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Anesthetic Implications for Tracheal Injury During Bronchoscopy-Guided Percutaneous Dilational Tracheostomy

Dizdarevic, Anis MD; Pagano, Parwane MD; Desai, Shivang MD

doi: 10.1213/XAA.0000000000000291
Case Reports: Clinical Care

Bronchoscopic-guided percutaneous dilational tracheostomy has become one of the most common elective tracheostomy methods for patients requiring prolonged ventilatory support. The safety profile, patient selection, and risks as well as complication management, when compared with an open surgical technique, remain somewhat controversial with no clear recommendations. We present a case of a critically ill patient undergoing percutaneous dilation tracheostomy complicated by tracheal wall injury and airway loss. The airway was successfully conservatively managed as well as the tracheal injury. Anesthetic implications, safety, and management options as well as recommendations are reviewed.

From the Department of Anesthesiology and Pain Management, Columbia University Medical Center, New York, New York.

Accepted for publication October 22, 2015.

Funding: None.

The authors declare no conflicts of interest.

LMA is a registered trade mark of The Laryngeal Mask Company Limited, an affiliate of Teleflex Incorporated.

Address correspondence to Anis Dizdarevic, MD, Department of Anesthesiology and Pain Management, Columbia University Medical Center, 622 West 168th St., PH 5, New York, NY 10032. Address e-mail to

Percutaneous dilational tracheostomy (PDT) has become an increasingly common method of performing elective tracheostomy for patients requiring prolonged ventilatory support.1–3 This procedure is often performed within the intensive care unit (ICU), avoiding the high morbidity risk of transporting intubated and critically ill patients to the operating room.4,5 By developing appropriate support systems, many operations can be performed safely and cost-effectively at the ICU bedside.6 Some of the benefits of performing PDT compared with an open surgical procedure are less tissue trauma, a smaller skin incision, shorter operative time, less operative bleeding, and fewer postoperative complications.7

Issues that still remain controversial are the safety and complication profile, proper patient selection for the procedure, and the most optimal anesthetic and complication management such as tracheal wall injury, airway loss, and bleeding. The patient’s family reviewed the case report and gave written permission for the authors to publish the report.

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A 72-year-old man (170 cm, 83 kg) with a medical history significant for triple-vessel coronary artery disease, newly diagnosed severe aortic stenosis, type 2 diabetes mellitus, acute exacerbation of chronic renal insufficiency, altered mental status, pneumonia, and respiratory insufficiency requiring ventilator assistance was scheduled for percutaneous tracheostomy (PT) in the ICU.

The patient was transferred for further management from an outside hospital after a myocardial infarction complicated by the findings of severe aortic stenosis, moderate pulmonary hypertension, decreased left ventricular ejection fraction (55%), acute hypoxic respiratory failure secondary to pulmonary edema, and subsequent pneumonia. The arterial blood gas revealed the following measurements: pH, 7.4; PCO2, 43; PO2, 102; and HCO3, 28 with an O2 saturation of 98%. The ventilator settings were Assist Control, Vt 500, respiratory rate 12 (11–20), FIO2 45%, and positive end-expiratory pressure 5. The PT procedure was started by the anesthesiology team with the patient anesthetized to a Richmond Agitation Sedation Scale score of −5 with dexmedetomidine (0.5–0.7 μg/kg/h) and fentanyl (25- to 50-μg increments). Cisatracurium (6 mg) was administered for muscle paralysis to minimize patient movement. A 1-cm vertical incision was made between the second and third tracheal rings by the thoracic team. Under indirect bronchoscopic visualization, through the endotracheal tube (ETT), the finder needle was inserted into the tracheal lumen and the guidewire was advanced. To facilitate optimal visualization and allow for a safe transtracheal operation, the ETT, held in place by the bronchoscopy operator, was pulled back (proximally) into the trachea with the tip remaining just below the vocal cords. By using the Seldinger technique, serial dilation was performed. At this point, bronchoscopic visualization of the trachea and the ETT became increasingly difficult because of secretions and bleeding. It also appeared that the ETT was misplaced further proximally to above the vocal cords. The ETT was immediately connected to the Ambu bag, but hand ventilation failed to provide adequate tidal volumes and seal. The oxygen saturation started to decrease (midhigh 80s%). The ETT was removed, and the anesthesiologist proceeded to perform a direct visualization with a Macintosh blade 3 laryngoscope aided by continuous suction. The anesthesiologist then replaced the ETT in the trachea, confirming correct endotracheal placement with the CO2 indicator and bilateral breath sounds. Endotracheal bronchoscopic examination revealed a posterior tracheal wall laceration, compromising the middle third of the trachea, with active bleeding. The tracheostomy procedure was aborted at this time, and the ETT was positioned further distally in the trachea, just above the carina, with the cuff slightly deflated, still allowing adequate positive pressure ventilation. Ventilator settings were changed to pressure control 14 cm H2O with an increased (16 breaths per minute) respiratory rate. The patient’s deep sedation was maintained with 0.6 to 0.8 μg/kg/h dexmedetomidine and 0.5 to 1 μg/kg/h fentanyl. No subcutaneous emphysema or signs of pneumothorax were noted on physical examination. Subsequent bronchoscopy confirmed the ETT position just above the carina and showed that the bleeding had subsided.

