Ventilatory assistance during translaryngeal percutaneous tracheostomy

Translaryngeal percutaneous tracheostomy (TLT) is a new technique to perform percutaneous tracheostomy.

The main advantage advocated in respect with other methods is the lower incidence of infection of the stoma and the safety of the procedure. The main disadvantage of TLT is the loss of ventilatory support during the manoeuvre of the extraction of the cannula. This can result in severe hypoxia mainly in patients with adult respiratory failure (ARF). To maintain an adequate level of blood oxygenation several methods have been proposed (high frequency ventilation, apneic oxygenation. etc). We describe our experience of TLT in ARF patients providing ventilatory support with a small size (4 mm ID) 40 cm long endotracheal tube.

Patient population

Six patients with ARF of different etiologies had been studied. PaO₂/FiO₂ 144.4 ± 60 (88.7–250.7), mean PEEP 10.4 ± 4.8 (5–16) cmH₂O, mean age 53.5 ± 17 (23–74), intubation time 8.5 ± 4.8 (3–15) days.

Technique

For the procedure the patients were sedated and paralysed, and ventilated with a Siemens Servo 900 C in volume controlled ventilation (VCV). By means of end expiratory and inspiratory occlusions, external PEEP (PEEP ext), intrinsic PEEP (PEEP i), total PEEP (PEEP tot) and plateau pressure P Plat) were measured.

Following tracheal puncture and guidewire extraction, that a performed under direct tracheoscope guidance, the small size tube is advanced distally after tracheoscope removal. Ventilatory parameters are adjusted as follows: TV was kept constant; ventilatory working pressure was increased in order to overcome the resistance of the small ET tube and to maintain the TV; PEEP ext was reduced in order to keep PEEP tot (PEEP ext + PEEP i) constant; P Plat was continuously monitored.

The wire is then connected with the tracheal cannula and pulled through the trachea till it emerges from the skin. Once the tracheal cannula is correctly positioned, the small ET tube is removed.

Blood gases and respiratory parameters were drawn repeatedly during the procedure. The mean duration of the procedure was 51.6 + 26.9 min. Blood gases and ventilatory parameters at the beginning and at the end of the procedure are shown in the Table.

Conclusions

TLT can be performed in severe ARF patients provided that ventilation is supported during the whole procedure. Small calibre long ET can be safely utilized if ventilatory parameters as PEEP i and P Plat are monitored.

Table