75.
51. Wijmans L, Baas P, Sieburgh TE, etal. Confocal laser
endomicroscopy as a guidance tool for pleural
biopsies in malignant pleural mesothelioma. Chest.
2019;156(4):754–763.
52. Zirlik S, Hildner K, Rieker RJ, Vieth M, Neurath MF,
Fuchs FS. Confocal laser endomicroscopy for diagnosing malignant pleural eusions. Med Sci Monit.
2018;24:5437–5447.
53. Roberts ME, Neville E, Berrisford RG, BTS Pleural
Disease Guideline Group Management of a malignant
pleural eusion: British oracic Society Pleural Disease
Guideline 2010. orax. 2010;65(Suppl 2):ii32–ii40.
54. Ceresoli GL, Locati LD, Ferreri AJ, etal. erapeutic
outcome according to histologic subtype in 121 patients
with malignant pleural mesothelioma. Lung Cancer.
2001;34:279–287.
55. Hollevoet K, Nackaerts K, impont J, etal. Diagnostic
performance of soluble mesothelin and megakaryocyte
potentiating factor in mesothelioma. Am J Respir Crit
Care Med. 2010;181:620–625.
56. Herbert A, Gallagher PJ. Pleural biopsy in the diagnosis
of malignant mesothelioma. orax. 1982;37:816.
57. Chan HP, Liew MF, Seet JE, Lee P. Use of cryobiopsy
during pleuroscopy for diagnosis of sarcomatoid malignant mesothelioma. orax. 2016;72:193–195.
58. Boutin C, Rey F, Viallat JR. Prevention of malignant
seeding aer invasive diagnostic procedures in patients
with pleural mesothelioma: a randomized trial of local
therapy. Chest. 1995;108:754–758.
59. O’Rouke N, Garcia JC, Paul J, Lawless C, McMeneminR,
Hill J. A randomized controlled trial of intervention site
radiotherapy in malignant pleural mesothelioma. Radio-
ther Oncol. 2007;84:18–22.
60. Scherpereel A, Astoul P, Baas P, etal. Guidelines of the
European Respiratory Society and the European Society
of oracic Surgeons for the management of malignant
pleural mesothelioma. Eur Respir J. 2010;35:479–495.
61. Sugarbaker DJ, Garcia JP, Richards WG, etal. Extrapleural pneumonectomy in the multimodality therapy of
malignant pleural mesothelioma. Results in 120 consecutive patients. Ann Surg. 1996;224:288–294.
62. Parker C, Neville E. Management of malignant mesothelioma. orax. 2003;58:809–813.
63. Loddenkemper R, Mai J, Scheeler N, Brandt HJ. Prospective individual comparison of blind needle biopsy
and of thoracoscopy in the diagnosis and dierential
diagnosis of tuberculous pleurisy. Scand J Respir Dis.
1978;102:196–198.
64. Diacon AH, Van de Wal BW, Wyser C, etal. Diagnostic
tools in tuberculosis pleurisy: a direct comparative study.
Eur Respir J. 2003;22:589–591.
65. Ernst A, Silvestri GA, Johnstone D, American College of
Chest Physicians Interventional pulmonary procedures:
guidelines from the American College of Chest Physicians. Chest. 2003;123:1693–1717.
66. Lee P, Colt HG. Steps to ex-rigid pleuroscopy. In: LeeP,
Colt HG, eds. Flex-Rigid Pleuroscopy: Step by Step. Singa-
pore: CMP Medica Asia; 2005:77–111.
S E C T I O N 4
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Additional IP Topics
18. Percutaneous Tracheostomy 193
Tenzing Phanthok, Crystal Ann Duran, and Shaheen Islam
19. How to Start an Interventional Pulmonology Program 207
Edward Kessler, Neeraj R. Desai, Kim D. French, and Kevin L. Kovitz
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Percutaneous Tracheostomy
Tenzing Phanthok, Crystal Ann Duran and Shaheen Islam
INTRODUCTION
Trachestmy s derved frm the Latn wrds “trachea
artera” and “stum,” whch means “creatng an penng
n the trachea.” e earlest dcumentatn f trachestmy s a descrptn f the healng f a thrat ncsn
n the Rg Veda.
the trachea t supprt ventlatn.
reslve upper arway bstructn was rst mentned n
herglyphcs by Imhtep.
a successful trachestmy was perfrmed n a patent
wth tnsllar bstructn by Antn Brassavla n
1
In 1620, Nclas Habct successfully resusctated
1546.
a by wh was ntally prnunced dead aer sustanng a stab wund t the neck, fllwng an emergent trachestmy and release f a tracheal bld clt.
