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Ann Thorac Surg 1995;59:707-709
© 1995 The Society of Thoracic Surgeons

Percutaneous Subcricoid Minitracheostomy: Report of 50 Procedures

Surgical Department, De Wever Hospital, Heerlen, the Netherlands

Accepted for publication November 28, 1994.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
A minitracheostomy is a small cannula in the trachea that allows permanent access to the tracheal lumen and that is used for the evacuation of bronchial secretions. It generally is performed through the cricothyroid membrane. We used a Seldinger technique in 50 patients to insert a minitracheostomy cannula in the subcricoid position. This technique proved to be easy to perform in translaryngeally intubated patients, both under local anesthesia and under general anesthesia. Operative complications occurred in 5 patients (10%), all of which were minor. The pros and cons of a minitracheostomy in the subcricoid position are discussed.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
A minitracheostomy is a small cannula that has been placed in the trachea and that enables the frequent and efficient suction of bronchial secretions. It prevents sputum retention and has been shown to be an effective measure in patients with severe pulmonary disorders, in patients with neurologic deficits, and in patients who have undergone major surgical procedures [1–4].

Minitracheostomy was reported on for the first time by Matthews and Hopkinson in 1984 [1]. In their procedure, the cannula was introduced into the trachea through a small incision in the cricothyroid membrane using a guarded knife and an introducer. Later, other authors advocated a Seldinger dilation technique to facilitate performance of the procedure. This involved passing a needle through the cricothyroid membrane and then, after insertion of a guidewire, placement of the cannula with the help of a dilatator [5].

Because we were not completely satisfied with the position of the cannula through the cricothyroid membrane and because of our excellent experience with full-sized percutaneous tracheostomy, we started to use a percutaneous minitracheostomy in the subcricoid position. We describe here our experience in the first 50 patients who underwent this procedure at our institution.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Between July 1990 and July 1993, 50 elective percutaneous minitracheostomies were carried out. These patients consisted of 36 men and 14 women with a mean age of 63 years (range, 22 to 88 years). The underlying reasons necessitating minitracheostomy are as follows: thoracic and upper abdominal operations, 33 patients; neurologic disease, 7 patients; thoracic trauma, 6 patients; chronic bronchitis, 2 patients; and upper airway obstruction, 2 patients. Thirty-one of the patients had previously required endotracheal intubation for mechanical ventilation for a median time of 18 days. They were too weak to clear their superfluous bronchial secretions and, before extubation, a minitracheostomy cannula was inserted next to the translaryngeal tube. Thirteen patients received their cannula at the end of a surgical procedure because they had had difficulty coughing up bronchial secretions even before the operation. In 6 patients, the cannula was placed because they could not clear sputum, and this resulted in progressive pulmonary distress.

Minitracheostomy was carried out by four senior surgeons and four surgical trainees. Surgical trainees performed their first procedures under close supervision of the one surgeon who was most experienced with the procedure. If the procedure was carried out in an endotracheally intubated patient, the anesthesiologist was responsible for withdrawing the endotracheal tube and monitoring the patient's oxygen saturation and blood pressure.

The technique we use is similar to the percutaneous dilational tracheostomy technique [6, 7]. The patient is placed supine with his or her neck hyperextended. The cricoid cartilage is palpated, and, after local infiltration of 2% lidocaine hydrochloride, a small vertical skin incision is made. In the endotracheally intubated patient, the tube is withdrawn so that the tip is just below the vocal cord. The tracheal lumen is then punctured below the first tracheal ring with a (cannulated) needle attached to a syringe. The intratracheal position of the needle is confirmed by the aspiration of air into the syringe. A guidewire is placed inside the trachea. The minitracheostomy cannula with an inside diameter of 4 mm, loaded over the dilator, is then passed over the guidewire and into the tracheal lumen using firm pressure.

Three types of commercially available kits have been used during the study period. From July 1990, a Cook minitracheostomy kit (No. C-CMTS-100; Cook, Son, the Netherlands) was used. Because of reported complications with this type of cannula, the set was not available from September 1991 to June 1993, and we switched to using the Minitrach II-Seldinger kit (Portex; Resprecare, the Hague, the Netherlands). Since June 1993, we have used the Cook minitracheostomy kit (No. C-TCCS-400-TT) containing a disposable scalpel, an 18-gauge cannulated needle, a J-tipped guidewire, a 12F dilator, and a reclosable flanged minitracheostomy cannula.