The decision was jointly made with the anesthesiology, ICU, and thoracic teams to leave the ETT in place and perform serial radiographs and bronchoscopic examinations to monitor the bleeding and the extent of injury. The ventilator was set at pressure control 14 to 15 cm H2O with lower peak airway pressures to allow for clot adherence. The patient was kept sedated to a Richmond Agitation Sedation Scale score of −5 to minimize active (over)breathing, cough, or other potential patient-triggered airway pressure increases. Serial chest radiographs obtained immediately and after the procedure revealed no pneumomediastinum or pneumothorax. Three days later, the patient’s hemodynamic and respiratory condition remained stable, and he underwent an uncomplicated open tracheostomy procedure in the operating room. Bronchoscopic examination showed a healing posterior tracheal wall injury and no tracheomalacia. A #7 extralong Covidien Shiley™ (Medtronic, Minneapolis, MN) tracheostomy tube was placed.

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The PT technique for airway management was developed not long after Seldinger8 described needle replacement over a guidewire for arterial catheterization in 1953. In 1957, Shelden et al.9 described the first attempt to perform a PT, but the method caused multiple complications and resulted in fatalities. Toye and Weinstein7,10 reported the technique using a guidewire in 1969 and subsequently described it in a series of trauma patients. In 1985, Ciaglia et al.11 described the PDT, a method based on the needle guidewire airway access followed by serial dilations with sequentially larger dilators.

Multiple other PT techniques have since been developed: rapid PT technique, Rapitrac, guidewire dilating forceps method, and translaryngeal tracheostomy technique.12–14 In 2000, Byhahn et al.15 introduced the Ciaglia Blue Rhino, a modified classic Ciaglia technique, which is currently one of the most commonly used PDT procedures worldwide.

The traditional method of choice for maintaining the airway during the PT procedure has been a cuffed ETT. During PT, the cuff is (partially) deflated and the tube is pulled back to a position just below the vocal cords to facilitate the safe placement of the tracheostomy. Some of the challenges of using the ETT have been a risk of cuff rupture from needle placement in the trachea16 and accidental transfixion of the Murphy eye of the tracheal tube guidewire insertion through the Murphy eye. Other potential but serious complications include the dislodgment of the ETT, loss of airway, and/or inadequate ventilation. These can occur as the ETT is being withdrawn proximally to the supraglottic region during tracheostomy placement during patient positioning into the extended head position or while manipulating the bronchoscope during visualization of the tracheostomy placement.

Several studies have recommended the use of bronchoscopy during PT because it allows direct visualization of the airway and ETT during tracheostomy needle placement, dilation, ETT positioning, and final tracheostomy tube placement.17–19 Kost20 reported a significantly reduced frequency of accidental extubation, false passage, pneumothorax, pneumomediastinum, posterior injury, and technical difficulties with endoscopic guidance. However, other authors have concluded that bronchoscopy is unnecessary, adds expense, and may lead to significant hypercarbia related to impaired ventilation.21–24 Jackson et al. concluded that PT was safe and could be effectively performed by an experienced surgical team both with and without bronchoscopic guidance without a difference in the complication rate. They suggested considering bronchoscopy in selected patients such as those with halo cervical fixation, difficult anatomy, and obesity.25

In recent years, ultrasound has emerged as a new addition to assist PDT and improve safety, both in preprocedure scanning and during the procedure (real time).26–30 Gobatto et al.,31 analyzing a retrospective cohort study, concluded that ultrasound-guided PDT was safe, effective, and associated with similar complication rates and clinical outcomes compared with bronchoscopy-guided PDT.

Laryngeal mask airway (LMA) placement, as an airway alternative to the ETT for a tracheostomy procedure, has been used and studied as well, but clear conclusions on the safety comparisons have been lacking. Price et al.32 studied the performance of the LMA Supreme® (Teleflex, Old Amersham, Bucks, UK) against a cuffed ETT in 50 consecutive ICU patients and reported more clinically important complications in the LMA group such as inability to secure the airway without a leak, inadequate ventilation, and worsening oxygenation. Ambesh et al.33 found that the classic LMA was inferior to an ETT, whereas Linstedt et al.34 and Dosemeci et al.35 found the opposite.