Trusseau saved mre than 200 patents wth dphthera
by perfrmng a trachestmy.
Trachestmy technques avalable tday are surgcal
trachestmy (ST) and percutaneus dlatnal trachestmy (PDT).
ST s usually perfrmed n the peratng rm under
general anesthesa and entals surgcal dssectn f the
neck tssue t create a stma. Cnversely, n PDT, a needle s placed percutaneusly and then, usng a mded
Seldnger technque, a stma s created by dlatn.
PDT has a smaller ncsn sze, shrter prcedural
duratn, less pstperatve bleedng, and faster healng
tme cmpared t ST.
dmzed cntrlled trals (RCTs) cmparng ST and
PDT have als cnrmed that PDT s asscated wth
sgncantly shrter peratve tme, lwer cst, lwer
ncdence f perperatve bleedng, shrter sedatn
tme, accelerated wund healng, and lwer rsk f stma
1
Hppcrates descrbed ntubatn f
2
e rst dcumented case f
4
Several meta-analyses and ran-
1
Trachestmy t
3
2
In 1833,
nfectns. Hwever, there s n derence n mrtalty
between ST and PDT.
In ths chapter, we wll prmarly fcus n PDT n the
ntensve care unt (ICU) settng.
5–9
SURGICAL TRACHEOSTOMY TECHNIQUE
ST s deally perfrmed n the peratng rm under
general anesthesa, althugh ST may be perfrmed at the
bedsde. Landmarks shuld be dented preperatvely,
ncludng the thyrd cartlage, crcd cartlage, and sternal ntch. Lcal anesthetc wth 1% ldcane wth epnephrne s nltrated at the ncsn ste f nt perfrmng
under general anesthesa. A 2–3-cm lng transverse skn
ncsn s made abut a centmeter belw the crcd
cartlage. e mdlne raphe s lcated, and retractrs are
used n ether sde f the strap muscles t expse the trachea. e endtracheal tube (ETT) s slghtly wthdrawn
t allw stma creatn. An ncsn s made n the nterspaces between the rst and the secnd tracheal rngs and
s extended laterally. Stay sutures are placed thrugh the
skn, arund the tracheal rng, and then back thrugh the
10
Oen a Bjrk ap s made. e trachestmy tube
skn.
(TT) s then placed thrugh the trachestmy stma, the
cu nated, and the ventlatr crcut cnnected. e TT
s secured wth sutures n the neck and ventlatn s then
transferred frm the ETT t TT.
TYPES OF PERCUTANEOUS DILATIONAL
TRACHEOSTOMY
e rst trachestmy technque descrbed n 1955
requred a specal needle t enter the trachea and nvlved
a ne-stage nsertn f the TT usng a cuttng trcar.
11
193
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SECTION 4 Additional IP Topics
Percutaneus trachestmy has been mded ver
the years. e Cagla technque, ntrduced n 1985,
s ne f the mst wdely used technques n Nrth
12, 13
Amerca.
In 1990, the Grggs gudewre dlatng frceps (GWDF) was develped, where a specal frceps
s threaded ver the gudewre nt the trachea, and a
14
tracheal aperture s created by penng the frceps.
15
1997, Fantn and Rpamnt
descrbed the transla-
In
ryngeal methd where the dlatr and the TT are pulled
n a retrgrade fashn thrugh the stma. Anther sngle-dlatr technque called the PercuTwst, develped
by Frva and Quntel n 2002, utlzes a sngle dlatr,
whch s advanced ver the gudewre nt the s tssue
usng a clckwse rtatn t create a stma.
16
Snce these latter technques d nt exert pressure
ver the tracheal wall durng dlatn, they were thught
t mnmze the rsk f psterr tracheal wall njury.
INDICATIONS
Indcatns fr PDT are smlar t ST (Bx 18.1). ST
s prmarly perfrmed n patents wth upper arway
bstructn frm laryngeal r cervcal malgnances r
n emergences. It s als dne n patents undergng
neck surgery, ttal laryngectmy, and n patents wth
neectve swallwng r cugh mechansms resultng
n an nablty t prtect ther arway.
In the medcal ICU, trachestmy s cmmnly perfrmed n patents requrng prlnged ventlatn
17
r fr arway prtectn. Transtnng frm ral ntubatn t trachestmy helps t mnmze sedatn
requrements, decrease the ncdence f lung nfectns,
reduce dead space ventlatn, mprve respratry
wrk, and ad n trachebrnchal tletng whle prtectng the arways.
18
CONTRAINDICATIONS
Althugh when rst ntrduced there were suggested cntrandcatns related t bdy habtus, tday t s recgnzed that PDT s a vable alternatve t ST and there are
n abslute cntrandcatns fr PDT as cmpared t ST.
