Percutaneous tracheostomy by guidewire dilating forceps technique: review of 98 patients.
MM Maddali, M Pratap, J Fahr, AW Zarroug
Deparment of Anesthesiology, Royal Hospital, Muscat, Oman. , Oman
M M Maddali
Deparment of Anesthesiology, Royal Hospital, Muscat, Oman.
BACKGROUND: Percutaneous tracheostomy to a large extent has replaced conventional surgical tracheostomy by virtue of its low incidence of complications and the rapidity with which the procedure can be performed at the bedside avoiding transport of critically ill patients to the operating rooms. Since it is a blind approach, bronchoscopic guidance has been suggested which might not always be possible due to logistic reasons. METHODS: A retrospective study of 98 patients who had guide wire dilating forceps technique of percutaneous tracheostomy without the aid of a bronchoscope was undertaken. By ensuring the free mobility of the guide wire at each step of the procedure, a safe placement of the tracheostomy tube was achieved. RESULTS: The mean operating time was 3.05 mins [S.D:2.20]. Two patients had peristomal bleeding as an early complication. 34 patients could be decannulated with good primary approximation of the stomal tissues [mean: 3.92days, S.D: 1.46]. There were no deaths or life threatening complications attributable to this technique. CONCLUSIONS: In the absence of bronchoscopic guidance, adopting the simple but effective precaution of free movement of guide wire at each step of the procedure, a safe tracheostomy tube placement is possible.
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Maddali M M, Pratap M, Fahr J, Zarroug A W. Percutaneous tracheostomy by guidewire dilating forceps technique: review of 98 patients. J Postgrad Med 2001;47:100-3
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Maddali M M, Pratap M, Fahr J, Zarroug A W. Percutaneous tracheostomy by guidewire dilating forceps technique: review of 98 patients. J Postgrad Med [serial online] 2001 [cited 2022 Aug 7 ];47:100-3
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Tracheostomy is frequently performed in patients admitted to intensive care units (ICUs). Ventilatory dependence and the need for tracheal toilet are the important indications for the tracheostomy., This has been conventionally achieved by performing the tracheostomy surgically. However, percutaneous tracheostomy is now preferred over the conventional surgical tracheostomy due to decreased incidence of complications associated with the technique. The technique of percutaneous tracheostomy described by Shelden in 1955 has undergone several modifications over a period of time.,, One of them uses a guide wire dilating forceps (GWDF), which is a specially designed instrument that is passed over a guide wire into the trachea. It has been recommended that fibre optic bronchoscope should be utilized in this method so that procedural complications are reduced and accurate placement of the tracheostomy tube is achieved., However, for logistic reasons this may not be routinely possible. Therefore, in an attempt to minimize complications it is a practice at our centre to follow a simple precaution that is to ensure the free mobility of the guide wire at each step of the procedure. This paper deals with the retrospective analysis of 98 patients admitted to Post Cardiac Surgical Unit [PCSU] and Adult Intensive Care Unit [AICU] in our institute, in whom the percutaneous tracheostomy was performed using GWDF technique, without the aid of a fibreoptic bronchoscope.
Ninety eight patients underwent percutaneous tracheostomy between November 1998 and May 2000 at our hospital. The procedure was performed after obtaining the informed consent from the closest relative of the patient and GWDF technique was utilized in all of them. Ventilator dependence or prolonged tracheal toilet was the main indication for the percutaneous tracheostomy. Patients with thyroid enlargement or unfavourable anatomy were excluded. Any significant coagulopathies were corrected and the following technique was employed. The procedure was performed at the bedside under aseptic precautions, by two anaesthesiologists. One of them actually performed the procedure and the other maintained the airway and monitored ventilation and circulation. ECG, blood pressure and SpO2 were monitored continuously. Local anaesthesia and sedation, with or without muscle relaxant were used during the procedure. A Portex percutaneous tracheostomy kit with its GWDF of appropriate size was used. The patient was positioned supine with a slight head-up tilt and a pillow underneath the shoulders to hyperextend the neck. After a thorough endotracheal and pharyngeal suction, the cuff of the endotracheal tube was deflated and the tube was withdrawn until the cuff was just above the laryngeal inlet. The cuff was inflated in this position to provide a good seal. The space between first and second or second and third tracheal rings was chosen for tube insertion. After infiltrating the selected site with 1% xylocaine (1-2 ml), the needle and cannula (provided in the kit) attached to a syringe containing saline was gradually inserted in a slightly caudal direction. Free aspiration of air confirmed the entry into the trachea. The needle and syringe were then removed leaving the cannula in the trachea. Bubbling of a saline drop placed on the hub of the cannula with ventilation reconfirmed the position of the tip of the cannula in the trachea. The guide wire was then inserted through the cannula for approximately 10 cms and checked for its free movement. The cannula was then removed leaving the guide wire in the trachea. After making small incision the 14- French dilator provided in the kit was passed over the guide wire dilating the tissues, following which the dilator was removed leaving the guide wire. A small horizontal skin incision of 1-1.5 cm was made across the guide wire insertion site and the GWDF was passed over the guide wire into the trachea. The free movement of the guide wire in the GWDF ensured correct placement. The GWDF was opened using both hands to dilate tissues just enough to accept the tracheostomy tube and the GWDF was withdrawn in the open position. 96% of the times we obtained the desired dilatation at first attempt, in the remaining a second attempt was required, and there was no over dilatation. The tracheostomy tube obturator along with the tracheostomy tube was now passed over the guide wire into the trachea. Free movement of the guide wire was once again ensured. The guide wire and the obturator were removed leaving the tracheostomy tube in the trachea, which was secured firmly. Endotracheal suction was performed and the ventilation was established through the tracheostomy tube. The endotracheal tube was then removed. Data is presented as mean ± standard deviation. Median values are considered for data that is not distributed normally.
