Translaryngeal tracheostomy: prospective experience in two Canadian tertiary intensive care units

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Introduction

Bedside percutaneous tracheostomy has supplanted open surgical tracheostomy as the procedure of choice in many Intensive Care Units for patients who require prolonged mechanical ventilatory support. The new translaryngeal tracheostomy (TLT) method described by Fantoni et al. [1] has inherent advantages over other percutaneous techniques. We present our prospective review of 111 cases using this new technique.

Methods

During a 26 month period, a TLT was performed on 111 patients who required an elective tracheostomy in our two ICUs. Under general anesthesia, the TLT was performed at the bedside using the Translaryngeal Tracheostomy kit (Mallinckrodt, Italy). This technique is performed under direct visualization with either a flexible bronchoscope or a rigid 30° endoscope. The tracheostomy tube with its dilator is pulled from within the trachea using a guide wire that is initially placed during direct visualization. After rotating the cut tube into place, bronchoscopic visualization confirms its correct position within the trachea.

Results

All 111 tracheostomies were performed successfully. Mean duration of the procedure was 28 ± 11 min with a mean oxygen saturation of 98 ± 3%; the lowest saturation occurring was 81%. Desaturations occurred in 20 patients; however, they were short lived and caused no harm. Mean blood pressure was 77 ± 26 mmHg. Blood loss was minimal (<5 mls) in all cases. Mean platelet count was 277 × 106 ± 135; range 39-818). Mean INR was 1.2 ± 0.3; range 0.9 - 2.8. Mean PTT was 48 ± 58 s; range 22-554. All patients tolerated the procedure well. Postoperative wound infections did not occur. One patient was noted to have a pneumothorax the day following the procedure while on positive pressure ventilation.

Conclusion

This technique induces minimal trauma due to its `dilation' of tissue as it passes through the anterior wall of the trachea. This new dilatational technique is easy, safe and reliable. Bleeding is minimal, even in patients with coagulopathies due to the tight approximation of the tube to the tissue. Ventilation and protection of the airway is maintained throughout the procedure. It has become our procedure of choice for patients requiring an elective tracheostomy.