Percutaneous Tracheostomy: A Practical Handbook. H. G. W. Paw, A. R. Bodenham. Greenwich Medical Media Ltd: Cambridge, UK, 2004, 158 pp; indexed, illustrated ISBN: 1-84110-142-7; Price £35.00
From the time when I witnessed the first percutaneous tracheostomy being performed by a general surgical registrar on our unit, percutaneous tracheostomy has become a well-established procedure in intensive care units (ICUs) across the UK. The early adopters of this technique were largely self-taught. They are now the likeliest people to be training the next generation of operators. The technique is commonly taught to intensive care trainees who, now more than ever, may have varying degrees of experience and understanding. The majority of trainees are probably taught at the bedside during the performance of a percutaneous tracheostomy with little or no ‘formal’ education in this area. This may lead to some important aspects of the technique not being covered by the trainer, as there is a tendency to concentrate on the practical aspects of the procedure that is being performed. Some variation in the approach to and timing of tracheostomies occurs between the consultant staff both within and between ICUs. This means that the trainee may be left unsure as to what is currently best practice. Therefore, there is a place for a text that allows the trainee to fill any knowledge gaps that can result from bedside teaching and supervised practice.
This book fills that gap admirably. It describes itself as a practical handbook, which it clearly is as the handbook is full of useful, applicable information and is of a concise size. The authors aim to produce a balanced overview of the subject without getting overwhelmed with detail. I believe that they have succeeded. This is a book of manageable proportions both in terms of its physical size and the ease with which one can access particular areas of interest. It is divided into 13 short chapters that deal with different aspects of percutaneous tracheostomy from the history of the technique to a series of hints and tips. Each chapter stands on its own, which leads to some repetition, but this is not a bad thing as it reinforces some of the important points. The chapters are colour coded to allow the reader to easily find the right section of the book. While this is a good idea, it has resulted in one chapter using white print on a yellow background for headings. This colour combination makes the headings difficult to read. The chapters otherwise are clear and easy to read, many diagrams and illustrations are used well to complement the text. The diagrams and illustrations are particularly useful in this context as much of the book is describing equipment and procedures. A picture is truly worth a thousand words.
I believe that the authors have done well to include all the areas pertinent to percutaneous tracheostomy. The chapters are set out in a logical order which leads the reader through the anatomy, indications for tracheostomy, techniques for performing percutaneous tracheostomy to the after care of the patient and the tracheostomy. Issues that may not normally be taught to trainees at the bedside, such as consent and aftercare with decannulation, are included in this book. It is clear that the authors are speaking from their own experience, while backing this up with reasonable numbers of references where they exist or referring the reader to larger textbooks.
I particularly approved of the standards they describe for the anaesthetic management of patients having percutaneous tracheostomies. They stress that inexperienced trainees should not be left unattended to manage the airway. The importance of achieving the same care and attention as required for a general anaesthetic in theatres is stated. They rightly include capnography as a monitoring standard when performing percutaneous tracheostomy. The hints and tips chapter contains extremely useful and applicable advice that can only have been learned the hard way by the authors. Following it may allow the less experienced to avoid rather than experience similar problems.
I have some differences of opinion with the authors where for instance they list patient comfort as their first indication for tracheostomy and suggest that the presence of an endotracheal tube will always require significant quantities of sedative and analgesic drugs. Unless the patient has known risk factors for bleeding, then is it really necessary to check their clotting? However, I do not feel that these minor points are sufficient to change my overall impression of the value of the book.
This book is an excellent short text to have in any ICU where percutaneous tracheostomies are carried out. It will be particularly useful to those trainees who see or practise the technique. It will aid trainers in covering all of the topics that should be taught to the trainees but are often overlooked. It also contains information for the experienced operator who wishes to remind themselves of facts they have forgotten or may not have come across before. I would recommend that it is readily available on all ICUs practising percutaneous tracheostomy.
P. W. Duncan