Feasibility and Safety of Dilatational Tracheotomy Using the Rigid Endoscope

A Multicenter Study

Andreas Nowak; Peter Kern; Sven Koscielny; Taras I. Usichenko; Klaus Hahnenkamp; Markus Jungehülsing; Matthias Tittel; Jens Oeken; Eckart Klemm

Disclosures

BMC Anesthesiol. 2017;17(7) 

In This Article

Methods

Study Design and Patient Selection

All consecutive patients who were scheduled for elective PDT with TED at one of four German hospitals: Hospital Dresden-Friedrichstadt (city of Dresden), Cardiovascular Center (city of Cottbus), Hospital Ernst von Bergmann (city of Potsdam) and Hospital Chemnitz (city of Chemnitz) from 2006 to 2010 were included in this prospective multicenter observational investigation. The exclusion criteria were as follows: age <18 years, emergency cases, primary critical oxygenation parameters, severe gastroesophageal reflux disease, anatomical peculiarities (large thyroid goiter, fixed cervical spine, herniated discs and instability of the cervical spine), difficult airway, coagulopathy with an international normalized ratio (INR) <1.5 and platelet count ≤50 Gpt/l, phlegmonous inflammation of the neck, and conditions after neck dissection or radiation therapy. The protocol was approved by the local independent ethics committee (Ethikkommission der Sächsischen Landesärztekammer, Dresden, Germany). All patients (or, for unconscious patients, the legal guardian) gave their written informed consent to participate.

PDT Procedure

All patients underwent PDT with rigid endoscopic guidance with TED (Figs. 1 and 2), which was also used for lung ventilation during the PDT procedure, as described previously.[5] To prevent tooth damage, a shield was recommended. Single dilatator Ciaglia and Griggs guide wire dilating forceps (GWDF) percutaneous tracheostomy Introducer kits were used (Table 2). All patients received a sedation using balanced anesthesia with intravenous application of an opioid e.g. remifentanil (Glaxo Smith Kline, Brentford, UK) titrated to effect and intravenous application of a hypnotic agent e.g. 4 to 6 mg/kg/h propofol (Ratiopharm, Ulm, Germany). During PDT, anesthesia was accomplished with intravenous application of a non-depolarizing muscle relaxing agent, e.g. 0.1 mg/kg body weight cisatracurium (Glaxo Smith Kline). Heart rate and rhythm were monitored, and blood pressure was monitored by arterial catheterization of the radial artery or non-invasive by Riva Rocci method. Oximetry was monitored using a finger probe. The manufacturer of the tracheostomy sets, medication for general anesthesia and ventilation mode, such as intermittent positive-pressure ventilation (IPPV), high-frequency jet ventilation (HFJV) or superimposed high-frequency jet ventilation (SHFJV), were selected by the study centers themselves. The indications and timing for PDT were directed by the attending physicians at the hospitals.

Figure 1.

The rigid tracheotomy endoscope (TED) for percutaneous dilatational tracheotomy. a The rigid tracheotomy endoscope (TED; Carl Reiner GmbH, Vienna, Austria) for percutaneous dilatational tracheotomy. b The TED in situ

Figure 2.

Handling the TED. a An introduction to the TED. b Diaphanoscopy with the TED - bright transillumination provides sufficient orientation. c Phase 1 puncture of the trachea. d Phase 1 endoscopic view. e Phase 2 dilation of the trachea. f Phase 2 endoscopic view. g Phase 3 insertion of the cannula. h Phase 3 endoscopic view

Outcome and Statistical Analysis

Data collection was performed using a structured protocol. Based on previous observational PDT research,[3] the complications of PDT with TED were defined as follows: i) bleeding (>10 ml, defined by the experts as clinically relevant during PDT[7]); ii) posterior tracheal wall lesion; iii) tracheal ring fracture; iv) desaturation < 90%; v) anesthesia complication; vi) pneumothorax; vii) other incidents (dislocation of guide wire, difficult dilation, dislocation of fractured fragment of tracheal ring, dental damage and airway obstruction by blood clots). Complications were classified as minor, intermediate or major depending on their severity (Table 1).[3] According to expert recommendation, the complications were attributed to the three phases of PDT: puncture (phase 1), dilatation (2) and cannula insertion (3).[8]

Statistical analysis was performed using SPSS 21.0 software (IBM, Armonk, New York, USA). The descriptive data are given as number (percent) of cases and as the mean ± standard deviation (SD) where appropriate. The relationships between dichotomous and categorical parameters were analyzed using the chi-square test. P values ≤ 0.05 were considered significant.

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