There were 71 males and 27 females with a mean age of 58 ± 15 years. (range 16-91 years). [Table:1] shows the distribution of patients as per the diagnosis. The majority of patients suffered from neurological ailments (42 patients) or cardiac diseases including those who had undergone prior cardiac surgical procedure (35 patients). The decision to perform tracheostomy by GWDF technique was taken within 6.6 ± 5.4 days of endotracheal intubations. The mean duration of the procedure in our patients i.e. from skin incision to successful insertion of tracheostomy tube was 3.05 ± 2.2 minutes with a range of 1.5 to 14 minutes. [Table:2] shows the duration of the procedure and the complications related to the procedure. There were no complications during the procedure. Bleeding was the early complication that occurred in our patients. One patient had minor bleeding, that was managed conservatively with stomal packs and a second patient had significant bleeding. This patient needed re-exploration that revealed a small arterial bleed, which was controlled, and tracheostomy tube reinserted. No blood transfusion was necessary in either case. There were no other complications such as excessive purulent exudate at stoma or major bleeding. There were no peroperative complications in our patients. [Table:3] shows the outcome of the patients. Successful decannulation was achieved in 34 patients (34.7%) and conversion to permanent tracheostomy was necessary in 5 patients (5.1%). Wound approximation by primary closure after decannulation was achieved within 3.92 ± 1.4 days. Fifty-nine patients (60.2%) died as a consequence of the primary disease and seven patients of those decannulated were lost to follow up.
Tracheostomy is frequently performed in critically ill patients requiring prolonged mechanical ventilation and tracheal toilet., Percutaneous tracheostomy is preferred over the conventional tracheostomy, as it can be rapidly performed at the bedside with fewer complications.,, The incidence of complications with percutaneous tracheostomy varies with the different techniques used. The peri-procedural complication rate with GWDF technique is reported to be 1-10%,,, with percutaneous dilational tracheostomy (PDT) technique 4 to 15%,,, and with Rapitrach method as high as 18 to 58%., Leinhardt et al have reported that complication rates are not different with different techniques and also noted that PDT could be performed faster without necessitating patient transfer to OR., Some authors have also suggested use of fibre optic bronchoscope to reduce the procedural complications., This has been mainly due to the fact that bronchoscopy can help to verify the safe placement of needle and guide wire., However, a survey carried out by Cooper et al in 1998 revealed that only 31.3% centres routinely use fibreoptic bronchoscopy during percutaneous tracheostomy. This may be due to logistic reasons or related to some reports of increased airway pressure leading to its sequel such as increased intracranial pressure, pneumothorax and hypoxia associated with PDT performed with bronchoscopic assistance., A more serious complication, a large posterior wall tear of trachea leading to tension pneumothorax has also been reported with bronchoscopic assisted percutaneous tracheostomy. Although, the incidence of peri-operative complications has been reported to be similar with and without bronchoscopy (7% and 6% respectively), the complications were more serious in patients in whom bronchoscopy was not used. These included perforation of posterior tracheal wall and one death due to tension pneumothorax., In Anon et al study, following GWDF technique there had been a tracheal tear with concomitant subcutaneous emphysema and lowering of SaO2. We performed percutaneous tracheostomy in all our patients using GWDF technique without the aid of bronchoscope. The placement of needle in the trachea was confirmed by free aspiration of air as well as bubbling of air through the drop of fluid placed over the hub of the needle. In addition the free movement of guide wire at each stage of the procedure was taken as prerequisite for proceeding further. By strictly adhering to these simple precautions, we were able to achieve successful and accurate placement of tracheostomy tube in all our patients without any major complications. In our study, there was no desaturation, accidental extubation, endotracheal tube or cuff puncture. The only complication encountered was persistent oozing from the stomal site after the procedure in 2% of our patients. This is in contrast to some of the reports that have described a complication rate of 10%. As our study had been without bronchoscopic assistance, paramedian puncture of trachea and superficial posterior tracheal wall injuries cannot be ruled out. The duration of the procedure was also much shorter in our patients (Mean: 3.05 min, median: 2 mins, inter-quartile range: 1.5 to 14mins) as compared to some other studies with duration of 4.3 to 13.6 min.,
Thirty four patients in our study were successfully decannulated, and had a good approximation of tissues with in a mean of 3.92 days. None of the 27 patients who were available for follow up had any late complications like left sided vocal cord paralysis, abnormal granulation tissue, hoarseness of voice and voice change, as was revealed by an ENT examination performed approximately one month after decannulation.
We conclude that percutaneous tracheostomy using GWDF technique is a simple, rapid and safe bedside procedure. By adopting the simple precautions described above, results as good as those that have been achieved using a bronchoscope can be obtained.
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