Relatve cntrandcatns (Bx 18.1) t PDT nclude
trauma resultng n an unstable cervcal spne, uncntrllable cagulpathy, r prr neck surgery. In addtn, PDT can be perfrmed wth cautn n patents
wth dcult anatmy (enlarged thyrd gland, lcal
malgnancy, shrt neck, tracheal devatn, prevus
BOX 18.1 Indications and
Contraindications
Indications
• Prolonged ventilator dependence with failure to wean
• Inability to protect airway (stroke, encephalopathy,
etc.)
• Obstruction of proximal trachea or upper airways
Relative Contraindications
• Gross distortion of neck anatomy due to tumor, high
innominate artery, thyromegaly
• Soft-tissue infection on anterior neck
• Anatomic landmarks
• Medically uncorrected bleeding disorders
• High positive end-expiratory pressure (PEEP) of more
than 20 cm of water
• Emergent airway
• Major head and neck surgery or trauma
• Overwhelming systemic infection
trachestmy), hgh ventlatr supprt (Fio
pstve end-expratry pressure [PEEP] >10 cm H
>70% r
2
O),
2
and radatn therapy t the cervcal regn wthn the
19
prevus 4 weeks.
Other cntrandcatns nclude
nfectn at the nsertn ste r palpable but bscured
neck anatmy. Recent data suggest that PDT s largely
20
dependent n peratr experence
and can be safely
perfrmed n patents wth relatve cntrandcatns.
PDT has been perfrmed n patents wth an aver-
age Pao
/Fio
f 130 and an average PEEP f 17 cm H
2
2
O
2
wthut any sgncant deterratn n xygen satura-
21
PDT has als been dne n patents wth acute
tn.
respratry dstress syndrme (ARDS) n hgh-frequency scllatry ventlatn wthut any sgncant
hemdynamc r respratry cmprmse.
22
ST s en preferred ver PDT n patents wth a
2
bdy mass ndex (BMI) >30kg/m
n head and neck malgnancy.
safely perfrmed n the bese ppulatn.
, n neck trauma, and
23
Hwever, PDT can be
24–26
A retrspectve study fund n sgncant derence between
PDT and ST n malpstnng f TT, lss f arway,
2 25
r bleedng n patents wth BMI >35 kg/m
Anther
prspectve study cmparng PDT n ICU patents wth
2
BMI ≥30 kg/m
versus lwer BMI revealed sgncantly
hgher majr cmplcatn rates (12% vs. 2%, P < 0.04)
27
n bese patents.
e creatn f a false passage due t
the ncreased dstance frm skn t trachea was a majr
28
cmplcatn n mrbdly bese patents.
e rsk f
CHAPTER 18 Percutaneous Tracheostomy
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195
cmplcatns can be mnmzed wth prper evaluatn, apprprate patent selectn, peratr experence,
and cncurrent brnchscpc vsualzatn t avd
unrecgnzed false passages.
TIMING OF TRACHEOSTOMY
In general the cnsensus fr apprprate tme t perfrm trachestmy s arund 10–20 days aer ntubatn. Early trachestmy (wthn 7 days aer ntubatn)
n crtcally ll patents s asscated wth a reductn
n weanng tme, cmplcatns, and mrbdty and
mrtalty.
29–31
Early trachestmy, perfrmed wthn 4–7 days f
admssn, s asscated wth a sgncant ncrease n
32
ventlatr-free days (VFD).
A systematc revew f
RCTs cmparng utcmes f early versus late trachestmy cnrmed mre VFD, shrter ICU stays, a shrter
duratn f sedatn, and reduced lng-term mrtalty
33
n patents wth early trachestmy.
Hwever, althugh
early trachestmy reduced hsptal length f stay and
cst, t dd nt aect n-hsptal mrtalty.
34
TRACHEOSTOMY TUBES AND TYPES
e man cmpnents f the TT are an uter cannula,
the ange, and an nner cannula (Fg. 18.1).
e curved uter cannula (Fg. 18.1a,b) s attached
t the ange and has a cu attached t the dstal end t
prvde a seal wthn the trachea fr ventlatn.
e ange s attached t the prxmal end r s a part
f the TT, whch s used t secure the TT n the neck
wth a trachestmy te r suture. e ange s cmmnly labeled wth the tube sze, type, and length.
e nner cannula (Fg. 18.1c) snugly ts nsde the
uter cannula and en has a 15-mm adapter fr cnnectng t the ventlatr crcut. e nner cannula can
be reusable r dspsable. Reusable nner cannulas need
t be cleaned at least twce a day. Sme TTs d nt have
the prvsn f an nner cannula and the nner aspect s
specally cated wth water-repellent materal t prevent
mucus pluggng.
e bturatr (Fg. 18.1d) s a rm gude wth a
runded tp desgned t be placed nsde the uter cannula f the TT fr easy placement thrugh a matured
stma durng trachestmy tube replacement.
