Percutaneous dilatational tracheostomy: an observational study at tertiary level teaching hospital

Rajeev Kumar Shah; Bipin Koirala; Lalit Kumar Rajbansi; Batsalya Arjyal

doi:10.4103/jhnps.jhnps_62_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 10 | Issue : 2 | Page : 179-182

Percutaneous dilatational tracheostomy: an observational study at tertiary level teaching hospital

Rajeev Kumar Shah¹, Bipin Koirala¹, Lalit Kumar Rajbansi², Batsalya Arjyal²
¹ Department of Otorhinolaryngology, Birat Medical College and Teaching Hospital, Tankisinuwari, Nepal
² Department of Anaesthesiology and Critical Care, Birat Medical College and Teaching Hospital, Tankisinuwari, Nepal

Date of Submission	13-Sep-2022
Date of Decision	21-Nov-2022
Date of Acceptance	22-Nov-2022
Date of Web Publication	15-Dec-2022

Correspondence Address:
Rajeev Kumar Shah
Department of Otorhinolaryngology, Birat Medical College and Teaching Hospital, Tankisinuwari
Nepal

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jhnps.jhnps_62_22

Abstract

Introduction: Tracheostomy is the most commonly performed procedure worldwide. It is mainly done in critically ill patients requiring long-term ventilation, facial trauma, laryngeal fractures, laryngeal malignancy, etc., Converting from endotracheal intubation to tracheostomy has many benefits in terms of maintaining laryngeal function, feeding, and safety, it is more comfortable than endotracheal intubation. Tracheostomized patients require less analgesics and sedatives. It also helps in easier and early weaning from the mechanical ventilator, possibility of speech, and initiation of oral intake of medication. Percutaneous dilatational tracheostomy (PDT) is a safe and feasible procedure performed at bedside with minimal invasive technique in the intensive care unit (ICU). This all contributes to shorter ICU stay and hospital stay which becomes more cost-effective. Methods: This is a prospective observational study that was conducted in the 22-bedded neurointensive care and medical ICU of Birat Medical College and Teaching Hospital. The data were collected from August 01, 2021, to February 28, 2022. All patients needing tracheostomy for prolonged intubation, protection of airway, and to maintain tracheobronchial toileting was taking under study. Results: Our study was a prospective observational regarding PDT. A total of 71 patients were included in the study. Out of which, 39 (54.9%) were male and 32 (45.1%) were female with the ratio of (1.2:1). The age of the patients ranged from 18 to 82 years with the mean age of 53.25 years. The most common indication of PDT was prolonged intubation and that accounted for 29 (40.8%) of the patients which was followed by airway protection in 27 (38%) patients and to maintain pulmonary hygiene was seen in 15 (21.1%) patients. Conclusion: Tracheostomy is among the most frequently performed procedures in critically ill patients. PDT is a safe and feasible procedure performed at bedside with minimal invasive techniques in ICU.

Keywords: Bleeding, percutaneous dilatation tracheostomy, premature extubation, prolonged intubation

How to cite this article:
Shah RK, Koirala B, Rajbansi LK, Arjyal B. Percutaneous dilatational tracheostomy: an observational study at tertiary level teaching hospital. J Head Neck Physicians Surg 2022;10:179-82

How to cite this URL:
Shah RK, Koirala B, Rajbansi LK, Arjyal B. Percutaneous dilatational tracheostomy: an observational study at tertiary level teaching hospital. J Head Neck Physicians Surg [serial online] 2022 [cited 2023 Jun 4];10:179-82. Available from: https://www.jhnps.org/text.asp?2022/10/2/179/363930

Introduction

Tracheostomy is the most commonly performed procedure worldwide.^[1] It is mainly done in critically ill patients requiring long-term ventilation, facial trauma, laryngeal fractures, laryngeal malignancy, etc., Converting from endotracheal intubation to tracheostomy has many benefits in terms of maintaining laryngeal function, feeding, and safety and it is more comfortable than endotracheal intubation. Tracheostomized patients require less analgesics and sedatives. It also helps in easier and early weaning from the mechanical ventilator, possibility of speech, and initiation of oral intake of medication. This all contributes to shorter intensive care unit (ICU) stay and hospital stay which becomes more cost-effective.^[2],[3],[4] The other advantage of percutaneous tracheostomy is it can be done at bedside and there is no need of transferring unstable and critically ill patients to the operating room. This method becomes cost-effective and time-effective in terms of the use of workforce and equipment required.^[5]

