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Ann Thorac Surg 1999;68:486-492
© 1999 The Society of Thoracic Surgeons

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Original Articles

Tracheostomy in cardiosurgical patients: surgical tracheostomy versus Ciaglia and Fantoni methods

^a Department of Anesthesiology, Intensive Care and Pain Therapy, J.W. Goethe-University Hospital, Frankfurt, Germany
^b Department of Thoracic and Cardiovascular Surgery, J.W. Goethe-University Hospital, Frankfurt, Germany

Address reprint requests to Dr Westphal, Department of Anesthesiology, J.W. Goethe-University Hospital, D-60590 Frankfurt, Germany
e-mail: byhahn{at}stud.uni-frankfurt.de

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Patients requiring prolonged mechanical ventilation are not uncommon in a cardiosurgical intensive care unit. Elective tracheostomy is considered the airway treatment of choice in these patients.

Methods. To evaluate different techniques for tracheostomy, we prospectively investigated 120 patients who had conventional open (n = 40), minimally invasive percutaneous dilatational (n = 40), or translaryngeal (n = 40) tracheostomy techniques. The main areas of investigation included oxygenation index (partial pressure of arterial oxygen divided by fraction of inspired oxygen), complications, infection, and cost.

Results. The oxygenation index decreased in almost every patient, regardless of the technique used, but the extent of decrease was significantly lower in both minimally invasive techniques compared with the conventional method. Overall complication rate was 12.5% both in open tracheostomy and in percutaneous dilatational tracheostomy, whereas no complications occurred in translaryngeal tracheostomy procedures. Bacterial contamination of the tracheostomy site was found in 35% of the open tracheostomies, whereas no infection was seen in percutaneous dilatational or translaryngeal tracheostomies. In terms of costs, PDT ($506) and TLT ($362) were both much cheaper than open tracheostomy ($699).

Conclusions. Percutaneous dilatational and translaryngeal tracheostomies are safe and cost-effective procedures that can be done easily at the patient’s bedside and thus are attractive alternatives to conventional surgical tracheostomy in long-term airway access in a cardiosurgical intensive care unit.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Patients who require prolonged mechanical ventilation are susceptible to many complications [1–3]. Common complications of long-term ventilation through endotracheal tubes are airway infection, ulcers, and prolonged weaning from the respirator [1, 4]. Therefore, early elective tracheostomy is recommended to avoid the typical disadvantages of long-term endotracheal intubation [1]. Because there are a number of disadvantages and serious complications [6] for standard open tracheostomy performed with Jackson’s technique [5], a simpler, safer, and more cost-effective procedure for tracheostomy was needed. Percutaneous dilatational tracheostomy, as described by Ciaglia and colleagues in 1985 [7], is considered an appropriate procedure that can be done at the patient’s bedside. In addition, the translaryngeal technique of Fantoni and Ripamonte [8] is another method for minimally invasive tracheostomy associated with a low rate of complications.

Frequently reported complications of all techniques of tracheostomy performed in critically ill patients are oxygen desaturation, bleeding, aspiration, and infection [2, 9–14]. The primary aim of the present study was to evaluate the effects of conventional, open (OT), percutaneous dilatational (PDT), and translaryngeal (TLT) tracheostomy techniques on the oxygenation index in patients in the cardiosurgical intensive care unit (ICU). Incidence of postoperative bleeding, aspiration, and infection of the tracheostoma were additional parameters investigated. Finally, we compared the costs of the conventional open and minimally invasive techniques.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Between January 1996 and July 1998, 2,909 patients were admitted to our cardiosurgical ICU, of whom 120 (4.13%) required elective tracheostomy because of the necessity of long-term mechanical ventilation. Tracheostomy was performed conventionally (n = 40) or according to the technique of Ciaglia and colleagues (n = 40) or Fantoni and Ripamonte (n = 40). The leading diagnoses for admission of these patients are shown in Table 1. Consecutive muscular insufficiency, adult respiratory distress syndrome, sepsis, pneumonia, low cardiac output, and neurologic complications, such as stroke or intracerebral hemorrhage, were the most common indications for long-term mechanical ventilation (Table 1).

Microbiological samples were taken from the wound edges every time the tracheostomy tube was replaced. Macroscopically visible signs of infection, such as rubor or induration, were considered conclusive evidence of infection of the tracheostoma. In addition, growth of pathogenic bacteria or fungus from the samples was likewise considered proof of infection. Growth of apathogenic bacteria from the skin was considered benign when there were no macroscopic signs of infection and when laboratory markers (white blood cell count, c-reactive protein, procalcitonine) did not provide evidence of infection.