Patents n a ventlatr r thse wth rsk f aspratn usually requre a cued TT. e cu s cnnected t
a plt balln (Fg. 18.1b) that prvdes nfrmatn n
the cu natn. When patents are weaned mechancal ventlatn, they can be transtned t a cuess TT
n preparatn fr decannulatn. Cu pressures shuld
be checked perdcally t avd schemc njury f the
tracheal mucsa.
A B C D
Fig. 18.1 Common tracheostomy tubes (Shiley tracheostomy, Medtronic, Minneapolis, MN, USA). From left to right:
a, Cufess tracheostomy tube with inner cannula. Inner cannula has 15-mm adapter. b, Cuffed tracheostomy tube. c,
Inner cannula with 15-mm adapter. d, Obturator.
196
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SECTION 4 Additional IP Topics
e TTs cme n derent szes and shapes dependng n the length, curvature, thckness, and a detaled
dscussn s beynd the scpe f ths chapter.
A mded TT s avalable fr placement wth the
PDT technque (Fg. 18.2b), whch has a taperng dstal
end t make t easer t nsert thrugh the newly created
stma by dlatn.
A lnger TT s used n bese patents t accmmdate the lnger skn t tracheal dstance s the dstal tp
f the TT (Fg. 18.2a) remans parallel t the lng axs
f the trachea. Varus cmmercally avalable TTs are
avalable that are extra lng.
PERCUTANEOUS TRACHEOSTOMY KIT
e tw well-knwn cmmercally avalable kts n the
Unted States that use a sngle-stage dlatr nclude the
Cagla Blue Rhn (Ck Medcal Inc, Blmngtn,
IN, USA) and Prtex Ultraperc (Smths Medcal,
Dubln, OH, USA).
BRONCHOSCOPY
ere s cnctng evdence, wth sme studes falng t demnstrate a benet fr cncurrent brnchscpy, whereas thers have fund that brnchscpc
vsualzatn durng PDT reduces cmplcatns. Fr
example, a retrspectve analyss f PDT wth and wthut brnchscpy n the trauma ppulatn revealed n
sgncant derence n safety and ecacy wth experenced peratrs.
have shwn the benets f rutnely utlzng brnchscpy when perfrmng PDT. Fr example, a prspectve
study reprted sgncantly lwer rates f majr cmplcatns ncludng bleedng, subcutaneus emphysema, r pneumthrax (20% vs. 40%); hgher rate f
rst-tme successful needle puncture; and sgncantly
shrter prcedural duratn wth brnchscpc gud-
36
On balance, gven that false lumens and unrec-
ance.
gnzed tracheal laceratns are the mst sgncant
majr cmplcatns f PDT, cncurrent brnchscpy
durng PDT shuld be cnsdered an essental element
f PDT n terms f safety. At present, brnchscpc
gudance s used rutnely by almst all nterventnal
pulmnlgsts.
35
Hwever, ver tme ther studes
Brnchscpc gudance s an mprtant adjunct n
prper placement f TTs durng PDT t avd psterr wall trauma r puncture, and s especally mprtant n patents wth besty, dcult anatmy, r thse
wth cervcal xatn r an unstable cervcal spne. A
mre detaled prcedural descrptn s prvded later,
ncludng hw brnchscpy can be utlzed t cnrm
placement f the gudewre, and t avd false lumen
frmatn and tracheal njury.
A B
Fig. 18.2 a, Extra-long tracheostomy tube with a cuff (Shiley XLT, Medtronic, Minneapolis, MN, USA) loaded on a
straight dilator. Note the raised distal end of the tube creating a sharp rise on the dilator. b, Regular tracheostomy tube
with tapered end for easy placement during percutaneous tracheostomy, loaded onto a straight dilator. Note the ush
distal end of the tracheostomy tube with the dilator (Shiley PERC, Medtronic, Minneapolis, MN, USA).
ULTRASOUND GUIDANCE DURING
PERCUTANEOUS DILATIONAL
TRACHEOSTOMY
Ultrasund gudance durng PDT can assst wth lcalzng anatmc landmarks and t dentfy the apprprate pnt f entry by examnng the pretracheal area
fr aberrant vasculature, tracheal rngs, neck mass, and
the thyrd gland. Real-tme ultrasund can be used t
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