HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Eduard Altman Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Nun, A. B. Articles by Best, L. A. Search for Related Content PubMed PubMed Citation Articles by Nun, A. B. Articles by Best, L. A.

Ann Thorac Surg 2005;80:1276-1279
© 2005 The Society of Thoracic Surgeons

---

Original article: General thoracic

Extended Indications for Percutaneous Tracheostomy

Accepted for publication February 1, 2005.

^_* Address reprint requests to Dr Ben Nun, Rambam Medical Center, Department of General Thoracic Surgery, Haifa, 31096 Israel (Email: a_ben_nun{at}rambam.health.gov.il).

	Abstract

Top Abstract Introduction Material and Methods Results Comment References

 
BACKGROUND: In recent years, percutaneous tracheostomy has become a routine practice in many hospitals. In the early publications, most authors considered adverse conditions such as short, fat neck or obesity as relative contraindications whereas cervical injury, coagulopathy, and emergency were regarded as absolute contraindications. More recently, several reports demonstrated the feasibility of percutaneous tracheostomy in patients with some of these contraindications. The aim of this study is to determine the safety and efficacy of percutaneous tracheostomy in conditions commonly referred to as contraindications.

METHODS: Between June 2000 and July 2001, 157 consecutive percutaneous tracheostomy procedures were performed on 154 critically ill adult patients in the general intensive care unit of a major tertiary care facility. The Griggs technique and Portex set were used at the bedside. All procedures were performed by staff thoracic surgeons and anesthesiologists experienced with the technique. Anatomical conditions, presence of coagulopathy and anti-coagulation therapy, demographics, and complication rates were recorded.

RESULTS: Five of 157 procedures (154 patients owing to three repeat tracheostomies) had complications. In patients with normal anatomical conditions and coagulation profiles, there was one case of bleeding (50 cc to 120 cc) and one case of mild cellulitis around the stoma. In patients with adverse conditions, there was one case of bleeding (50 cc to 120 cc) and two cases of minor bleeding (< 50 cc).

CONCLUSIONS: Patients with adverse conditions had a low complication rate similar to patients with normal conditions. For this reason, we believe that percutaneous tracheostomy is indicated in patients with short, fat neck; inability to perform neck extension; enlarged isthmus of thyroid; previous tracheostomy; or coagulopathy and anti-coagulation therapy.

	Introduction

Top Abstract Introduction Material and Methods Results Comment References

 
The procedure of percutaneous tracheostomy (PCT) has become routine in many centers. A significant number of articles have been published comparing several techniques of PCT to open surgical tracheostomy [1–6], as well as to one another [7–11]. The majority of comparisons of PCT to open surgical tracheostomy have demonstrated either lower complication rates associated with PCT [1–4, 12] or no statistical differences between the two [5, 13].

A significant number of reports considered adverse anatomical conditions such as short, fat neck or obesity with unidentifiable anatomy [4, 7, 14–17]; enlarged thyroid [1, 16, 18]; an inability to extend the neck, including either documented or suspected cervical spine fracture [17]; or previous neck surgery, including previous tracheostomy [1, 5, 18] as relative contraindications. The presence of a coagulopathy or use of anticoagulants have also been referred to as contraindications [14–16]. Only a small number of these reports included data from cases performed under various combinations of these conditions [19–21]. More recently, an even smaller number of reports specifically directed at performing PCT in patients without cervical spine clearance [22] and the obese patient [23–25] have appeared.

Reported herein is a series of 157 procedures carried out on 154 critically ill patients who required tracheostomy. Fifty-five of the 154 patients (57 cases) fell into one or more of these categories, referred to by most authors as relative contraindications to performing PCT. The aim of this study was to assess the validity of these contraindications in adult patients in the general intensive care unit setting.

