Percutaneous multidilatational tracheostomy endoscopic guided: a simple and safe bedside procedure done by intensivists

Purpose

Tracheotomy (Trach) is one of the most frequently performed operations in critically ill patients, and percutaneous dilatational tracheotomy (PDT) has become increasingly popular as an alternative to formal surgical Trach. This study was designed to examine prospectively the incidence of perioperative and early complications associated with elective PDT in critically ill adults, and to assess the feasibility and advantage of widespread application of flexible fiberoptic bronchoscope (FFB) in this setting.

Method

Over a 6-month period 48 consecutive patients requiring mechanical ventilation underwent bedside endoscopic guided PDT. Ciaglia's technique was performed by intensivists, in majority not familiar with PDT. Bronchoscope guide was performed to provide the following: a good identification of venous circulation on the site of needle puncture by transillumination; appropriate middle-trach placement of dilators and Trach tube; and security to help prevent injury of the posterior tracheal mucosa (PTM) supposed in risk by the procedure and to clean the upper airway with aspiration.

Results

A correct median puncture was observed by FFB in 21 interventions (43.7%). An initial paramedian puncture was detected in 27/48 (56.2%) and was corrected by renewed insertion in all cases. There was no procedure-related death or PTM injury. Procedure-related complications included haemodinamic instability in 4/48 (8.3%); stoma hemorrhage requiring blood transfusion in 1/48 (2%); stoma infection in 3/48 (6.2%); and moderate internal stomal bleeding without external oozing 17 p and 7 p with concomitant external visualization (Χ²P = 0.009).

Conclusion

FFB guidance increases the safety of this procedure, better identification of bleeding complications and may help prevents paratracheal false passage and pneumothorax reported in the literature with blinded PDT.

Clinical implications

(1) Curved dilators ensure that PTM perforation does not occur. (2) The stiffness of the guiding catheter-guidewire assembly, the depth of dilator insertion and gentle movement with dilators having an oily smoothness prevents PTM damage. (3) All endotracheal tubes (ET) were withdrawn guided by FFB until they were just below the vocal cords. This approach warranted good oxygenation during the procedure. (4) FFB confirmed median needle insertion and was able to correct guidewire placement, so avoiding paratracheal insertion of the canula. (5) The FFB would enable inexperienced operators to perform PDT safely and cost-effectively.