Ann Thorac Surg 2004;77:1045-1047
© 2004 The Society of Thoracic Surgeons
Original article: general thoracic
Emergency percutaneous tracheostomy in trauma patients: an early experience
Alon Ben-Nun, MD, PhDa*,
Edward Altman, MDa,
Lael-Anson E. Best, MDa
a Department of General Thoracic Surgery, Rambam Medical Center, Haifa, Israel
Accepted for publication September 8, 2003.
* Address reprint requests to Dr Ben-Nun, Department of General Thoracic Surgery, Rambam Medical Center, Haifa, Israel 31096
e-mail: mangn{at}netmedia.net.il
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Abstract
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BACKGROUND: In recent years, percutaneous tracheostomy (PCT) has become a routine practice in many hospitals. In the early publications, most authors considered adverse conditions such as short or fat neck or obesity as relative contraindications, whereas cervical injury and emergency were regarded as absolute contraindications. More recently, several reports demonstrated the safety and feasibility of PCT in patients with some of the above contraindications. We, like many others, gradually reduced the contraindications and expanded the indications for PCT. In this paper, we report our early experience with emergency PCT in trauma patients.
METHODS: Ten adult patients suffering from multiple injuries after motor vehicle accident (7) or severe head and neck burns (3) required emergency surgical airway control after failure to accomplish orotracheal intubation. A modified Griggs' technique was used by experienced thoracic surgeons. Recorded data included patient demographics, clinical and anatomic conditions, length of procedure, and complications. Short-term follow-up was performed in the hospital by thoracic staff surgeons. Long-term follow-up was carried out in the outpatient clinic.
RESULTS: Six male and 4 female patients underwent emergency PCT. The mean time from skin incision to intubation was 5.5 minutes including the oxygen insufflation period. There was no failure, no procedure-related complication, and no conversion to open technique. Five patients survived and underwent uneventful decannulation. In approximately 1 year of follow-up, there were no clinical symptoms or signs of complications related to the tracheostomy.
CONCLUSIONS: Emergency PCT using a modified Griggs' technique is feasible and safe. In experienced hands, it might be even easier and faster than the open surgical tracheostomy.
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Introduction
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In the last decade, percutaneous tracheostomy (PCT) has become a routine practice in many hospitals. A significant number of articles have been published comparing several techniques of PCT with open surgical tracheostomy [1–10], as well as with one another [11–15]. The majority of comparisons of PCT with open surgical tracheostomy have demonstrated either a lower complications rate associated with PCT [4–7], or no statistical differences between the two [2, 3, 8, 10]. The length of the surgical procedure was frequently shorter for PCT. Most authors considered adverse conditions such as short or fat neck or obesity as relative contraindications to PCT, whereas cervical injury, pediatric age, and emergency were regarded as absolute contraindications. More recently, a smaller number of reports specifically directed at performing PCT in patients with the above contraindications have appeared. Percutaneous tracheostomy was performed safely in obese patients with short or fat neck [16–18] and in patients without cervical spine clearance [19]. In a computerized search of the literature, we could not find articles addressing the feasibility and safety of emergency PCT in trauma patients. Reported herein is our early experience with 10 consecutive cases of emergency PCT in trauma patients.
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Material and methods
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From January 2000 to May 2002, emergency PCT procedures were performed on 10 adult patients suffering multiple blunt head and neck injuries or severe head and neck burns (Table 1). In all cases, the indication for tracheostomy was an emergency need for airway control because of impending airway obstruction. Tracheostomy was performed after failure to accomplish orotracheal intubation by the trauma team anesthesiologist. A small group of qualified thoracic surgeons who had large experience with PCTs (more than 80 previous cases of elective PCTs and an equivalent number of surgical tracheostomies) performed the operations. The Helsinki committee approved the use of this procedure. All PCTs were performed as a bedside operation in the emergency room or the critical care unit using a modification of the Griggs' technique and a Portex set of instruments (SIMS Portex, Hythe-Kent, England). The appropriate monitoring, including electrocardiography, pulse oximetry, and blood pressure, was used in all cases. The procedure was performed as described in the manual accompanying the Portex PCT kit, with some modifications.