	Material and Methods

Top Abstract Introduction Material and Methods Results Comment References

 
Between June 2000 and July 2001, 157 consecutive PCT procedures were performed on 154 critically ill adult patients in the general intensive care unit using the Griggs technique and Portex set of instruments (SIMS Portex, Hythe-Kent, England). The procedures were performed by a small group of qualified thoracic surgeons and anesthesiologists who had experience in performing PCTs, and had already passed out their so-called learning curve (at least 30 cases of PCTs and a previous experience of more then 50 surgical tracheostomies). Of these cases, 57 were in conditions previously described in the literature as relative contraindications. Of the 154 patients comprising the 157 cases in this series, 90 were male and 64 were female (58% and 42%, respectively). The average age was 62 years (range, 18 to 83 years). The procedure was approved by the Helsinki Committee and was performed as a bedside operation in the intensive care unit. All patients were unconscious, and the informed consent was signed by the appointed legal guardian.

The conditions under which the PCT was performed are outlined in Table 1. Short, fat neck was defined as a neck circumference greater than 46 cm with the distance between the cricoid cartilage and the sternal notch less than 2.5 cm, and the pretracheal soft tissues deeper than 2.5 cm. An inability to extend the neck was defined as either a documented or suspected cervical spine injury or cervical spondylarthropathy. Anti-coagulation therapy or documented coagulopathy was defined as either a partial thromboplastin time greater than 30 seconds, prothrombin international normalized ratio greater than 2, or platelet count less than 20,000. These patients were treated with fresh frozen plasma, with platelets, and by discontinuation of anticoagulation therapy. Despite this, none of the coagulation profiles returned to normal. Cases were also documented of patients who were noted to have an enlarged thyroid isthmus, a high-riding innominate artery, or had undergone a previous tracheostomy. The remaining 99 cases performed during this time period had none of the previously mentioned conditions and had both normal anatomical characteristics and coagulation profiles.

A horizontal incision was performed, and the sequence of guidewire insertion, skin incision, and soft tissue blunt dissection were adjusted according to the patient's anatomical conditions. In cases in which there were no adversities and there was straightforward anatomy, the trachea was first punctured with the needle cannula, followed by insertion of the guidewire, skin incision, and blunt dissection of the pretracheal soft tissues to a diameter equal to that of the cannula. In patients with a short, fat neck, skin incision was done first, followed by careful blunt dissection of the soft tissues down to the anterior tracheal wall with a Pean clamp in a stepwise fashion to minimize trauma and prevent subsequent bleeding. After reaching the cricoid cartilage and palpating the cervical trachea, puncture of the tracheal wall was performed with the needle cannula in the space between the first and second tracheal cartilages, and the rest of the procedure was completed using the guidewire and the dilating forceps.

In 18 cases (17 patients—one patient underwent PCT twice during the study period) in whom the cricoid cartilage was almost at the level of the sternal notch, the same sequence as described for short, fat necks was used, but with rostral traction on the larynx to expose the space below the first tracheal cartilage. After insertion of the needle cannula, the procedure was completed in the usual fashion.

In the 4 cases involving an enlarged thyroid isthmus, the main landmark was the cricoid cartilage as the cervical trachea was covered. After incising the skin and dissecting the soft tissues down to the isthmus, the isthmus was dissected from the cricoid cartilage using a Pean clamp and index finger to distract the isthmus caudally. Only after the isthmus was drawn below the second tracheal cartilage was the needle cannula inserted between the first and second tracheal cartilages.

For cases encountered with a high-riding innominate artery, all were patients with a short-fat neck, the same approach as with an enlarged thyroid isthmus was used. After exposure of the cricoid cartilage, the soft tissues (including the innominate artery) were distracted caudally with the index finger to expose the second tracheal cartilage. After palpation of the cervical trachea, the procedure was continued as previously described.

Extension of the neck was impossible in a total of 21 patients due to conditions previously mentioned. Therein, these cases were in patients with a concomitant short, fat neck. A PCT was performed in these patients as described for patients with a short, fat neck. The remaining cases without a short, fat neck were performed as dictated by the coexisting anatomical conditions.