As PDT has become an increasingly common procedure for an elective tracheostomy, multiple publications have examined and reported on the efficacy and relative safety of this approach.20,23,36–40 Simon et al.36 studied the incidence and risk factors associated with mortality following cases of PDT. They suggested the following measures, among others, to improve the safety of PDT: strict adherence to contraindications, bronchoscopic guidance during the procedure, presence of an experienced team, and avoidance of guidewire kinking.

A meta-analysis of 5 prospective controlled studies comparing PDT and surgical tracheostomy (ST) in critically ill patients was reported by Freeman et al.38 The issues they noted with PDT included paratracheal insertion, loss of airway as well as mortality, and difficulty passing the tracheostomy tube. The most prominent ST complication was major perioperative bleeding. For overall postoperative complications, the results favored PDT over ST. In a series of ICU patients, comparing PDT with ST, Polderman et al.39 found bronchoscopy-assisted PDT to be a safe and effective procedure when performed by a team of experienced physicians under controlled circumstances. Beiderlinden et al.23 analyzed mechanically ventilated ICU patients, many with thrombocytopenia and coagulation deficits, undergoing PDT. They concluded that, with experience in performing PDT, fixation of the tracheal cannula and omission of a routine change of tracheostomy tubes, the complication rate of PDT was low.

Extensive posterior wall tracheal lacerations have been reported in several reviews.41–44 Lin et al.44 retrospectively analyzed 134 cases of bronchoscopic-guided PDT (1997–1999) and found 3 cases of extensive posterolateral longitudinal tracheal laceration that required operative repair. Trottier et al.41 reported a 12.5% rate of posterior tracheal wall laceration among 23 medical–surgical ICU patients undergoing PDT. The use of concurrent endoscopic visualization of the trachea to confirm proper needle insertion placement, sequential dilation technique, avoidance of excessive force, and proper patient selection have all been identified as minimizing this complication.

Tracheal injuries, regardless of their etiology, can be life-threatening, and, traditionally, surgical repair has been recommended as the treatment of choice.44–47 With tracheal perforation, persistent air leakage can result in pneumothorax, pneumomediastinum, and pneumopericardium as well as tracheal stenosis if left surgically unrepaired.

Several authors described successful conservative treatments of tracheal injuries.48–51 It has been suggested that as long as the injury is localized in the middle and upper third of the trachea and the patient shows no signs of hemodynamic instability or pneumothorax, no (rapid) progression of subcutaneous and mediastinal emphysema, mediastinitis, or difficulty with ventilation, noninterventional conservative treatment might be equally effective and should be considered.

Given the aforementioned considerations, risks, and complications associated with PT, it would be of utmost importance to perform proper patient selection before choosing a tracheostomy method of choice, especially for critically ill patients.

Bronchoscopic-guided PT may be associated with more frequent and prolonged episodes of hypoventilation and apnea, and this might not be appropriate for patients unable to tolerate hypercapnia and hypoxia (severe respiratory insufficiency, increased pulmonary pressures, right-sided heart failure, severe cardiovascular compromise, etc.). In addition, there is a small but potentially life-threatening risk of posterior tracheal wall injury that could result in significant bleeding, airway loss, and cardiorespiratory compromise.

Polderman et al.,52 Blankenship et al.,53 and Saito and Morisaki54 suggested a collaborative approach when performing PDT of multidisciplinary teams involving otolaryngologists and intensivists or pulmonary/critical care specialists as well as having anesthesia support and airway management provided by an intensivist or anesthesiologist during the bronchoscopy. Rajendran and Hutchinson55 proposed using the checklist before performing PT in critical care situations to reduce errors and harm as well as improve safety based on the World Health Organization Surgical Safety Checklist introduced in 2008.

Table 1

Table 1

Table 2

Table 2

On the basis of our experience, the case presented, and available research, we recommend following the safety preparation steps summarized in Table 1 before performing an ICU bedside PDT. Finally, in the event of a procedure-related tracheal laceration resulting in significant injury and bleeding, the management steps summarized in Table 2 would be recommended.56,57

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This case report describes and reviews the indications, safety, anesthetic implications, risks, and complications associated with PDT as well as the successful anesthetic and nonsurgical management of one of its riskiest complications, tracheal wall injury, and airway loss. It also emphasizes the significant importance of proper patient selection, preparedness for the anesthetic, intensive care management of a difficult airway, and tracheal injury as well as effective communication among all members of multidisciplinary medical teams involved in patient care.

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The authors thank Charles W. Emala, MD (Henrik H. Bendixen Professor of Anesthesiology and Vice Chair for Research, Columbia University Medical Center) for his continued guidance, tremendous support, and suggestions for this publication.

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