All patients were in a supine position on a back-supporting board (blunt trauma patients). The anterior part of the Philadelphia cervical-support device was removed without neck extension (blunt trauma patients). The available anatomic landmarks (thyroid cartilage, cricoid cartilage, tracheal cartilages, and sternal notch) were identified. In 8 patients, it was possible to palpate all of these landmarks. However, in 2 patients only the sternal notch and the thyroid cartilage were clearly identifiable. Gentle rostral traction on the larynx was applied to gain better exposure of the surgical field. The neck was quickly prepared and draped consistent with an emergency procedure. Local anesthesia was used in 5 patients (1% lidocaine solution). Horizontal skin incision was followed by a brief blunt dissection of the pretracheal tissues using a Pean clamp, to form a tract wide enough to accommodate the tip of the surgeon's index finger. Thereafter, puncture of the tracheal wall was performed with a needle cannula in the first or second space between tracheal cartilages. The needle was removed and oxygen flow was applied through the plastic cannula into the trachea for 30 to 60 seconds. The rest of the procedure was completed as described in the manual accompanying the Portex PCT kit. The balloon on the tracheostomy cannula was overinflated (15 mL) for approximately 30 minutes as a preventative tamponade on the luminal surface of the trachea. If the length of the skin incision was greater than the diameter of the tracheostomy cannula, simple cutaneous sutures were placed on either side of the cannula and the tissues approximated until the stoma fitted snugly around the cannula. The thoracic staff surgeons did the in-hospital follow-up until removal of the cannula was accomplished. Long-term follow-up was performed in the outpatient clinic.
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Results
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Six male and 4 female patients with an average age of 28 years (range, 19 to 40 years), underwent emergency PCT from January 2000 to May 2002 (Table 1). Seven patients had multiple blunt injuries, which included maxillofacial fractures, and suspected cervical spine trauma (confirmed later in 2 patients). These patients could not tolerate neck extension during the PCT procedure, and the anterior part of the neck was exposed by gentle rostral traction on the larynx. Three patients had severe head and neck burns combined with smoke inhalation injury. All patients were spontaneously breathing with an average oxygen saturation of 87% (range, 83% to 93%). Five minutes after the completion of PCT the mean oxygen saturation increased to 95% (range, 90% to 100%). Before the procedure was started, 5 patients were in coma (Glasgow Coma Scale 
7) and others were partially conscious (Glasgow Coma Scale 8 to 12). The average Glasgow Coma Scale was 8.7 (range, 6 to 12). The percutaneous operation was completed in all patients without conversion to the open technique. The mean time from skin incision to intubation was 5.5 minutes (Table 2). There were no procedure-related complications. During the early (in-hospital) follow-up, 5 patients died of causes unrelated to the PCT, and 3 underwent uneventful cannula removal. Two patients were cannula removal a few months later in a rehabilitation hospital without complications. During the first year of follow-up, 1 patient underwent fiberoptic bronchoscopy because of recurrent minor hemoptysis. Three patients required computed tomographic scan of the neck as part of their orthopedic and maxillofacial follow-up. No tracheostomyrelated complications were diagnosed.
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Comment
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The technique of PCT is widely used throughout the world. Many series reports were devoted to assessing PCT with regard to safety of the procedure, length of operation, and incidence of complications. Most authors concluded that PCT has several advantages over the traditional form of surgical tracheostomy. A number of clinical and anatomic conditions such as short or fat neck, inability to extend the neck, an enlarged thyroid, previous neck surgery, and coagulopathy were considered as relative contraindications [1, 2, 4, 7, 11, 20, 21]. Emergency or pediatric cases were referred to as absolute contraindications by most authors. Recently, more than a few studies reported the safety and feasibility of PCT in situations regarded as relative contraindications [16–19]. Mayberry and coauthors [19] reported their successful experience with PCT in trauma patients without cervical spine clearance, and Urwin and associates [17] demonstrated good results with PCT in obese patients. Two case report publications described successful, lifesaving, emergency PCT in hospitalized patients with acute airway problems [22, 23]. However, there are no studies referring to the safety and feasibility of PCT in trauma patients. We, like many others, gradually reduced the relative contraindications and expanded the indications for PCT. In recent years, few hospitalized patients have required emergency tracheostomy in our institution. With our large experience in PCT, we preferred using this technique to the conventional open procedure. Percutaneous tracheostomy was performed in a patient with bilateral vocal cord paralysis after thyroid operation and in a number of patients with failure to achieve orotracheal intubation. All cases were successfully performed using the modified Griggs' guidewire dilating forceps technique of PCT as described above.
In this paper, we report our small, but positive, experience with PCT in trauma patients. In all cases, the indication for tracheostomy was impending airway obstruction and failure to achieve orotracheal intubation. All patients were still breathing spontaneously (although desaturated and severely dyspneic), and thus PCT was preferred over cricothyrotomy, which is not regarded as a definitive airway.
We found that in experienced hands PCT in trauma patients is feasible and safe. Actually, in the emergency room setting PCT is even easier when compared with open tracheostomy. The oxygen insufflation using the plastic cannula supports temporarily the patient's oxygenation. The procedure is completed within only few minutes and involves the use of minimal equipment. There were no complications in the short-term or the long-term follow-up.
Based on these results we suggest that emergency cases should not be considered anymore as an absolute contraindication for PCT. We do think, however, that experienced surgeons familiar with the technique and beyond their learning curve should perform these emergency procedures.