To facilitate introduction of the cannula, we currently use a second larger dilatator that has been added to the set. Especially in young male patients, the force needed to insert the cannula is reduced substantially by this additional dilational step.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
The procedure was accomplished successfully in 48 patients. In 2 patients (4%), the cannula was not inserted into the tracheal lumen but pretracheally in 1 and through the tracheal lumen into the paratracheal space in the other. Both times the procedure was carried out by a senior surgeon inexperienced with either percutaneous tracheostomy or percutaneous minitracheostomy. Both cannulas were removed and a new cannula was inserted without problems or sequelae.

Minor complications occurred in 3 patients (6%); and consisted of minor skin edge bleeding in 1 and subcutaneous emphysema in 2. The bleeding was controlled by suture ligation, and the subcutaneous emphysema was minor and required no therapy. Secondary displacement of the cannula occurred in the first 4 endotracheally intubated patients. In all the cannula had been inserted next to the endotracheal tube at the end of their operation. When the tube was removed, the minitracheostomy cannula came out as well. Later this complication was simply avoided by holding the minitracheostomy cannula in place during extubation.

The mean duration of minitracheostomy was 11 days (range, 1 to 50 days). Thirty-six patients were decannulated successfully, 1 of whom died in the hospital of congestive cardiac failure. In 7 patients, the minitracheostomy was converted to a larger tracheostomy cannula using the percutaneous dilational technique. In 2, bronchial secretions proved to be too viscid to be aspirated through a cannula with a 4-mm lumen, and a cannula with an inside diameter of 7 mm was inserted. Mechanical ventilatory support was required in 5, who suffered respiratory failure despite their minitracheostomy, and their cannula was converted to one with an inside diameter of 8.5 mm. Seven patients died during the time the minitracheostomy cannula was in place. They were judged to be unsuitable candidates for ventilation, in 2 because of a disseminated malignancy and in 5 because of old age and severe chronic obstructive pulmonary disease. Of the 50 patients receiving a minitracheostomy, 11 died in the hospital. Their cause of death was never tracheostomy related, but was due to respiratory insufficiency in 5, sepsis in 4, pulmonary embolus in 1, and congestive heart failure in 1. Two of the patients with sepsis and the 1 with pulmonary embolus were mechanically ventilated after conversion to a full-sized tracheostomy cannula.

Decannulation was easy in all patients. Their wounds healed nicely without signs of infection within 3 days of decannulation with only minimal scarring.

Outpatient follow-up was complete. No late complications were seen 1 to 4 years after the procedure. In particular, no clinical signs of tracheal stenosis or voice changes were found.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Minitracheostomy gives permanent access to the trachea and makes frequent aspiration of bronchial secretions possible. It is considered superior to both translaryngeal intubation and full-sized tracheostomy. Translaryngeal intubation is uncomfortable for the patient, often requires sedation, and makes eating, speaking, and coughing impossible [1]. The mortality and the complication rates associated with tracheostomy are relatively high; the complication rate varies from 6% to 51%, although it may decrease substantially to rates of 3% to 25% if the percutaneous technique is used [8–10]. A normal-sized tracheostomy cannula with an outside diameter of 12 or 13 mm abolishes the ability to eat and to generate a normal explosive cough. A minitracheostomy is much smaller and is the better choice if the patient is not able to evacuate his or her own superfluous bronchial secretions. The best position for the minitracheostomy cannula may be questionable.