Open tracheostomy
Regardless of the technique used, the patient’s neck was positioned in slight extension and the surgical area was cleaned and prepared. For OT, a transverse incision between 3 and 4 cm, depending on the features of the neck, was made. All muscles were split in the midline until the trachea was identified. Thyroid tissue was removed as required. A tracheostomy according to Jackson’s technique [5] was made between the second or third tracheal ring. The endotracheal tube was withdrawn as the tracheostomy tube was inserted. After cannulation of the trachea, the position of the tube was secured with an umbilical tape around the neck attached to the base plate of the tube, which was 10 (n = 11) or 11 mm (n = 29) in diameter.

Percutaneous dilatational tracheostomy
In PDT, the Ciaglia Percutaneous Tracheostomy Introducer Set (Cook, Bjaeverskov, Denmark) was used. First, the endotracheal tube in place was pulled back under bronchoscopic control so that the tracheal lumen could be punctured without problems. When the lumen was identified clearly, the trachea was punctured between the second and third tracheal ring, using a 14-G Teflon cannula. Correct position of the cannula in the middle of the trachea was confirmed bronchoscopically. A guide wire was then introduced through the cannula and armed with a thin, synthetic catheter. Thereafter, a 2-cm transverse skin incision was made, and once the trachea could be identified, it was dilated to 36 F, using Seldinger’s technique. The tracheostomy tube was then inserted into the trachea over a smaller dilator. The tubes used were 9.0 mm (n = 13) and 10.0 mm (n = 27) Rueschelit Ultra (Ruesch, Germany).

Translaryngeal tracheostomy
All TLT maneuvers took place under bronchoscopic visualization, and the Translaryngeal Tracheostomy Kit (Mallinckrodt, Mirandola, Italy) was used. First, the endotracheal tube was pulled back to gain access to the trachea. Then, a slightly curved cannula was introduced into the lumen between the second and third tracheal rings, followed by introduction of a special guide wire. The guide wire was advanced retrograde parallel to the tube (Fig 1). When the wire was seen in the pharynx, it was caught with a Magill forceps, pulled out of the patient’s mouth, and connected to the tracheal cannula. The endotracheal tube in place was removed and replaced with a thin endotracheal tube (Fig 2). The tracheal cannula was passed over the guide wire and advanced beyond the pharynx and larynx into the trachea. By rotating the wire’s distal end, the cannula’s tip penetrated the anterior tracheal wall, muscular structures, and skin (Fig 3). It was then cut at a predetermined length and turned 180 degrees by means of an obturator (Fig 4). The thin replacement tube was removed, the cannula’s cuff inflated, and the cannula connected to the respirator (Fig 5). The tube size used in TLT was 9.5 mm in all patients. Correct position of the tracheostomy tube was confirmed in both PDT and TLT by bronchoscopy and auscultation of the lungs.

View larger version (24K): [in this window] [in a new window]   Fig 1. After bronchoscopically guided puncture of the trachea, the guide wire is introduced and advanced retrograde parallel to the endotracheal tube.

View larger version (19K): [in this window] [in a new window]   Fig 2. When the endotracheal tube is in place, (a) was replaced under direct laryngoscopy with the thin tube of the set (b), the tracheostomy tube is connected to the guide wire and, (c), by pulling the wire’s distal end, is advanced to the trachea.

View larger version (20K): [in this window] [in a new window]   Fig 3. By pulling the wire and by using digital counterpressure, the tracheostomy tube is advanced through the anterior tracheal wall and the soft tissues of the neck.

View larger version (19K): [in this window] [in a new window]   Fig 4. Correct placement of the tracheostomy tube is achieved with 180° rotation by means of an obturator. Intratracheal rotation of the tracheal cannula can be done either with the thin endotracheal tube in place or after removal.

View larger version (13K): [in this window] [in a new window]   Fig 5. The cuff is inflated, and the tube is connected to the respirator.

Statistical analysis
Once the homogeneity of the data was confirmed, the Wilcoxon-Mann-Whitney test was used to compare the data in terms of mean and standard deviation, whereas Fisher’s exact test was used to compare contingencies. All statistical calculations were performed with GraphPad InStat Version 3.00 (GraphPad Software, Inc, San Diego, CA). Statistical significance was confirmed with a p value less than 0.05.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
A total of 120 patients on long-term ventilation in our cardiosurgical ICU received elective tracheostomy during a 31-month period. Tracheostomy was done in 40 patients by OT and in 40 patients each by the minimally invasive PDT and TLT techniques. Open tracheostomy was performed in the operating room, PDT, and TLT at the patient’s bedside. Mean age of the patients who had tracheostomy, coagulation factors, and time intervals between endotracheal intubation and tracheostomy are shown in Table 2.

