Percutaneous Dilational Tracheostomy in the Emergent Setting

doi:10.4236/ijcm.2013.42018

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International Journal of Clinical Medicine, 2013, 4, 96-98

http://dx.doi.org/10.4236/ijcm.2013.42018 Published Online February 2013 (http://www.scirp.org/journal/ijcm)

Percutaneous Dilational Tracheostomy in the Emergent

Setting

Andrew McCague*, David T. Wong

Arrowhead Regional Medical Center, Colton, USA.

Email: *[email protected]

Received October 15th, 2012; revised November 15th, 2012; accepted November 22nd, 2012

ABSTRACT

Objective: Since its inception, the use of the percutaneous dilational tracheostomy (PDT) has been contraindicated in

the setting of an emergent airway. Emerging in the literature are several cases of successful emergent PDTs. Here we

present our experience with the use of PDT in managing emergent airways. Study Design: All patients who underwent

emergent PDT, using the Ciaglia Blue Rhino Introducer Set (Cook Critical Care, Bloomington, IN), in an academic

county hospital setting between February 2010 and May 2012 were included in the study. Electronic medical records

were reviewed for demographic and procedural data. Results: Twelve patients were included in the study with ages

ranging from 20 to 87 (mean 57) years old. The most common reason for emergent airway was trauma (7 patients), fol-

lowed by obstructing neck mass (2 patients), septic shock (2 patients), and angioedema (1 patient). Seven PDTs were

performed in the OR, four at bedside and one in the ER. Three of the 12 patients had emergent cricothyroidotomies in

place that malfunctioned, requiring emergent conversion. No patients suffered from short term complications. One pa-

tient developed a neck abscess at the site of the PDT one month post operatively, two patients had accidental decanula-

tion post operatively, and both were replaced without complication. Conclusions: PDT can be used in the emergent

setting in the hands of trained practitioners with minimal complications. A larger, prospective trial is needed to make

conclusi ons regar ding patie n t care.

Keywords: Percuta neous Di l at i onal Tracheostomy; Em ergent Airway; Trache ostomy

1. Introduction

The use of percutaneous dilational tracheostomy (PDT)

has continuously increased since its original description

by Ciagla in 1985. Since its inception, a need for an

emergent airway has been considered an absolute con-

traindication for the use of PDT. As case reports emerge,

a growing body of eviden ce is showing that PDT may be

an option in specific emergent conditions where an emer-

gent airway is necessary.

Most published articles consider cervical injury, pedi-

atric age < 8 years old, gross distortion of the neck anat-

omy, unidentifiable landmarks, visible large blood ves-

sels in the operative field, and need for emergent airways

as absolute contraindications, whereas obesity with a

short neck, coagulopathy, need for positive end-expira-

tory pressure of >20 cm of water, and evidence of infec-

tion in the soft tissues of the neck at the prospective sur-

gical site are relative contraindications [2].

With difficult intubations occurring in approximately

2% - 4% of all intubation attempts, the clinician may

expect emergent surgical airways to periodically be re-

quired [2]. Unfortunately, most clinicians find them-

selves performing these procedures for the first time in

an emergency, where failure rates and complication rates

are already high [2]. The opportunity to perfect the tech-

nique of PDT in an elective setting improves perform-

ance of this technique during an emergent setting.

Here we pr esen t our exper ience with th e use of PDT in

managing emergent airways.

2. Methods

All patients who underwent emergent PDT, using the

Ciaglia Blue Rhino Introducer Set (Cook Critical Care,

Bloomington, IN), in an academic county hospital setting

between February 2010 and May 2012 were included in

the study. Electronic medical records were reviewed for

demographic and procedural data. Emergent PDTs were

defined as PDTs performed in the setting of impending

airway loss. Short term complications were defined as

bleeding, malposition, pneumothorax, tracheal ring rup-

ture, conversion to open and procedural hypoxia. Long

term complications included bleeding, infection, acciden-

tal decanulation, granuloma formation, tracheal stenosis

*Corresponding a uthor.

