The dilatational tracheotomy – minimally-invasive, bed-side, inexpensive – but safe?

Introduction

The dilatational tracheotomy becomes more and more a standard procedure in many ICUs. Complications of the dilatational tracheotomy are subject of controversial discussions. The estimation leads from 'inappropriate for the critically ill' up to 'even without surgical background to practice easily and safely'.

On the bases of the experience of 80 self-practiced dilatational tracheotomies we critically report observed complications, possible complications and in conclusion we present the 'quality-standard for dilatational tracheotomy'.

Patients and methods

Between 12/98 to 8/2000 we initiated a prospective trial on 80 patients of a 12 bed surgical intensive care unit in a 1100-bed primary care hospital, undergoing a dilatational tracheotomy. The free available tracheotomy-sets by Portex (one-step-dilatational-system) and Cook (more-step-system) have been used. All occuring complications were documented, such as fractures of the cartilagines, transfusion requiring bleeding, infection, cubcutaneus emphysema, dislocations of the oral tube, necessity of oral tube change and perforation of the cuff during the punction procedure, injuries of the pars membranaceus tracheae or the esophagus with possible following mediastinitis, rate of conversion to conventional tracheotomy, decrease of SpO₂ during the procedure.

Results

In four patients we found a subcutaneus emphysema which receded spontaneously. Fractures of tracheal cartilagine, dependent on the age of patients were observed in six patients. Dislocation of the oral tube occured in 21 (26%) patients and required immediate reposition of the oral tube but led just in one case to a short-time decrease of the SpO₂ down to 70 mmHg. In the tube-cuff was perforated by punction six times, but just in one patient the tube had to be changed before continuing the tracheotomy. In one patient we detected the punction through the esophagus, the patient remained asymptomatic. In two patients the procedure had to be converted to a bed-side conventional tracheotomy. In one case due to obesity, in the other case caused by post-traumatic collar hematoma the insertion of the canule, following successful punction, was made impossible. Transfusion requiring bleeding neither occurred during insertion, nor at the following change of the canule. We never had a Stoma-infection which required surgical or pharmacological treatment.

Conclusion

We established the dilatational tracheotomy in a onestep, or a more-step-technique as a standard procedure in our ICU. The small account of complications must not deceive us by the fact that an abundance of complications may occur. We consider the experience in conventional tracheotomy as a salvage procedure in difficult cases and security in emergency re-intubation just like the experience in bronchoscopy as the standard qualification for everyone who starts the tracheotomy-procedure.