With regard to complications of the procedure of tracheostomy itself, we saw minor complications from aspiration of blood-stained saliva in 4 of the OT patients. Another patient who had OT needed surgical revision of the tracheostomy site to ligate a bleeding vessel. Minor complications occurred in 4 patients who received PDT. In 3 of these patients, bronchoscopic revision after tracheostomy showed mild aspiration of saliva mixed with traces of blood, which was suctioned off by the bronchoscope. In another PDT patient, severe oxygen desaturation occurred because of severe aspiration, but there were no adverse sequelae because of its short duration. In another patient, the skin incision made for PDT was too large, and bleeding required surgical intervention to adapt the wound edges. In patients who received TLT, there were no complications that required further intervention. Accidental traumatization of the posterior tracheal wall or neighboring structures never occurred, regardless of the tracheostomy technique.

In 13 (32.5%) patients who had TLT, initial problems occurred in advancing the guide wire retrograde toward the pharynx. In most of these cases, it took several trials to place the guide wire’s intratracheal end in the correct position. When the wire was pulled and rotated simultaneously, it tore in 1 patient. In a patient who was scheduled for TLT, a subcutaneous artery ran diagonally across the tracheostomy site, so TLT or PDT were considered high-risk maneuvers. We did an OT to identify the vessel clearly. In another patient with a short neck and a goiter who had already initially been intubated bronchoscopically, the guide wire did not reach the oropharynx and could not be caught elsewhere in the patient’s airways with Magill forceps because glottis, vocal cords and trachea could not be visualized by direct laryngoscopy. We had to switch from TLT to PDT, which was done without complication.

Exchange of the tracheostomy tube was done in 20 (50%) of the PDT and 24 (60%) of the TLT patients. Except for 1 patient, there were no complications during the procedure. In that patient, accidental tube dislocation required an emergency tube exchange 2 days after PDT. A mediastinal emphysema occurred, which we attribute to the prolonged and difficult procedure. On the average, tube removal was performed 11 days (range, 2 to 14 days) after PDT and 11 days (range, 9 to 14 days) after TLT. In OT, the initial tube was routinely replaced after 1 day by a low-pressure cuff tube without any complications. Because of a very small incision in the anterior tracheal wall in two cases, difficulties occurred during reinsertion of the tube, which required changing to an 8-mm tube.

Overall survival rates were 50% for OT, 65% for PDT, and 45% for TLT and showed no statistical significance among the different techniques (Fisher’s exact test). Regardless of the technique used for tracheostomy, no deaths could be attributed to the procedure itself. Neither stridor nor tracheal stenosis developed in any of the patients discharged from our hospital after decannulation (n = 56 in total) within the next 6 months. Even in a patient who required PDT twice during his hospital stay, no impairment of the tracheal lumen was seen under bronchoscopic control 6 months after final decannulation.

Compared with OT, the total costs for PDT and TLT were much lower because costs for transportation and operating room rental were eliminated. The difference in cost for PDT versus TLT results from the different equipment charges, because personnel fees and anesthesia charges are identical (Table 4).

	Comment

Top Abstract Introduction Material and methods Results Comment References

The oxygenation index represents a suitable means of evaluating arterial oxygen tension in relation to the fraction of inspired oxygen. With all three tracheostomy procedures, there was an initial decrease in oxygenation index; however, the decrease was significantly less with the minimally invasive techniques. We believe this is because of the significantly longer duration of conventional tracheostomy and its relatively high degree of invasiveness accompanied by significant compromise of the airway during manipulation. These aspects seem to outweigh the advantages of the larger tracheostomy tube size used in OT.

In patients with respiratory insufficiency (eg, adult respiratory distress syndrome, sepsis), a prolonged and severe decrease of the oxygenation index increases the risk of tissue hypoxia. Likewise, even mild hypoxia can highly impair cardiac function in cardiosurgical patients who have coronary insufficiency or valve malfunction. Therefore, a minimally invasive tracheostomy technique should be chosen for those patients. Nevertheless, these techniques should be not be used in patients with an inspired oxygen concentration greater than 0.8 or a baseline oxygenation index less than 100 to avoid hypoxia and associated morbidity during the procedure.

