Percutaneous dilatational tracheostomy in the ICU: optimal organization, low complication rates, and description of a new complication.
ABSTRACT To assess short-term and long-term complications of bronchoscopy-guided, percutaneous dilatational tracheostomy (PDT) and surgical tracheostomy (ST) and to report a complication of PDT that has not been described previously.
University teaching hospital.
Two hundred eleven critically ill patients in our ICU.
PDT was performed in 174 patients, under bronchoscopic guidance in most cases. ST was performed in 40 patients.
No procedure-related fatalities occurred during PDT or ST. The incidence of significant complications (eg, procedure-related transfusion of fresh-frozen plasma, RBCs, or platelets, malpositioning or kinking of the tracheal cannula, deterioration of respiratory parameters lasting for > 36 h following the procedure, or stomal infection) in patients undergoing PDT was 4.0% overall and 3.0% when bronchoscopic guidance was used. No cases of paratracheal insertion, pneumothorax, pneumomediastinum, tracheal laceration, or clinically significant tracheal stenosis occurred in patients undergoing PDT. We attribute this low rate of complications to procedural and organizational factors such as bronchoscopic guidance, performance by or supervision of all PDTs by physicians with extensive experience in this procedure, and airway management by physicians who were well-versed in (difficult) airway management. In addition, an ear-nose-throat surgeon participated in the procedure in case conversion of the procedure to an ST should become necessary. We observed a complication that, to our knowledge, has not been reported previously. Five patients developed intermittent respiratory difficulties 2 to 21 days (mean, 8 days) after undergoing PDT. The cause turned out to be the periodic obstruction of the tracheal cannula by hematoma and the swelling of the posterior tracheal wall, which had been caused by intermittent pressure and chafing of the cannula on the tracheal wall. In between the episodes of obstruction, the cannula was open and functioning normally, which made the diagnosis difficult to establish.
Bronchoscopy-assisted PDT is a safe and effective procedure when performed by a team of experienced physicians under controlled circumstances. The intermittent obstruction of the cannula caused by swelling and irritation of the posterior tracheal wall should be considered in patients who develop unexplained paroxysmal respiratory problems some time after undergoing PDT or ST.
Article: Percutaneous dilatational tracheostomy with bronchoscopic guidance: Ramathibodi experience.[show abstract] [hide abstract]
ABSTRACT: Tracheostomy is considered as the airway management of choice for patients in the ICU who require prolonged mechanical ventilation or airway protection. Percutaneous dilational tracheostomy (PDT) was first described in 1985 and now is a well-established procedure that can be performed at the bedside by a pulmonologist with less surgical equipment required. A retrospective analysis. Twelve patients underwent PDT because of prolonged endotracheal intubation between March and December 2006. The procedures were done by using bedside percutaneous dilatation tracheostomy with guidewire dilator forceps (GWDF) technique with bronchoscopic guidance under general anesthesia in either the intensive care unit or the intermediate care unit of Department of Medicine, Ramathibodi Hospital. There were seven men and five women with a mean age of 55.0 +/- 11.8 years. Operative mortality was 0%. Procedure related complication was not found Operation time in each case was less than ten minutes. Bronchoscopic examination performed in one of the cases after one month of tracheostomy tube removed showed no scar at the tracheostomy site. PDT with bronchoscopic guidance is a safe and easy procedure that can be done by pulmonologist at the bedside setting.Journal of the Medical Association of Thailand = Chotmaihet thangphaet 09/2007; 90(8):1512-7.
Article: Late complications of tracheostomy.[show abstract] [hide abstract]
ABSTRACT: Tracheostomy may be associated with numerous acute, perioperative complications, some of which continue to be relevant well after the placement of the tracheostomy. A number of clinically important unique late complications have been recognized as well, including the formation of granulation tissue, tracheal stenosis, tracheomalacia, tracheoinnominate-artery fistula, tracheoesophageal fistula, ventilator-associated pneumonia, and aspiration. The clinical relevance of these complications is considerable, as their manifestations range from minimally symptomatic to failure to wean from the ventilator (tracheal stenosis) to life-threatening hemorrhage (tracheoinnominate fistula). Treatment modalities vary depending upon the nature of the complication. For the most frequent complication, tracheal stenosis, a multidisciplinary approach utilizing bronchoscopy, laser, airway stents, and tracheal surgery is most effective.Respiratory care 05/2005; 50(4):542-9. · 2.01 Impact Factor