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Percutaneous Tracheostomy in Critically Ill Patients

Lighthall, Geoffrey K. MD, PhD

doi: 10.1213/ANE.0000000000001482
Books, Multimedia, and Meeting Reviews: Book Review

Department of Anesthesia and Critical Care, Stanford University School of Medicine, Stanford, California

One consequence of critical illnesses is the use of organ supports such as hemodialysis and ventilatory assistance as the patient recovers. Related to chronic respirator failure is the performance of tracheostomy procedures, an increasing number of which are placed by intensivists at the bedside. Such procedures are of interest to anesthesiologists, because they may be called on to assist with these procedures, manage related crises, or develop the procedure within their own intensive care units. Contributing to the interest in bedside tracheostomy is the development and widespread availability of self-contained tracheostomy kits during the past 15 years.

As a result of increasing performance of this procedure, texts on tracheostomy placement and management are beginning to appear, most recently Percutaneous Tracheostomy in Critically Ill Patients.1 The book consists of 17 chapters spanning 159 pages where topics range from core content such as history of tracheostomy, description of various techniques, their complications, and general postoperative patient care to emergency procedures, to a consideration of evidence regarding the optimal timing of the procedure. Additional chapters address the use of ultrasound in performing the procedure, informed consent, and quality of life.

Most chapters contain current information and include studies up to 2015, but the balance of content graphics and quality among the chapters is asymmetric; the book comes across as a collection of monographs more than a well-planned project. The use of introductions, orienting statements, and concluding paragraphs was highly inconsistent. Some chapters with key content seem overly abbreviated, while others cover multiple topics, some overlapping entirely with other chapters. The chapter on the percutaneous single-dilator technique—the technique most likely to be used by a physician beginning to perform tracheostomies—provides an abbreviated and wandering description of the technique. Although it would be valuable for this chapter to contain charts and multiple drawings or photographs of the procedure and some practical pointers, the description occupies only 2 pages. A physician, who wishes to practice the technique would not glean sufficient information from this chapter to proceed and would have to seek guidance elsewhere.

The chapters that follow describe the less common percutaneous techniques based on forceps dilation, pneumatic balloon dilation, a rotational introducer, and (inside to out) transtracheal puncture. One chapter compares the various techniques, but the book’s up-to-date review covers only about half of the techniques mentioned, and could be enhanced by the inclusion of a table comparing the various methods. Additional information from the individual chapters could then be extracted and placed in their proper context.

On the negative side, the syntax in the majority of chapters contains multiple errors and produces a turbulent read. Chapter 10, which is on complications, is an especially tedious march through 5.5 pages of text presented as 2 paragraphs. In this case, well-intentioned scholarship is completely neutralized by poor organization and presentation. The graphic images also lack quality and consistency throughout; the photographs in the single-dilator technique chapter are uninformative and too few to illustrate this overly popular technique. Likewise in the emergency tracheostomy chapter, a 7-photograph series of this procedure is presented in a 4 × 6 inch composite image. I found these miniature images far too small for a demonstration of a lifesaving procedure! In the chapter on surgical tracheostomy, a series of 6 illustrations is used to walk the reader through the stages of this procedure; unfortunately, the pertinent details in these images occupy <10% of the total image area. My hopes to actually get the surgeon’s-eye view of this procedure for the first time were rapidly dashed. The use of photography is at its best in the chapter on choice of tracheostomy tube types; however, this chapter is a bit thin on the rationale one would use to select one tube over another, as well as how to work with tube types that are not intrinsically compatible with commercial insertion kits. Quality of life and complications while being the best-written chapter is also the longest; given the divergent nature of the topics, complications could have been split off to replace the other chapter on the subject that appears earlier.

On the positive side, the chapter on anatomy appropriately includes ultrasound images, and highlights how to incorporate ultrasound in tracheostomy placement. It nicely introduces some techniques I look forward to trying. A chapter on postoperative management is also well written and treats the posttracheostomy care issues, which are likely to arise in the intensive care unit and after discharge, with appropriated depth and breadth.

Textbook publishers and editors work in the unenviable environment where knowledge and evidence can change within a book’s gestational cycle. There is competition from traditional review articles and the explosion of on-line information. The enduring products are those that can anticipate the reader’s needs and master the world of print to affirm their relevance. Prevention of overlap, filling of voids, maintaining consistency of themes, depth and level of analysis are the qualities of editorial oversight that we can expect. Unfortunately, Tracheostomy Management fails to do this in a consistent manner. In my opinion, the text lacks the necessary details to serve as a stand-alone text for a new practitioner. Established practitioners looking for new angles and alternative approaches for difficult cases may find some new information, but its paucity does not justify the cost of the book. Those interested in other aspects of tracheostomy management such as weaning of mechanical ventilation and development of hospital-wide systems of care will find this text incomplete and may be best served by looking at other texts on the subject.2–4 The expanding interest in the field of percutaneous tracheostomy essentially guarantees that other texts on this subject will appear; however, modifications to this text would be necessary if it is to become a pioneer in the field.

Geoffrey K. Lighthall, MD, PhD

Department of Anesthesia and Critical Care

Stanford University School of Medicine

Stanford, California

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REFERENCES

1. Servillo G, Pelosi P. Percutaneous Tracheostomy in Critically Ill Patients. 2016:Switzerland: Springer International Publishing AG, 159.
2. Seidman PA, Sinz EH, Goldenberg D. Tracheotomy Management: A Multidisciplinary Approach. 2011:Cambridge, UK: Cambridge University Press, 202.
3. Ambesh SP, Trotter TN, Lin ES. Principles and Practice of Percutaneous Tracheostomy. 2010:New Delhi, India: Jaypee Brothers Medical Pub, 165.
4. Paw GW, Boderham AR. Percuteneous Tracheostomy, a Practical Handbook. 2004:Cambridge, UK: Greenwich Medical Media, 161.
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