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


BMC Anesthesiol. 2017;17(7) 

In This Article


One hundred eighty patients (66 women) were scheduled to undergo elective PDT with TED, 56 patients (31.1%) in Hospital Dresden-Friedrichstadt, 40 patients (22.2%) in Cardiovascular Center (city of Cottbus), 20 patients (11.1%) in Hospital Ernst von Bergmann (city of Potsdam) and 64 (35.6%) in Hospital Chemnitz (city of Chemnitz). The mean age of the patients was 64.0 ± 14.7 (range 19–86) years and the mean body mass index (BMI) was 26.7 ± 5.0 (range 14.5–46,9) kg/m2 (Table 2). In 31 patients (17.2%) BMI was ≥ 30. In 179 patients, tracheotomy was successfully performed; in one case, tracheotomy was declined after endoscopy because of the atypical position of the innominate artery, which was identified by synchronous heart rate pulsations in the anterior wall of the trachea. In 5 (2.8%) patients, PDT was converted to a surgical tracheotomy (ST) because of complications during the PDT procedure. Two cases of conversion to ST took place during phase 1, three conversions to ST occurred during dilatation (phase 2), in all 5 cases PDT were converted to ST without complications. The reasons for PDT conversion to ST are provided in Fig. 3. The total rate of adverse events and complications was 40.8% (Table 3). No major (life-threatening) complications or procedure-related deaths occurred in 174 cases during PDT, which required 14.8 ± 6.2 (mean ± SD) minutes of procedural time. The incidence of minor and intermediate complications and incidents within different phases of PDT is provided in Table 3. The incidence of complications in patients with BMI ≥ 30 was comparable with those of BMI < 30 (P ≥ 0.05).

Figure 3.

Enrollment and exclusion flowchart


In seven patients, the bleeding exceeded 10 ml of blood loss and required additional treatment during PDT. In 2 cases, the bleeding stopped after suction, in 1 case, bronchoscopy was necessary with the change from HFJV to IPPV. In 1 case of bleeding at the lower edge of the tracheostomy, electrical coagulation was required. Another patient developed outward bleeding from a superficial vein, which stopped after suction and compression. The procedure-associated administration of blood products, nor any other additional procedures were required. The conversion of PDT to ST was necessary in two patients because of bleeding (Fig. 1 and Table 3). Death or persistent sequelae due to bleeding did not occur. There was no difference in the incidence of bleeding between genders (Fisher's exact test; p = 0.424) and among the study centers (Kruskal-Wallis test; p > 0.096). In addition, the differences between the various phases of PDT (X2 test by Pearson; p = 0.501) were not significant.

Tracheal Ring Fractures

Tracheal ring fractures occurred in 30 out of 173 patients (17.1%); 23 of these fractures occurred during phase 2 of PDT (Table 3). Seventeen cases (13 in phase 2) required endoscopic resection, which was performed immediately after PDT over the rigid TED. The amassment of tracheal ring fractures in phase 2 was significant (Kruskal-Wallis test; p = 0.000)

Posterior Tracheal Wall Injuries

Two patients (1.1%) suffered mild lesions of the posterior tracheal wall. One posterior tracheal wall injury occurred in phase 1 as a result of difficulty locating the puncture site; the tracheal posterior wall was punctured below the TED by a needle (Table 3). A second case with injury to the tracheal structures occurred because of dilatation during phase 2. Because of the anatomically short trachea, the tip of the dilator caused minor mucosal erosion in the left main bronchus. Neither case required additional treatment.

Anesthesia Complications

In eight patients (4.5%), anesthesia complications occurred. Six anesthesia complications were documented in phase 1 (3.4% of n = 178 valid cases). Five anesthesia complications during phase 1 were related to ventilation and oxygenation, and four of these complications required the change of ventilation mode from HFJV to IPPV. The sixth complication resulted from an insufficient depth of anesthesia: as a result adrenergic stimulation occurred and the trachea moved synchronously with vascular pulsation because of transitory hypertension, making it difficult to perform PDT. In phase 2, one patient was switched from HFJV to IPPV because of desaturation and hypercapnia; another patient developed hypotension that required correction with volume administration. No anesthesia complications occurred during phase 3. There were no differences in anesthesia complications between genders (X2 test by Pearson; p > 0.05) and among study centers (Kruskal-Wallis test; p > 0.05). However, there was a difference in the incidence of anesthesia complications between the phases of PDT (Kruskal-Wallis test; p < 0.05).


In 12 patients (6.8%), short transitory desaturations with SpO2 < 90% occurred, in two patients classified as minor complication and in 10 patients as intermediate complication (Table 1) The reasons for the drop in oxygen saturation during phase 1 were predominantly associated with aspects of underlying pulmonary disease. Six patients with desaturations in phase 1 were ventilated with HFJV with subsequent conversion to IPPV via the TED. During phase 2, desaturation resulting from tracheal bleeding was documented in one patient and required surgical treatment with conversion to ST. The TED was removed and an endotracheal tube replaced (Fig. 1). During phase 3, desaturation occurred in five patients. Their desaturation was associated with medical factors (i.e., bronchospasm or technical problems associated with cannula insertion; Table 4). The notified lowest value was 72% and was caused by heavy tracheal bleeding. In all cases of desaturation no hypoxia sequelae or life-threatening events occurred. No desaturation or bleeding was registered in 25 (14.0%) patients, who were ventilated using the SHFJV mode. There were no differences regarding the incidence of desaturation between genders (Fisher's Exact test, p > 0.540), among study centers (Kruskal-Wallis test; p = 0.204) and among the phases of PDT (Kruskal-Wallis test, p > 0.110).

Other Incidents

Dental Damage. In one out of the 118 patients (0.85%) with remaining teeth, the tooth, which was loose prior to PDT, was removed during rigid endoscopy with TED. The patient's teeth were described as extremely carious before the PDT procedure. An experienced otolaryngologist performed the endoscopy with TED.

Difficult Intubation With TED. Easy placement of the TED was confirmed in 90.6% of patients. In 17 patients (9.4%), the introduction of the TED was difficult (Table 5). Cormack and Lehane grades III–IV were associated with difficult intubation using TED (P = 0.001).