Tracheostomy is an important part of airway management in most intensive care units (ICU). Improvements in technology have led to increasing numbers of critically ill patients who require prolonged mechanical ventilation with tracheostomy. Until recently, surgical tracheostomy (ST) performed in the operating room (OR) was the only option available. As an alternative to the standard surgical approach, the percutaneous technique was introduced by Toye and Weinstein  and similar techniques have gradually become more widely used [2-6].
The percutaneous technique has been shown to be safe, with complication rates during the procedure similar to those seen with standard ST [3,7]. The proposed benefits of percutaneous tracheostomy (PCT) are reduced transport risks as this is a bedside procedure not requiring OR transfer, rapid insertion, and decreased infection rates [2,8,9]. Here we report our experience with a Seldinger-based, single-dilator tracheostomy technique as an elective procedure in 72 critically ill patients in our ICU.
Since November 1996, 72 patients, of whom 58 were males, have been electively selected for PCT at the University hospital with a nine-bed combined medical-surgical ICU. Inclusion criteria were expected long-term ventilation, difficult or prolonged weaning (i.e. COPD). Exclusion criteria included children < 18 years, previous tracheostomy, cervical spine fracture, enlarged thyroid gland, local infection, abnormal anatomy, marked obesity or a bleeding diathesis. PCT was performed at the bedside with a Portex Griggs Percutaneous Tracheostomy Kit (Portex Ltd, Kent, UK) and all procedures were performed by the same two anaesthesiologists (S.F.K. and S.G.).
All patients were monitored with electrocardiography, a non-invasive/invasive arterial pressure device, a pulse oximeter and a capnogram. Intravenous (i.v.) propofol was used as the anaesthetic and neuromuscular paralysis was obtained using vecuronium. Five minutes before the procedure, we increased the inspired O2 concentration to 100%. The patient was positioned in the bed with the head extended and the skin of the neck was cleaned. The skin near the surgical site and underlying tissues was infiltrated with 1% lidocaine with 1:200.000 epinephrine to minimize bleeding. The endotracheal tube (ETT) was withdrawn under direct laryngoscopy until the cuff was above the cords and the tip of the tube was just below the cords in order to avoid puncturing the tube during PCT. After palpating the tracheal cartilages, a 1-2 cm transverse skin incision and tracheal puncture (using a 14-gauge i.v. catheter) were made between the 1st and 2nd, or 2nd and 3rd, tracheal cartilages. Correct placement was confirmed by air aspiration. A guide wire was inserted and the catheter was removed. Next, over the guide wire a 14-gauge dilator was introduced followed by Griggs' guide wire dilating forceps. The forceps were opened to split the tracheal membrane between the tracheal cartilages. After the forceps was removed, the tracheostomy cannula (8.0 or 9.0 mm I.D.) with obturator was advanced over the guide wire into the trachea. The obturator and guide wire were removed and the tracheostomy cannula was connected to the breathing circuit and was secured with tape tied around the neck.
PCT was performed in 72 patients with ages ranging from 18 to 86 years (mean 47.6 years ± 19.2 SD year) and APACHE II scores ranging from 8 to 32 (21.5 ± 6.9). The relevant diseases at the time of admission to the ICU are listed in Table 1.
The procedure (from skin incision to insertion of the tracheostomy tube) was performed within 7.4 min (3-20 min) and was successful in all patients. A learning curve needed to be overcome to decrease the time of procedure from 15.6 ± 4.0 min for the first 10 patients to 4.4 ± 1.0 min in the last 10 patients. During the procedure, none of the patients had haemodynamic instability or oxygen desaturation. The average duration of artificial ventilation before PCT was 10.9 ± 5.5 days (range 2-28 days) and after PCT was 12.5 ± 9.1 (range 1-42 days). The mean duration of PCT was 20.9 ± 19.8 days (range 1-140 days). There were no PCT-related deaths.
Major bleeding occurred in two patients during the procedure. In these patients, the bleeding was controlled at bedside with anterior jugular vein ligation by a surgeon. In the third patient, major bleeding occurred 48 h after the PCT. The origin of the bleeding was a minor superficial artery that was damaged by the tracheostomy cannula. This bleeding was controlled by surgical intervention in the OR. The tracheostomy cannula was easily reinserted during the surgical procedure; blood transfusion was necessary in this patient. One patient developed minor bleeding which was resolving with simple direct pressure.