Three patients required repeat PCT due to respiratory failure after initial de-cannulation. In each case, the stoma remained partially open at the time of the repeat PCT. In 2 patients, the Portex set of instruments was used to recannulate. In the third patient, a set of elbowed cylindrical bougies was used to progressively dilate the stoma to the appropriate size. In each case, the re-dilation of the stoma and insertion of the cannula proceeded uneventfully.

The 12 cases of anticoagulation therapy or a coagulopathy were performed as dictated by the anatomical conditions of the patient. The balloon on the tracheostomy cannula was over inflated (15 cc) for 30 minutes as a preventative tamponade on the surface of the tracheal lumen. If the length of the skin incision was greater than the diameter of the tracheostomy cannula, a simple cutaneous suture was placed on either side of the cannula and the tissues approximated until the stoma fitted snugly around the cannula.

	Results

Top Abstract Introduction Material and Methods Results Comment References

 
Of the 157 cases performed in this series, none were aborted in favor of conversion to open surgical tracheostomy. The complications encountered, along with the conditions in which they arose are listed in Table 1. Three of the four instances of bleeding (2 less than 50 cc and one between 50 cc and 120 cc) occurred in patients who met our criteria for either anticoagulation therapy or a coagulopathy. However it should be noted that in none of the four cases of bleeding were any of the patients in a life-threatening situation, and no cases required transfusion or conversion to an open surgical method to achieve hemostasis. In both instances in which bleeding was between 50 cc and 120 cc, the bleeding was controlled with a cutaneous pursestring suture placed around the stoma site. In the 2 cases in which bleeding was less than 50 cc, packing of the operative site by fitting gauze pads between the skin and the wings of the tracheostomy cannula was sufficient to control the bleeding.

One case of mild cellulitis occurred in a patient with normal anatomy and normal coagulation profile. This resolved uneventfully after 3 days of antibiotic therapy. No instances of paratracheal cannulation and airway loss were noted. In one case with normal anatomical characteristics, kinking of the guidewire occurred. A new guide wire was inserted into the tracheal lumen through the already dilated opening, after which the original guidewire was removed. The procedure was completed uneventfully utilizing the new guidewire.

In one case of short, fat neck, the guidewire was inadvertently inserted through the Murphy's eye of the endotracheal tube. The situation was controlled by inserting a suction catheter through the dissected tract into the tracheal lumen. A new guidewire was then inserted through the suction catheter. After removal of the suction catheter and the original guidewire, cannulation proceeded in the usual fashion over the new guidewire. Because these problems were readily recognized and overcome with no undue effects to the patients, they were regarded as technical difficulties inherent in the procedure, not as complications.

No instances of mediastinal or subcutaneous emphysema, pneumothorax, stomal infection, tracheal lacerations, or difficult cannula changes were encountered. There were no cases of mortality attributable to PCTs. At the conclusion of this series, 87 patients (56%) were deceased from other causes, 49 (32%) were decannulated, and 18 (12%) remained cannulated.

Of the 49 patients (50 cases due to one repeat tracheostomy) decannulated, closure of the stoma occurred in a mean of 5.3 days (range, 4 to 7 days). The cosmetic results were promising, with no cases of failure to close, skin tethering, or abnormal granulation tissue. Evaluation at 6 months post-decannulation follow-up in 32 patients has not revealed any symptomatic tracheal stenosis. However, it should be noted that this had been a clinical evaluation and that endoscopic or roentgenologic visualization has not been performed.

	Comment

Top Abstract Introduction Material and Methods Results Comment References

 
The technique of PCT is widely used throughout the world. Many series reports were devoted to assessing PCT with regard to complication rates and concluded that PCT has several advantages over the traditional forms of surgical tracheostomy. However, to date there is no unanimously accepted group of contraindications for this procedure. Several authors have listed conditions such as short, fat neck or an inability to extend the neck [4, 7, 14–16]; an enlarged thyroid [17]; previous surgery in the region, including previous tracheostomy [1, 5, 18]; and coagulopathy or anti-coagulation therapy [14–16, 21] as relative contraindications. Only more recently has a small number of reports directed at PCT in trauma patients without c-spine clearance [22], emergency situation [23], and in morbidly obese patients [25, 26] appeared. The only condition consistently referred to as an absolute contraindication is young pediatric patients. Because independent assessment of the Griggs technique of PCT was incomplete, we prospectively assessed the safety, utility, and complication rates specifically in cases of these aforementioned adverse conditions.