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References
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- Hazard P., Jones C., Benitone J. Comparative clinical trial of standard operative tracheostomy with percutaneous tracheostomy. Crit Care Med 1991;19:1018-1024.[Medline]
- Khalili T.M., Koss W., Margulies D.R., Morrison E., Shabot M.M. Percutaneous dilatational tracheostomy is as safe as open tracheostomy. Am Surg 2002;68:92-94.[Medline]
- Graham J.S., Mulloy R.H., Sutherland F.R., Rose S. Percutaneous versus open tracheostomy: a retrospective cohort outcome study. J Trauma 1996;42:245-250.
- Friedman Y., Fildes J., Mizock B., et al. Comparison of percutaneous and surgical tracheostomies. Chest 1996;110:480-485.[Abstract/Free Full Text]
- McHenry C.R., Raeburn C.D., Lange R.L., Priebe P.P. Percutaneous tracheostomy: a cost-effective alternative to standard open tracheostomy. Am Surg 1997;63:646-652.[Medline]
- Stoeckli S.J., Breitbach T., Schmid S. A clinical and histologic comparison of percutaneous dilational versus conventional surgical tracheostomy. Laryngoscope 1997;107:1643-1646.[Medline]
- Holdgaard H.O., Pedersen J., Jensen R.H., et al. Percutaneous dilatational tracheostomy versus conventional surgical tracheostomy—a clinical randomised study. Acta Anaesthesiol Scand 1998;42:545-550.[Medline]
- Gysin C., Dulguerov P., Guyot J.P., et al. Percutaneous versus surgical tracheostomy—a double-blind randomized trial. Ann Surg 1999;230:708-714.[Medline]
- Porter J.M., Ivatury R.R. Preferred route of tracheostomy—percutaneous versus open at the bedside: a randomized, prospective study in the surgical intensive care unit. Am Surg 1999;65:142-146.[Medline]
- Westphal K., Byhahn C., Rinne T., Wilke H.J., Wimmer-Greinecker G., Lischke V. Tracheostomy in cardiosurgical patients: surgical tracheostomy versus Ciaglia and Fantoni methods. Ann Thorac Surg 1999;68:486-492.[Abstract/Free Full Text]
- Ambesh S.P., Pandey C.K., Serivastava S., Agarwel A., Sinh D.K. Percutaneous tracheostomy with single dilatation technique: a prospective randomized comparison of Ciaglia blue rhino versus Griggs' guidewire dilating forceps. Anesth Analg 2002;95:1739-1745.[Abstract/Free Full Text]
- McLure H.A., Dob D.P., Mannan M.M., Soni N. A laboratory comparison of two techniques of emergency percutaneous tracheostomy. Anaesthesia 1997;52:1199-1201.[Medline]
- Powell D.M., Price P.D., Forrest L.A. Review of percutaneous tracheostomy. Laryngoscope 1998;108:170-177.[Medline]
- Ambesh S.P., Kaushil S. Percutaneous dilational tracheostomy: the Ciaglia method versus the Rapitrach method. Anesth Analg 1998;87:556-561.[Abstract/Free Full Text]
- Westphal K., Byhahn C., Wilke H.J., Lischke V. Percutaneous tracheostomy: a clinical comparison of dilatational (Ciaglia) and translaryngeal (Fantoni) techniques. Anesth Analg 1999;89:938-943.[Abstract/Free Full Text]
- Mansharamani N.G., Kaziel H., Garland R., et al. A. Safety of bedside dilatational tracheostomy in obese patients in the ICU. Chest 2000;117:1426-1429.[Abstract/Free Full Text]
- Urwin S., Short S., Hunt P. Percutaneous dilational tracheostomy in the morbidly obese. Anaesthesia 2000;55:393-394.[Medline]
- Scott M.J.P., Leigh J. Percutaneous tracheostomy in three morbidly obese patients using the ‘Blue Rhino’ technique. Anaesthesia 2000;55:917-919.
- Mayberry J.C., Wu I.C., Goldman R., Chestnut M. Cervical spine clearance and neck extension during percutaneous tracheostomy in trauma patients. Crit Care Med 2000;28:3436-3440.[Medline]
- Escarment J., Suppini A., Sallaberry M., et al. Percutaneous tracheostomy by forceps dilation: report of 162 cases. Anaesthesia 2000;55:125-130.[Medline]
- Van Heurn L.W.E., van Geffen G.J., Brink P.R.G. Clinical experience with percutaneous dilatational tracheostomy: report of 150 cases. Eur J Surg 1996;162:531-535.[Medline]
- Dob D.P., Mclure H.A., Soni N. Failed intubation and emergency percutaneous tracheostomy. Anaesthesia 1998;53:72-74.[Medline]
- Basaranoglu G., Erden V. Failed intubation due to posterior fossa haematoma requiring emergency percutaneous tracheostomy. Br J Anaesth 2002;88:310-311.
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Abstract
Introduction