Percutaneous Dilational Tracheostomy in the Emergent Setting 97

and dysphagia.

All PDTs were performed with attending physician at

bedside, most by a surgical resident. The Ciaglia Blue

Rhino Single Dilator Introducer Kit™ (Cook Medical

Inc., Bloomington, IN.) was used for all PDTs. All PDTs

were performed without bronchoscopic guidance with

local anesthetic and minimal or no sedation. Wh en avail-

able, positioning was confirmed with bronchoscopy.

Follow-up was determined from the most recent visit

as recorded in the electronic medical records. All data

was recorded and stored in an Excel (Microsoft, Red-

mond Wa.) spreadsheet for descriptive analysis.

3. Results

Results are presented in Table 1 below. Twelve patients

were included in the study with ages from 20 to 87 (mean

57) years old, length of stay 5 to 114 (mean 30) days and

body mass index from 23.9 to 47 (mean 31) kg/m2. The

most common reason for emergent airway was trauma (7

patients), followed by obstructing neck mass (2 patients),

septic shock (2 patients), and angioedema (1 patient).

Seven PDTs were performed in the OR, four at bedside

and one in the ER. Three of the 12 patients had emergent

cricothyroidotomies in place that malfunctioned, requir-

ing emergent bedside conversion.

No patients suffered from short term complications.

No patient expired or suffered anoxic brain injury as a

result of the procedure. One patient expired six days after

the PDT was performed due to a pulmonary embolism.

Six patients were discharged home, four sent to rehab,

one transferred to another hospital and one expired. Long

term complications occurred in 3 of the 12 patients. One

patient developed a neck abscess at the site of the PDT

one month post operatively, two patients had accidental

decanulation post operatively, and both were replaced

without complication. Follow-up ranged from 6 to 658

(mean 132) days.

4. Discussion

The use of PDT in the emergent setting has been revered

as an absolute contraindication since its inceptio n. As the

use of PDTs has grown in recent years, a growing body

of literature has shown the successful use of PDTs in the

emergent setting. Though PDTs will not replace the

emergent cricothyroidotomy, in specific clinical scenar-

ios we have shown that the PDT can be safely used in an

emergent setting avoiding the need for a future conver-

sion procedure.

In the above study, twelve patients underwent PDT in

an emergent setting without any sh ort term complications.

Three patients suffered from long term complications

though these are unlikely related to the emergent nature

of the procedure. One patient had a neck abscess and two

patients had accidental decanulation. These complica-

tions could equally have occurred if the procedure was

elective. One patient expired during the study due to a

Table 1. Descriptive data.

Case Age Sex Diagnosis Indication LocationLosFollow upDischarge Confirmation bronchoscopy Complication

1 78 M Cancer Difficult

intubation ER 5193 Home No Abscess

2 45 F Angioedema

Difficult

intubation OR 597 Home Yes Decanulation

3 50 M Trauma Obstructed

Cricothyroidotomy Bedside24659 Rehab Yes None

4 20 M Trauma Obstructed

cricothyroidotomy Bedside931 Home No Decanulation

5 80 M Trauma C-spine deformity,

difficult intubation OR 1528 Rehab Yes None

6 60 M Trauma Tracheal laceration

extending over ET tube OR 828 Home Yes None

7 87 F Trauma Difficult airway

impingment OR 19245 Hospital TransferYes None

8 61 M Sepsis Edematous airway,

failed intubation Bedside9080 Home Yes None

9 49 M Sepsis Obesity Bedside114158 Rehab Yes None

10 27 M Trauma GSW to Neck OR 66 Expired Yes None

11 62 M Cancer Larygneal Cancer,

Difficult intubation OR 3434 Home Yes None

12 66 F Trauma C-spine fx,

difficult airway OR 3131 Rehab Yes None

Percutaneous Dilational Tracheostomy in the Emergent Setting

pulmonary embolism, unrelated to the use of PDT. For

difficult to intubate patients with impending airway loss

PDT is a possible alternative to cricothyroidotomy when

performed in the hands of experienced practitioners.