Even though our patient population reflects adverse conditions in 57 of 157 cases, our complication rates were 3% (5 of 157) overall, 2% (2 of 99) in cases with normal anatomical conditions and coagulation profile, and 5% (3 of 57) in cases with adverse anatomical conditions or coagulopathy or anti-coagulation therapy. These results compare favorably with previously reported case series in which some or all of these conditions were excluded from the study group. A possible explanation of our unusually low complication rate during this series is that the procedures were performed by a group of thoracic surgeons and anesthesiologists who already had a significant experience with PCT and had advanced beyond their learning phase. It is reasonable to assert that this had a direct impact on the results, most certainly explaining the low incidence of complications, even in patients with multiple adversities. Therefore, we agree with Mayberry and colleagues [22], in asserting that undertaking PCT on patients without straightforward anatomy and a normal coagulation profile be better left to the experienced operator.

Although we have demonstrated that adverse anatomical conditions and coagulopathy or anti-coagulation therapy are not contraindications to percutaneous tracheostomy, we have no experience in pediatric patients younger than 8 years old. For this reason, we agree with the majority of authors and regard this as the only contraindication to performing percutaneous tracheostomy.

In summation, the Griggs guidewire dilating forceps technique of percutaneous tracheostomy can be performed in most patients with coagulopathy and adverse anatomical conditions, using minor variations in the procedure, tailored as the situation demands with the same positive results as in normal conditions. Since its introduction in our institution, PCT rapidly gained the favor of our group. We prefer the Griggs technique of PCT over surgical procedures for our critically ill adult patients and emergency situations [23]. Because we have gained significant experience with the Griggs technique of PCT, we have stopped performing surgical tracheostomies.

	References

Top Abstract Introduction Material and Methods Results Comment References

 