An exchange of the tracheal cannula is not a problem after OT once the tracheostomy has healed; however, when minimally invasive techniques were used, exchange of cannulas was initially more difficult. After OT, the original cannula was exchanged routinely for a low-pressure cuff on the first postoperative day. With minimally invasive techniques the original cannula should be left in place for at least 12 days [16]. Mediastinal emphysema developed after an emergency tracheal cannula exchange on the second day after a PDT. The exchange had been difficult. Fortunately, the emphysema resolved without sequelae. We therefore believe that it is important to first reintubate the patient translaryngeally when a tracheal cannula exchange is necessary within the first few days after a percutaneous tracheostomy. Airway control should always be established first, only then should cannula exchange with a dilator be attempted [16].

Any tracheostomy poses the problem of wound contamination by bacteria. According to the literature, the incidence of bacterial wound contamination is lower with minimally invasive techniques than with the conventional method [13, 14]. In OT, incidence of wound contamination has been as high as 36% [2]. In the present study we noted a 35% incidence of wound contamination after OT, although all procedures had been done in the operating room under strictly aseptic conditions. The spectrum of bacteria found within the wound was almost identical to that found on tracheal and bronchial probes of the same patient. We conclude that OT results in a contamination of the wound with the patient’s own tracheal and bronchial bacteria. Patients who had minimally invasive tracheostomy also were checked routinely for bacterial colonization. However, there was not a single case of wound infection or irritation of the wound tissue. In some cases, we found unsuspected colonization with bacteria from the skin (mostly Staphylococcus epidermidis), but no antibiotic treatment was required.

According to the recent literature, minimally invasive tracheostomy procedures can be associated with a high rate of complications, some fatal [9–13]. However, there were complications only with the first patients who had PDT. If the method of Ciaglia and colleagues [7] is accompanied by fiberoptic bronchoscopic control, puncture of the trachea can be done under safe and visually confirmed conditions [17]. There were no complications in patients who had translaryngeal tracheostomies. However, advancing the guide wire retrograde into the oropharynx was often difficult. Perhaps it is possible to prevent distal kinking of the guide wire by using the rigid endotracheal tube that is part of the TLT set. Use of the tube could also prevent accidental traumatization of the posterior tracheal wall. However, because of the tube’s rigidity, a straight line between oropharynx and trachea must be present, which cannot be expected routinely.

By routine use of a bronchoscope, bleeding from the posterior tracheal wall can be recognized immediately and secretions can be suctioned off. In PDT, massive bleeding from traumatization of the posterior tracheal wall has reportedly resulted in some fatalities [13]. We found that if bronchoscopic control was used for tracheostomies according to the technique of Ciaglia and colleagues [7] or Fantoni and Ripamonti [8], there was no tracheal bleeding or traumatization of tracheal structures. We saw no bleeding from accidental tracheal lesions, and even minimal bleeding from the wound edges was rare when minimally invasive techniques were used, as the wound edges were compressed by the cannula. For instance, we saw no bleeding in a patient with compromised coagulation (prothrombin time 60%, partial thromboplastin time 87 seconds, platelets 63,000/µL) who had TLT. The safety of minimally invasive techniques is considerably enhanced by mandatory bronchoscopic control of the airways. Bleeding and aspiration can be recognized immediately and treated if necessary. Nevertheless, minimally invasive tracheostomies can be associated with massive bleeding, which could require surgical intervention. Therefore, PDT and TLT should be used only by physicians who, by virtue of their experience and training, are able to master any eventual surgical complications [18, 19].

In an era of constantly increasing health care costs, economic aspects have become highly important. We found that the overall costs of minimally invasive, bedside tracheostomies were significantly lower than those of the conventional OT. Open tracheostomy required transportation of the patient and more personnel than either TLT or PDT. There are also rental costs of the operating room, which can be quite high and which can result in an overall cost increase of the procedure of up to 90% [20]. In contrast, bedside tracheostomies require fewer personnel, and there is no patient transport or operating room rental. Of the minimally invasive techniques, TLT costs about 30% less than PDT. Personnel and anesthesia costs are as high for TLT as for PDT, but less material costs are charged for TLT.

Both PDT and TLT are attractive alternatives to OT. They are not costly and do not require as much time or personnel. Furthermore, the risks involved in transporting the patient from the ICU to the operating room are eliminated [21, 22]. It should be emphasized that these procedures should be performed under bronchoscopic control by an experienced physician. Only then can they be considered safe and unlikely to result in major complications. Conventional tracheostomy should still be considered for patients whose neck anatomy would make a minimally invasive procedure difficult, when it is impossible to identify the trachea clearly enough, or when there are large vessels at the tracheostomy site.

	References

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