Shelden et al. first reported percutaneous tracheostomy in 1955.^[6] Several tracheostomy techniques have been described as percutaneous.^[6],[7] Several methods of percutaneous techniques came into practice. However, the most popular technique which is being practiced was described by Ciaglia and Graniero^[8] as it performed rapidly and safely at the bedside. In the past, open surgical tracheostomy was the only method and is one of the oldest known procedures known to humankind. Only after 1985, percutaneous dilatation tracheostomy was popularized and it became an alternative to traditional open surgical tracheostomy.^[9]

The aim of this study is to record the learning curve, operative time, safety, complication, and different hemodynamic parameters of the body during the percutaneous tracheostomy.

Methods

This is a prospective observational study that was conducted in the 22-bedded neurointensive care and medical ICU of Birat Medical College and Teaching Hospital. The sample was collected from August 01, 2021, to February 28, 2022. The written and informed consent for inclusion in the study were taken from close patient relatives. Approval for the study was obtained from the institutional review committee.

The inclusion criteria for tracheostomy were patients requiring tracheostomy while the patients having any form of previous radiation of the neck, infection at the site of tracheostomy, age <18 years, bleeding diathesis, neck mass, history of neck surgery, and patient with cervical injury and emergency tracheostomy were excluded from the study group.

Smith Medical Portex kit was used for the procedure. The procedure was done under the supervision of an anesthesiologist. Adequate sedation with midazolam or propofol and adequate analgesia with intravenous fentanyl were given to achieve anesthesia. Routine monitoring including electrocardiogram, heart rate, blood pressure, and oxygen saturation was done.

The patient was positioned in supine position with head extension which was maintained by a sand bag in the back of the patient. Before the procedure, the tube was pulled back such that the tip of the endotracheal tube was located just at the level below the vocal cord with Murphy's eye below the cord. The tube was then refixed with tape.

Appropriate size percutaneous dilator (7, 7.5, and 8) was selected for the patient. The site for percutaneous puncture was marked two fingers above the sternal notch and was painted and draped. Injection 2% of lignocaine with adrenaline (1:80,000) was injected at the marked site. A horizontal incision up to the subcutaneous fascia was given and after that artery forceps were used to split underlying tissue. A 14-gauge needle was used to locate the trachea and was confirmed by the sudden loss of resistance and gush of air in the syringe. Once the needle sheath is inside the trachea, the guide wire was inserted till the white marking on the guidewire followed by a 14-gauge needle was used to locate the trachea insertion of the short dilator. The short dilator was removed leaving the guidewire in situ and the long guiding catheter was passed over the guidewire into the trachea in the direction of the arrow marked on the catheter. A well-lubricated “single-stage dilator” passed over the guiding catheter until it reached the safety stop. Finally, the dilator was removed and a well-lubricated tracheostomy tube was loaded on its introducer over the guiding catheter through the stoma with a slight twisting motion. The tracheal tube position was then finally confirmed by capnography. After that, the tube was connected to mechanical ventilator.

Results

Our study was a prospective observational regarding percutaneous dilatational tracheostomy (PDT). A total of 71 patients were included in the study. Out of which, 39 (54.9%) were male and 32 (45.1%) were female with the ratio of (1.2:1). The age of the patients ranged from 18 to 82 years with the mean age of 53.25 years.

The most common indication of PDT was prolonged intubation and that accounted for 29 (40.8%) of the patients which was followed by lower airway protection in 27 (38%) patients and to maintain the tracheobronchial toileting was seen in 15 (21.1%) patients.

The intraoperative and postoperative complications were noted. Bleeding was the most common complication seen and it accounted for 9 (12.7%) patients. This was managed during the intraoperative period by applying pressure and suture. Seven patients were managed by pressure, whereas two patients needed suturing. Five patients had stomal site infections. This was due to excessive secretion and poor tracheostomy care. Stomal site infection was managed with daily dressing and applying dry Neosporin powder. Premature extubation was seen in four patients who were managed by reinsertion of the Portex tracheostomy tube.

