From the Department of Anesthesiology and Intensive Care Medicine, Henri Mondor University Hospital and Paris XII School of Medicine, Créteil, France
Accepted for publication November 15, 2003.
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Because of difficult weaning from mechanical ventilation, a 59-yr-old man admitted for emergency cardiac surgery underwent a bedside PercuTwist tracheostomy on day 14 of his intensive care unit stay. We observed a double fracture of the second tracheal ring during the initial dilation process with the PercuTwist dilator, associated with distal migration of a cartilage fragment, which was avulsed from the anterior portion of the second cartilaginous ring.
Percutaneous tracheostomy (PT) has become a safe procedure for airway management of critically ill patients (1). All PT methods share a similar principle: a tracheal puncture with subsequent dilation allowing positioning of the tracheal cannula. However, methods differ in the dilation process, which is either antegrade or retrograde and uses multiple-step or single-step dilators. Although single-step dilator techniques are associated with fewer and less severe immediate complications than the multiple-dilator technique (2), antegrade dilation exposes the patient to tracheal wall injury. Recently, a new antegrade, single-step screw-like dilating device (PercuTwist) has become available that lifts the anterior wall of the trachea while dilating. This new concept was developed to minimize tracheal wall injury (3). We report a tracheal ring double fracture with bronchial migration of a piece of cartilage during a PercuTwist tracheostomy procedure.
A 59-yr-old man (1.85 m, 78 kg) was admitted to our University Hospital for emergency cardiac surgery. Aortic proximal repair was uneventful. The patient was tracheally extubated 11 h after the end the surgery, but severe hypoxemia related to infectious pneumonia required reintubation and mechanical ventilation on the fourth postoperative day. Because of a predictable difficult weaning from mechanical ventilation, we decided to perform a bedside tracheostomy on day 14. Enteral feeding was stopped and gastric contents were suctioned before the procedure. General anesthesia was induced and maintained with propofol, sufentanil, and cisatracurium. Volume-controlled mechanical ventilation variables were set according to an internal procedure (zero end-expiratory pressure and Fio2 = 1). The patient’s neck was slightly extended and his head was tilted back. External anatomical landmarks were easily drawn on the patient’s skin and the surgical area was cleansed and prepared with surgical drapes. A flexible video-endoscope connected to a digital camera recorder was inserted in the tracheal tube, and the partially deflated cuff was placed in a translaryngeal position under direct laryngoscopy. For PT, the PercuTwist Set (Rusch France, Betschdorf, France) with a 9.0-mm inner diameter tracheostomy tube was used. After endoscopic identification of the second and third tracheal rings, transillumination of the anterior wall of the trachea confirmed the external site of puncture. Although directed medially, the first puncture resulted in a left-side lateral tracheal puncture. With the cannula tip correctly placed intratracheally at the second puncture attempt (Fig. 1), the internal metal needle was removed. The guidewire with the flexible J tip was advanced caudally until resistance was felt. The plastic indwelling cannula was removed and 2 radiant incisions of 3–4 mm length and depth were made on both sides of the guidewire. The wetted PercuTwist dilator was then rotated clockwise over the guidewire. When there was difficulty widening tracheal access through pretracheal soft tissue, the dilator was firmly pressed on the anterior wall of the neck, resulting in transient collapses of the tracheal lumen. With the dilator’s conical tip 3–4 mm inside the trachea, between the second and third tracheal rings (at the third screw’s groove), screwing was continued while the anterior tracheal wall was towed upward. The dilating process was rapidly stopped because of endoscopic evidence that the second tracheal ring was fractured. Both extremities of the cartilage ring became progressively more apparent (ungloved from their tracheal mucous membrane) apart to the dilator. Continuing dilation resulted in both hemi-cartilages of the second ring almost being denuded (Fig. 2). The dilator was removed carefully (counter-clockwise rotation) under video-endoscopic control. Apparently, both parts of the cartilages of the second ring had returned to their normal position. The tracheostomy tube placed on its insertion stylet was threaded over the guidewire. Once the tracheostomy tube was positioned distally in the trachea, the insertion stylet was removed along with the guidewire. While controlling distal placement of the tracheostomy tube and suctioning secretions, a piece (8 mm × 4 mm) of the second cartilage ring (anterior arch) was found in the right main bronchus and extracted with the flexible endoscope (Fig. 3).
We describe a double fracture of the second tracheal ring during a PercuTwist tracheostomy procedure, associated with distal migration of a cartilage fragment that had come off the anterior tracheal wall.
Single-step PT techniques, including the translaryngeal tracheostomy (TLT) method introduced by Fantoni and Ripamonti in 1997 (4) and the Blue Rhino (BR) method derived from the classic percutaneous dilatational tracheostomy (DT) developed by Ciaglia in 1999 (2), have been reported to be safe, with very infrequent serious complications (5) mainly concerning tracheal wall injuries. Indeed, except for the retrograde TLT method, which allows controlled dilating forces to be applied from inside the trachea, sparing tracheal walls, dilating pressure inevitably exerted on the rigid anterior trachea arch compressed upon the cervical block may result in both tracheal anterior and posterior wall injury during all antegrade techniques. Many authors have reported the frequent incidence of PT-induced damage to tracheal rings (6–9), with almost one-third of patients suffering from fractures of tracheal cartilage (7–9), most of them attributed to either poor puncture technique (multiple and traumatic) or an excessively forceful dilation process.
Although the PercuTwist method was developed to spare tracheal walls, we report a case of tracheal ring fracture using this new form of PT. Our intensive care unit medical team is experienced in PT. Since 1999, we have performed (under video control) more than 350 PTs, mainly TLT (250), but also DT and BR methods. The case we report concerns our sixth PercuTwist procedure. All of our PercuTwist procedures were performed by the same two senior physicians according to the manufacturer’s recommended instructions. As usual during the learning curve of a new PT technique we systematically use a camera recorder. We affirm that our tracheal punctures were not traumatic. However, multiple punctures performed in the same interspace might have caused the second tracheal ring fracture. In addition, dissection of pretracheal tissues and hooking tracheal rings with the dilator was difficult, requiring intense pressure exerted on the anterior wall of the trachea, whose lumen was almost occluded during the dilating process. We probably seriously damaged the second tracheal ring during the initial dilation of cervical tissues or while splitting tracheal rings. The relatively large size of the tracheostomy tube fitted to our patient’s anatomy possibly increased our difficulties in the initial dilating process. Westphal et al. (3) demonstrated similar difficulties before screwing the PercuTwist dilator and lifting the anterior wall of the trachea. In the case we report, the two fractures of the second tracheal ring probably occurred during the initial dilating process, before the PercuTwist dilator was correctly driven between the tracheal rings.
Continuing dilation resulted in further mobilization of the denuded posterior cartilage fragment, which finally moved downward into the right main bronchus lumen. This was not detected while the tracheostomy was being performed but was evident on careful retrospective review of the videotape of the procedure. Such migration of a piece of cartilage had never been described in these conditions.
As compared with the BR method, we were impressed by the endotracheal aspect of the stoma, which remained almost circular after removal of the PercuTwist dilator. In addition, the large penetration index (13.5-mm diameter reached on 20-mm length) of the PercuTwist dilator, which was conceived to prevent posterior wall injury, may promote damage to the tracheal ring in predisposed patients or when initial dilation is problematic.
We conclude that, like other antegrade single-step techniques, the PercuTwist tracheostomy presents a risk of anterior tracheal wall damage during the initial stage of the dilation process. Antegrade forces applied to the trachea should be minimized with sufficiently deep skin incision and both slow and smooth initial rotation of the dilator.
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