1. Friedman Y, Fildes J, Mizock B, et al. Comparison of percutaneous and surgical tracheostomies Chest 1996;110:480-485.[Abstract/Free Full Text]
2. McHenry CR, Raeburn CD, Lange RL, Priebe PP. Percutaneous tracheostomya cost-effective alternative to standard open tracheostomy. Am Surg 1997;63(7):646-652.[Medline]
3. Stoeckli SJ, Breitbach T, Schmid S. A clinical and histologic comparison of percutaneous dilational versus conventional surgical tracheostomy Laryngoscope 1997;107:1643-1646.[Medline]
4. Holdgaard HO, Pedersen J, Jensen RH, et al. Percutaneous dilatational tracheostomy versus conventional surgical tracheostomy—a clinical randomised study Acta Anaesthesiol Scand 1998;42:545-550.[Medline]
5. Gysin C, Dulguerov P, Guyot JP, et al. Percutaneous versus surgical tracheostomy—a double-blind randomized trial Ann Surg 1999;230(5):708-714.[Medline]
6. Porter JM, Ivatury RR. Preferred route of tracheostomy—percutaneous versus open at the bedsidea randomized, prospective study in the surgical intensive care unit. Am Surgeon 1999;65(2):142-146.[Medline]
7. Van Heerden PV, Webb SAR, Power BM, Thompson WR. Percutaneous dilational tracheostomy—a clinical study evaluating two systems Anaesth Intens Care 1996;24:56-59.[Medline]
8. McLure HA, Dob DP, Mannan MM, Soni N. A laboratory comparison of two techniques of emergency percutaneous tracheostomy Anaesthesia 1997;52:1199-1201.[Medline]
9. Powell DM, Price PD, Forrest LA. Review of percutaneous tracheostomy Laryngoscope 1998;108:170-177.[Medline]
10. Ambesh SP, Kaushil S. Percutaneous dilational tracheostomythe Ciaglia method versus the Rapitrach method. Anesth Analg 1998;87:556-561.[Abstract/Free Full Text]
11. Westphal K, Byhahn C, Wilke HJ, Lischke V. Percutaneous tracheostomya clinical comparison of dilitational (Ciaglia) and translaryngeal (Fantoni) techniques. Anesth Analg 1999;89:938-943.[Abstract/Free Full Text]
12. Friedman Y, Mizock BA. Percutaneous versus surgical tracheostomyprocedure of choice or choice of procedure. Critical Care Medicine 1999;27(8):1684-1685.[Medline]
13. Dulgeurov P, Gysin C, Perneger TV, Chevrolet JC. Percutaneous or surgical tracheostomya meta-analysis. Critical Care Medicine 1999;27(8):1617-1625.[Medline]
14. Wilson RC, Bodenham AR. Percutaneous tracheostomy Br J Hosp Med 1993;49(2):123-126.[Medline]
15. Suh RH, Margulies DR, Hopp ML, Ault M, Shabot MM. Percutaneous dilatational tracheostomystill a surgical procedure. Am Surg 1999;65(10):982-986.[Medline]
16. Vigliaroli L, DeVivo P, Mione C, Pretto G. Clinical experience with Ciaglia's percutaneous tracheostomy Eur Arch Otorhinolaryngol 1999;256:426-428.[Medline]
17. Petros S, Engelmann L. Percutaneous dilatational tracheostomy in a medical ICU Intensive Care Med 1997;23:630-634.[Medline]
18. Holdgaard HO, Pedersen J, Paaske PB, et al. Percutaneous dilatational tracheostomy Acta Anaesthesiol Scand 1996;40:838-841.[Medline]
19. Friedman Y, Mayer AD. Bedside percutaneous tracheostomy in critically ill patients Chest 1993;104(2):532-535.[Abstract/Free Full Text]
20. Atweh NA, Possenti PP, Caushaj PF, et al. Dilatational percutaneous tracheostomymodification of technique. Journ Trauma 1999;47(1):142-144.
21. Escarment J, Suppini A, Sallaberry M, et al. Percutaneous tracheostomy by forceps dilationreport of 162 cases. Anaesthesia 2000;55:125-130.[Medline]
22. Mayberry JC, Wu IC, Goldman R, Chestnut M. Cervical spine clearance and neck extension during percutaneous tracheostomy in trauma patients Crit Care Med 2000;28(10):3436-3440.[Medline]
23. Ben-nun A, Altman E, Best LA. Emergency percutaneous tracheostomy in trauma patients Ann. Thorac Surg 2004;77(3):1045-1047.[Abstract/Free Full Text]
24. Mansharamani NG, Kaziel H, Garland R, et al. A. Safety of bedside dilatational tracheostomy in obese patients in the ICU Chest 2000;117(5):1426-1429.[Abstract/Free Full Text]
25. Urwin S, Short S, Hunt P. Percutaneous dilational tracheostomy in the morbidly obese Anaesthesia 2000;55:393-394.[Medline]

This article has been cited by other articles:

				P. De Leyn, L. Bedert, M. Delcroix, P. Depuydt, G. Lauwers, Y. Sokolov, A. Van Meerhaeghe, and P. Van Schil Tracheotomy: clinical review and guidelines Eur. J. Cardiothorac. Surg., September 1, 2007; 32(3): 412 - 421. [Abstract] [Full Text] [PDF]

				A. Ben Nun, M. Orlovsky, and L. Anson Best Percutaneous tracheostomy in patients with cervical spine fractures - feasible and safe Interactive CardioVascular and Thoracic Surgery, August 1, 2006; 5(4): 427 - 429. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Eduard Altman Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Nun, A. B. Articles by Best, L. A. Search for Related Content PubMed PubMed Citation Articles by Nun, A. B. Articles by Best, L. A.