Tracheostomy in faulty passage was seen in 3 (4.2%) cases. This complication was noted immediately through capnograph. Transient hypotension was seen in 2 (2.8%) patients which was managed accordingly.

The tubal blockage was seen in 2 (2.8%) cases. This was managed by immediate removal of the tracheostomy and reinsertion of new tracheostomy tube in situ. Two patients had pneumothorax which was managed by insertion of a chest tube by surgeons. Similarly, two patients showed tracheoesophageal fistula which was managed conservatively by inserting feeding tube, and the patients was kept nil per orally for 7 days. While 42 (59.2%) did not have any kind of complication during the procedure and throughout their hospital stay.

The operating time for PDT was noted. The minimum time noted was 5 min, whereas the maximum time noted was 25 min. The mean operating time was 11.87. The heart rate ranged from 78 to 122 beats/min with the mean of 93.97. The mean arterial pressure was between 61 and 110 mm Hg with the mean of 84.34 during the procedure.

Discussion

The purpose of our study was to find out the efficacy, operating time, complication, and different hemodynamic paraments of the body during the PDT. The main advantage of PDT is the ability to perform it at the bedside in the ICU, thus avoiding a potentially hazardous transfer of critically ill patients to the operating room.

PDT has been shown to reduce significantly the cost of tracheostomy compared with surgical tracheostomy. The incision for percutaneous tracheostomy is relatively smaller compared to open surgical tracheostomy. The Portex tracheostomy tube is fitted tightly against the stoma so that there is less tissue dissection and less damage to the tissue in PDT procedure. The advantages being shorter hospital stays and long-term follow-up studies who underwent PDT in terms of complication and esthetically more favorable scar.^{[10],[11],[12]}

A study conducted by Kearney et al.^[13] found out that perioperative complication was seen in 6% of the cases and premature extubation was the most common complication. The early postoperative complication in form of bleeding was seen in 5% of the cases. While in our study, bleeding was the most common complication which was seen in 9 (12.7%) of the patients. The early postoperative complication in form of bleeding was seen in 5% of the cases. The mortality rate was 0.6% in the study conducted by Kearney et al.

In the study conducted by Toursarkissian et al.,^[14] the mean procedural time was 15 ± 9 min (range 5–60 min), whereas in our study. the operating time for the PDT range from 5 to 25 min with the mean of 11.87.

Percutaneous dilatational procedure is a closed procedure and has a risk of paratracheal insertion of tracheostomy tube insertion and posterolateral wall laceration. This complication has to be managed surgically with good outcomes.^[15]

There is certain situation in which open surgical tracheostomy is preferred over PDT. The procedure is mostly done by interventionist/anesthetist, surgeons prefer surgical tracheostomy. Similarly, open surgical tracheostomy is preferred during emergency placement of tracheostomy tube, in the condition where the anatomical landmarks are not clearly palpable such as short neck, obese, enlarged thyroid gland, nonpalpable cricoid cartilage, and gross shifting of the trachea.

The use of adjuncts like preoperative ultrasonography helps in identifying aberrant blood vessels thus preventing damage to the vessels and avoiding the risk of bleeding. Based on the preoperative ultrasound finding, Kollig et al.^[16] changed the site of tracheal puncture in 24% of the cases. The use of bronchoscopy during the procedure gives the additional benefit of confirmation of needle placement, dilatation, and tube placement.

Conclusion

Tracheostomy is among the most frequently performed procedures in critically ill patients. PDT is a safe and feasible procedure performed at bedside with minimal invasive techniques in ICU. It has very low morbidity if performed by skilled surgeon. The complication following PDT is relatively less. This technique is very cost-effective as it can be performed in the bedside thus eliminating the use of operating room and extra workforce. It also saves time for transporting the critically ill patients to the operating room. Thus, this method is safe, cost-effective, and can be done in a bedside. It is believed that the use of technical adjuncts like the use of ultrasound and bronchoscopy will improve patient safety.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Disclosure

This material has never been published and is not currently under evaluation in any other peer reviewed publication.

Ethical approval

The permission was taken from Institutional Ethics Committee prior to starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

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