The minitracheostomy cannula is commonly inserted through the cricothyroid membrane [1, 4, 5, 11, 12]. Minicricothyroidostomy would be a more accurate name for a cannula in this position, however [12]. Minitracheostomy in the subcricoid position has several advantages over a cannula placed through the cricothyroid membrane. First, the procedure can be performed percutaneously in the endotracheally intubated patient. The oral tube is then withdrawn between the vocal cords. After the minitracheostomy cannula has been inserted, the endotracheal tube can be placed in its former position. If a minicricothyroidostomy is performed in the intubated patient, the cannula has to be introduced between the tube and the cricothyroid membrane using an open procedure, and this carries a higher risk of misplacement of the cannula [13]. Second, many clinicians are reluctant to use a cannula placed through the cricothyroid membrane because of the risk of subglottic stenosis and voice changes. In some reports, this risk in adults is described as being only minimal if a small-bore minitracheostomy cannula is used for a short time [11, 14]. However, it remains a devastating complication, and its incidence is increased in the setting of predisposing conditions such as an injured larynx caused by prolonged intubation [15]. Third, it is possible to convert a minitracheostomy to a larger subcricoid cannula if bronchial secretions prove to be too viscid to be aspirated through a small minitracheostomy cannula or if a patient with progressive respiratory failure has to be ventilated. In this event, a guidewire is passed through the minitracheostomy and the cannula is removed. After a few dilational steps, a cannula with an inside diameter of 8 mm or more is then easily introduced into the trachea. In our series, conversion to a full-sized tracheostomy was carried out in 7 patients (14%). Fourth, the upper airways are wider below the cricoid cartilage than they are at the level of the larynx and the false vocal cords. Cannulas with an inside diameter of 4 mm and larger can be used in the subcricoid position with little obstruction of the trachea and good preservation of normal glottic function. They only minimally interfere with speaking and eating.

Access to the trachea below the cricoid cartilage appears to be more difficult than that through the cricothyroid membrane. As a result, there may be more operative complications in association with the subcricoid procedure. However, the complication rate of minicricothyroidostomy is comparable with or even higher than our operative complication rate of 10% [3, 16, 17]. Twice the cannula was misplaced during introduction. Both times the procedure was carried out by a senior surgeon who was not experienced with percutaneous dilational tracheostomy, and who was performing a minitracheostomy for the first time. To prevent malplacement of the cannula, one should take care to confirm that air can be aspirated into the syringe after the tracheal lumen is punctured. After removal of the needle and before insertion of the guidewire, the intraluminal position of the introducer catheter must be checked again. The minitracheostomy cannula has to be introduced more or less upward. In a patient with a hyperextended neck, the distal trachea runs slightly toward the back. If forced downward, the cannula may slide off on the anterior aspect of the trachea as the guidewire is kinked, resulting in pretracheal insertion of the cannula [18].

The most common complications of percutaneous dilational tracheostomy also include hemorrhage and subcutaneous emphysema. In reports on this technique, the incidence of these usually minor complications is low [9, 10]. Secondary displacement of the cannula occurred in the first 4 endotracheally intubated patients who underwent this procedure. As mentioned earlier, it was simply avoided by holding the cannula in place during extubation, and never occurred again.

We do not believe that percutaneous subcricoid minitracheostomy carries a higher complication rate than the technically more difficult percutaneous dilational tracheostomy, and our results confirm this. However, to compare percutaneous subcricoid minitracheostomy with percutaneous minicricothyroidostomy a prospective randomized trial is necessary.

In conclusion, we found that percutaneous subcricoid minitracheostomy is an easy procedure to perform and is associated with a low complication rate. Because of the advantages of the subcricoid position, we prefer percutaneous subcricoid minitracheostomy in patients who require frequent suctioning of bronchial secretions.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Address reprint requests to Dr van Heurn, Surgical Department, De Wever Hospital, Postbox 4446, 6401 CX Heerlen, the Netherlands.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 

1. Matthews HR, Hopkinson RB. Treatment of sputum retention by minitracheotomy. Br J Surg 1984;71:147–50.[Medline]
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12. Au J, Walker WS, Inglis D, Cameron EWJ. Percutaneous cricothyroidostomy (minitracheostomy) for bronchial toilet: results of therapeutic and prophylactic use. Ann Thorac Surg 1989;48:850–2.[Abstract]
13. Mastboom WJB, Wobbes T, van den Dries A, Goris RJA. Bronchial suction by minitracheotomy as an effective measure against sputum retention. Surg Gynecol Obstet 1991;173:187–92.[Medline]
14. Campbell JB, Watson MG, Povey L, Shenoi PM. Minitracheotomy and laryngeal function. A prospective study. J Laryngol Otol 1988;102:49–52.[Medline]
15. Brantigan CO, Grow JB. Subglottic stenosis after cricothyroidotomy. Surgery 1982;91:217–21.[Medline]
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