Journal of Postgraduate Medicine Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India ISSN: 0022-3859 EISSN: 0972-2823 Vol. 47, Num. 2, 2001, pp. 100-103

Journal of Postgraduate Medicine, Vol. 47, Issue 2, 2001 pp. 100-103

Percutaneous Tracheostomy by Guidewire Dilating Forceps Technique: Review of 98 Patients

Abstract

BACKGROUND: Percutaneous tracheostomy to a large extent has replaced conventional surgical tracheostomy by virtue of its low incidence of complications and the rapidity with which the procedure can be performed at the bedside avoiding transport of critically ill patients to the operating rooms. Since it is a blind approach, ponchoscopic guidance has been suggested which might not always be possible due to logistic reasons. METHODS: A retrospective study of 98 patients who had guide wire dilating forceps technique of percutaneous tracheostomy without the aid of a ponchoscope was undertaken. By ensuring the free mobility of the guide wire at each step of the procedure, a safe placement of the tracheostomy tube was achieved. RESULTS: The mean operating time was 3.05 mins [S.D:2.20]. Two patients had peristomal bleeding as an early complication. 34 patients could be decannulated with good primary approximation of the stomal tissues [mean: 3.92days, S.D: 1.46]. There were no deaths or life threatening complications attributable to this technique. CONCLUSIONS: In the absence of ponchoscopic guidance, adopting the simple but effective precaution of free movement of guide wire at each step of the procedure, a safe tracheostomy tube placement is possible.

Key Words: Percutaneous Tracheostomy, precautions, safety.

Tracheostomy is frequently performed in patients admitted to intensive care units (ICUs). Ventilatory dependence and the need for tracheal toilet are the important indications for the tracheostomy.1,2 This has been conventionally achieved by performing the tracheostomy surgically. However, percutaneous tracheostomy is now preferred over the conventional surgical tracheostomy due to decreased incidence of complications associated with the technique.3 The technique of percutaneous tracheostomy described by Shelden in 19554 has undergone several modifications over a period of time.5,6,7 One of them7 uses a guide wire dilating forceps (GWDF), which is a specially designed instrument that is passed over a guide wire into the trachea. It has been recommended that fipe optic ponchoscope should be utilized in this method so that procedural complications are reduced and accurate placement of the tracheostomy tube is achieved.8,9 However, for logistic reasons this may not be routinely possible. Therefore, in an attempt to minimize complications it is a practice at our centre to follow a simple precaution that is to ensure the free mobility of the guide wire at each step of the procedure. This paper deals with the retrospective analysis of 98 patients admitted to Post Cardiac Surgical Unit [PCSU] and Adult Intensive Care Unit [AICU] in our institute, in whom the percutaneous tracheostomy was performed using GWDF technique, without the aid of a fipeoptic ponchoscope.

Subjects and Methods

Ninety eight patients underwent percutaneous tracheostomy between November 1998 and May 2000 at our hospital. The procedure was performed after obtaining the informed consent from the closest relative of the patient and GWDF technique was utilized in all of them. Ventilator dependence or prolonged tracheal toilet was the main indication for the percutaneous tracheostomy. Patients with thyroid enlargement or unfavourable anatomy were excluded. Any significant coagulopathies were corrected and the following technique was employed. The procedure was performed at the bedside under aseptic precautions, by two anaesthesiologists. One of them actually performed the procedure and the other maintained the airway and monitored ventilation and circulation. ECG, blood pressure and SpO(2) were monitored continuously. Local anaesthesia and sedation, with or without muscle relaxant were used during the procedure. A Portex percutaneous tracheostomy kit with its GWDF of appropriate size was used. The patient was positioned supine with a slight head-up tilt and a pillow underneath the shoulders to hyperextend the neck. After a thorough endotracheal and pharyngeal suction, the cuff of the endotracheal tube was deflated and the tube was withdrawn until the cuff was just above the laryngeal inlet. The cuff was inflated in this position to provide a good seal. The space between first and second or second and third tracheal rings was chosen for tube insertion. After infiltrating the selected site with 1% xylocaine (1-2 ml), the needle and cannula (provided in the kit) attached to a syringe containing saline was gradually inserted in a slightly caudal direction. Free aspiration of air confirmed the entry into the trachea. The needle and syringe were then removed leaving the cannula in the trachea. Bubbling of a saline drop placed on the hub of the cannula with ventilation reconfirmed the position of the tip of the cannula in the trachea. The guide wire was then inserted through the cannula for approximately 10 cms and checked for its free movement. The cannula was then removed leaving the guide wire in the trachea. After making small incision the 14- French dilator provided in the kit was passed over the guide wire dilating the tissues, following which the dilator was removed leaving the guide wire. A small horizontal skin incision of 1-1.5 cm was made across the guide wire insertion site and the GWDF was passed over the guide wire into the trachea. The free movement of the guide wire in the GWDF ensured correct placement. The GWDF was opened using both hands to dilate tissues just enough to accept the tracheostomy tube and the GWDF was withdrawn in the open position. 96% of the times we obtained the desired dilatation at first attempt, in the remaining a second attempt was required, and there was no over dilatation. The tracheostomy tube obturator along with the tracheostomy tube was now passed over the guide wire into the trachea. Free movement of the guide wire was once again ensured. The guide wire and the obturator were removed leaving the tracheostomy tube in the trachea, which was secured firmly. Endotracheal suction was performed and the ventilation was established through the tracheostomy tube. The endotracheal tube was then removed. Data is presented as mean ± standard deviation. Median values are considered for data that is not distributed normally.

Results

There were 71 males and 27 females with a mean age of 58 ± 15 years. (range 16-91 years). Table-1 shows the distribution of patients as per the diagnosis. The majority of patients suffered from neurological ailments (42 patients) or cardiac diseases including those who had undergone prior cardiac surgical procedure (35 patients). The decision to perform tracheostomy by GWDF technique was taken within 6.6 ± 5.4 days of endotracheal intubations. The mean duration of the procedure in our patients i.e. from skin incision to successful insertion of tracheostomy tube was 3.05 ± 2.2 minutes with a range of 1.5 to 14 minutes. Table-2 shows the duration of the procedure and the complications related to the procedure. There were no complications during the procedure. Bleeding was the early complication that occurred in our patients. One patient had minor bleeding, that was managed conservatively with stomal packs and a second patient had significant bleeding. This patient needed re-exploration that revealed a small arterial bleed, which was controlled, and tracheostomy tube reinserted. No blood transfusion was necessary in either case. There were no other complications such as excessive purulent exudate at stoma or major bleeding. There were no peroperative complications in our patients. Table-3 shows the outcome of the patients. Successful decannulation was achieved in 34 patients (34.7%) and conversion to permanent tracheostomy was necessary in 5 patients (5.1%). Wound approximation by primary closure after decannulation was achieved within 3.92 ± 1.4 days. Fifty-nine patients (60.2%) died as a consequence of the primary disease and seven patients of those decannulated were lost to follow up.