Tracheostomy in obese patients: the best tube choice issue

Introduction

Obesity is not an absolute contraindication for percutaneous tracheostomy (PDT). Video-endoscopy (video-FBS) and ultrasound (US) facilitate PDT techniques and reduce complications in obese patients (OPs) [1],[2]. OPs may have a higher trachea-skin distance that makes it difficult to place or to manage a tracheostomy tube (TT).

Methods

A retrospective review was performed using data in the last 5 years. All OPs were from the ICU of our university hospital. Only OPs who underwent a PDT were selected with BMI >30 kg/m². All OPs needed prolonged mechanical ventilation. A total of 67 OPs were identified, with 60 PDTs placed using the Ciaglia Blue Rhino (CBR) Introducer Kit and seven PDTs with the UniPerc PDT Kit. All PDTs were performed by dedicated staff including residents. Valuation of clinical anatomical and physio-pathological features of the OPs and US scan of the neck came before the procedure. At the beginning of the procedure we placed a 5 mm ID orotracheal tube by tube exchange with video-FBS assistance, as already described [3]. An 8 to 9 mm ID wire-reinforced silicone tracheostomy tube (rTT) with adjustable flange was chosen instead of a standard PVC or silastic TT (sTT) in all OPs treated with CBR because of the anatomical particularities of OPs and because of external traction by the weight of the tubing attached to the TT. An extralong TT (eTT) was chosen because the pretracheal tissue was too thick for a regular-sized TT in 16 OPs with BMI >40 kg/m² treated with CBR. For three OPs treated with CBR we needed to change rTT to eTT because of tube dislodgement and subocclusion X-ray and video-FBS diagnosis. The UniPerc technique was chosen for OPs with BMI >40 kg/m².

Results

No major complications (aborting procedure, >50 ml bleeding, TT misplacement, death) were observed. We had only minor complications (<50 ml bleeding: 3%; ring fracture: 2%; difficult insertion: 21% only with CBR rTT because of the step between the tip of the rTT and its introducer). UniPerc eTT placement has always been easy.

Conclusion

In our experience, the data do not support what previous studies have shown suggesting increased risk of complication in OPs [1][2]. We know that the sTT could not be effective in OPs. The use of US, video-FBS assistance [3], and rTT with an adjustable flange allows a safe and effective adjustment to anatomical OP particularities, avoiding collected risks.