In 2003, Ault et al. reported the largest series to date

of successful emergent PDT which included nine patients

with compromised airways. In their paper all nine pa-

tients were successfully intubated with a PDT technique

either in the Emergency Room or one of the Intensive

Care Units. They conclude that in specific clinical situa-

tions the PDT technique may play a role in management

of emergent surgical airways [2].

Because of the emergent nature of the PDTs per-

formed in our study, bronchoscopy was not used to guide

placement. When available we did, however, use bron-

choscopy to confirm placement. In the emergent situation,

neither time nor the presence of an existing endotracheal

tube permits the use of broncoscopy [2]. Bronchoscopic

guidance is a valuable but not essential adjunct to per-

formance of PDT and should not preclude use of this

procedure in the emergent setting [2]. In 2011, Jackson et

al. reported on 168 PDTs performed without broncho-

scopy compared with 78 performed with bronchoscopy

[3]. They found that there was not a difference in com-

plication rates between the two groups thus confirming

the practice of PDTs without bronchoscopy [3].

Though cricothyroidotomy is still the standard of care

for an emergent surgical airway; PDT has several advan-

tages. The major advantage of PDTs is the ab ility to gain

and maintain competence in an elective and controlled

setting [2]. This experience is invaluable as comfort and

familiarity with any procedure improves success and

reduces complications. Indications for performing a cri-

cothyroidotomy (surgical or needle) are very limited. It is

therefore extremely difficult to gain experience and be-

come confident in performing this procedure [4]. The

PDT also has the possibility of becoming a definitive

airway for the patient, there is no need to convert to a

formal tracheostomy as is the case with the cricothryroi-

dotomy. PDT has the advantage over an open surgical

technique as it is faster, can be performed under local

anesthesia at the bedside with or without prior airway

access, and can be performed within three minutes [4].

When comparing PDT to open tracheostomy, not only

is PDT a faster procedure but it has also been reported to

have lower complication rates. Moe et al. demonstrated

that PDTs have lower rates of pneumothorax, major

hemorrhage and laryngeal granulation when compared to

open tracheostomy [2]. They also reported an 8 minute

shorter procedure with PDTs as compared with open

tracheostomy [2]. Graha et al. also reported similar ad-

vantages with the use of PDT. They fou nd no significant

difference in major or minor complications when com-

paring PDT to open tracheostomy [2].

Our experience with PDT has shown that difficult air-

ways can be managed with this technique safely. In our

series of twelve patients, all attempted emergent PDTs

were performed successfully without loss of airway or

need to convert to a conventional tracheostomy. Though

additional trials are necessary to provide conclusive evi-

dence, we suggest that the use of PDTs may have a place

in the management of difficult and emergent airways.

5. Conclusion

Here we present twelve patients all who have undergone

PDT in an emergent setting. None of these patients suf-

fered short term complication s. Long term complications

seen in these patients were not related to the emergent

nature of the procedure. PDT can be used in the emergent

setting in the hands of trained practition ers with minimal

complications. Our study shows a lower complication

rate compared to previously published reports. A larger,

prospective trial is needed to make conclusions regarding

patient care.

REFERENCES

[1] A. McCague, H. Aljanabi and D. T. Wong, “Safety Ana-

lysis of Percutaneous Dilational Tracheostomies with

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[2] M. J. Ault, B. Ault and P. Ng, “Percutaneous Dilational

Tracheostomy for Emergent Airway Access,” Journal of

Intensive Care Medicine, Vol. 18, No. 4, 2003, pp. 222-

226. doi:10.1177/0885066603254108

[3] L. S. Jackson, J. W. Davis, K. L. Kaups, L. P. Sue, M. M.

Wolfe, J. F. Bilello and D. Lemaster, “Percutaneous Tra-

cheostomy: To Bronch or Not to Bronch—That Is the

Question,” Journal of Trauma, Vol. 71, No. 6, 2011, pp.

1533-1536. doi:10.1097/TA.0b013e31823ba29e

[4] N. Jonas, W. Mulwafu and J. Joubert, “Emergent Percu-

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