Thirty patients had successful decannulation. Early clinical examination revealed hoarseness in three patients. Twenty-two of the 30 decannulated patients were followed up for 10 weeks; the remainder of these patients were lost to follow up. We know that 10 weeks is not long enough for significant long-term complications to develop. Nevertheless, none of these 22 patients showed clinical signs of laryngotracheal stenosis. Stomas were closed within a few days leaving an approximately 1-cm scar. There were only two cases of wound infection, which were treated with local antiseptics. Other reported complications (e.g. pneumothorax, subcutaneous emphysema, misplacement) were not encountered.
Benjamin  described the complications attributed to prolonged intubation but laryngeal injuries can occur even within a few hours after intubation. There is widespread disagreement regarding the timing of tracheostomy [11,12]. Although the length of safe intubation time remains controversial, most prospective studies agree that endotracheal intubation beyond 7 days increases the probability of severe damage to the larynx [10,13,14]. Also, in our previous series, postintubation injuries were very common after a 10.6-day intubation period . Therefore, tracheostomy with PCT or ST should be considered after 1 week of endotracheal intubation.
ST is associated with complications including pneumothorax, local haemorrhage, stomal infection and death [8,16]. PCT solves some of these problems. It does not require a large incision, anterior neck dissection or tracheal cartilage removal. Therefore local haemorrhage and infection are seen more frequently in ST than in PCT. Also, there are hazards in transporting critically ill patients with risks of accidental disconnection of the breathing circuit or extubation as well as reduced monitoring during transfer . Also, PCT is a more rapid procedure, which is beneficial to unstable critically ill patients.
Although PCT is a minimally invasive method, some complications related to the different PCT techniques have been reported. The overall incidence varies from 0% to 25% and includes, tracheal cuff laceration, misplacement of the tracheostomy tube, haemorrhage, tracheal mucosal lesions, pneumothorax, subcutaneous emphysema and hypercarbia [8,18-23]. In our study, the only significant complication was haemorrhage (5.5%) which was controlled by surgical intervention or pressure applied to the stomal site. Local anaesthetic solutions containing epinephrine improve haemostasis, especially at the incision edges. Furthermore, the tracheostomy tube tamponades the skin edges. In this study, one patient required blood transfusion for haemorrhage.
To ascertain the location of the tip of the ETT and the needle, endoscopic guidance is generally recommended [24,25]. With the aid of a bronchoscope, accurate placement can be performed and complications can be avoided or diagnosed early . However, this is not ideal because conventional bronchoscopes do not easily fit through the ETT and may cause ventilation problems because significant hypercarbia has been reported with this technique [20,27]. Needle-induced damage to the bronchoscope is another danger reported by Juste and his colleagues . They also pointed out the inefficiency of a bronchoscope inside the ETT in assessing the needle position in relation to the tracheal rings. Fernandez and his colleagues  suggested that because of the problems cited above, major complications could be avoided by continuous bronchoscopic observation during the procedure. However, bronchoscopy is advocated after placement of the guide wire  and/or after tracheostomy . The use of the laryngeal mask and bronchoscope may offer an alternative approach ; however, further controlled studies are required.
Infection occurring in the stoma site is another major concern. Only two patients had minor skin infections, which were treated with topical antiseptics. Infection occurs significantly more frequently in ST [11,13]. The low incidence of haemorrhage and the small incision decrease the entry of bacteria in the stomal area. This may account for the lower incidence of infection. No patient suffered from pneumothorax, subcutaneous emphysema or tube misplacement with this technique. End-tidal CO2 monitoring was useful in confirming correct intratracheal position.
The optimal time for changing the tracheostomy cannula is considered to be within the first 2 weeks after PCT insertion . We changed the tracheostomy cannulas after 1 week and there were no misplacements of the cannulas at this time.
In conclusion, PCT is a simple and safe procedure. The guide wire dilating forceps proved to be a quick, easy-to-learn and effective method of performing PCT. This technique can be performed rapidly at the bedside in the ICU and with minimum stress to the patient. With increased experience and confidence with this technique, we feel that this method can be performed with greater safety. For these reasons, we believe that PCT is the procedure of choice for selected ICU patients who require tracheostomy.
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