Percutaneous dilational tracheostomy following anterior cervical spine fixation - a retrospective propensity-matched cohort study.

PURPOSE: In patients with traumatic, infectious, degenerative, and neoplastic surgical indications in the cervical spine, commonly the anterior approach is used. Often these patients require a tracheostomy necessary due to prolonged mechanical ventilation. The limited spinal mobility and proximity to the surgical site of anterior cervical spine fixation (ACSF) could pose an increased risk for complications of percutaneous dilational tracheostomy (PDT.) Importantly, PDT might raise wound infection rates of the cervical spine approach. The aim of this study is to prove safety of PDT after ACSF. METHODS: We performed a retrospective, single-center study comparing patients with and without ACSF who underwent Ciaglia-single step PDT. After propensity score matching using logistic regression, we compared intra- and postprocedural complication rates. Furthermore, surgical site infections were evaluated. Putensen's definitions of complications and Clavien-Dindo's classification were used. RESULTS: A total of 1175 patients underwent PDT between 2009 and 2021. Fifty-seven patients underwent PDT following ACSF and were matched to fifty-seven patients without ACSF. The mean interval between ACSF and PDT was 11.3 days. The overall complication rate was 19.3% in the ACSF group and 21.1% in the non-ACSF group. The mean follow-up was 388 days (± 791) in the ACSF group and 424 days (± 819) in the non-ACSF group. Life-threatening complications (Clavien-Dindo IV to V) were found in 1.8% of ACSF patients and 3.5% of non-ACSF patients. There were no significant differences in complication rates. No surgical site infection of the anterior spine access was detected. CONCLUSION: PDT is a feasible and safe procedure in patients after ACSF. Complication rates are comparable to patients without ACSF. Surgical site infections of ACSF are very rare.

Transillumination and Point-of-Care Ultrasonography to Delineate Tracheal Deviation for Challenging Tracheostomy: A Case Report.

Tracheostomy is indicated for varied reasons and is a relatively safe procedure that can be done with both open and percutaneous methods. However, the procedure is often challenging in cases of distorted neck anatomy. Neck swellings often push the trachea laterally or shield it. Even some gross intrathoracic pathology may shift the trachea from the typical trajectory making it challenging to delineate the course of the trachea. A bedside point-of-care technique having a visual aid that can guide the performer thus appears beneficiary. Fiber-optic assistance for correct puncture and confirmation is known, and light-based techniques have been used for tracheostomies. As fiberscopes are not infrequent in tertiary and even secondary care hospitals, transillumination from a flexible bronchoscope can identify the altered course of the trachea, much like a navigation system, and systematically aid the performer in steering away from the obstacles. We present two cases in two scenarios with tracheal deviation who underwent either open or percutaneous tracheostomy with point-of-care ultrasound and transillumination to delineate the course of the trachea and facilitate difficult tracheostomies safely.

A Novel COVID-19 Severity Score is Associated With Survival in Patients Undergoing Percutaneous Dilational Tracheostomy.

INTRODUCTION: Tracheostomy in patients with COVID-19 is a controversial and difficult clinical decision. We hypothesized that a recently validated COVID-19 Severity Score (CSS) would be associated with survival in patients considered for tracheostomy. METHODS: We reviewed 77 mechanically ventilated COVID-19 patients evaluated for decision for percutaneous dilational tracheostomy (PDT) from March to June 2020 at a public tertiary care center. Decision for PDT was based on clinical judgment of the screening surgeons. The CSS was retrospectively calculated using mean biomarker values from admission to time of PDT consult. Our primary outcome was survival to discharge, and all patient charts were reviewed through August 31, 2021. ROC curve and Youden index were used to estimate an optimal cut-point for survival. RESULTS: The mean CSS for 42 survivors significantly differed from that of 35 nonsurvivors (CSS 52 versus 66, P = 0.003). The Youden index returned an optimal CSS of 55 (95% confidence interval 43-72), which was associated with a sensitivity of 0.8 and a specificity of 0.6. The median CSS was 40 (interquartile range 27, 49) in the lower CSS (<55) group and 72 (interquartile range 66, 93) in the high CSS (≥55 group). Eighty-seven percent of lower CSS patients underwent PDT, with 74% survival, whereas 61% of high CSS patients underwent PDT, with only 41% surviving. Patients with high CSS had 77% lower odds of survival (odds ratio = 0.2, 95% confidence interval 0.1-0.7). CONCLUSIONS: Higher CSS was associated with decreased survival in patients evaluated for PDT, with a score ≥55 predictive of mortality. The novel CSS may be a useful adjunct in determining which COVID-19 patients will benefit from tracheostomy. Further prospective validation of this tool is warranted.

Percutaneous Dilational Tracheostomy at the Epicenter of the SARS-CoV-2 Pandemic: Impact on Critical Care Resource Utilization and Early Outcomes.

BACKGROUND: The COVID-19 pandemic overwhelmed New York City hospitals early in the pandemic. Shortages of ventilators and sedatives prompted tracheostomy earlier than recommended by professional societies. This study evaluates the impact of percutaneous dilational tracheostomy (PDT) in COVID+ patients on critical care capacity. METHODS: This is a single-institution prospective case series of mechanically ventilated COVID-19 patients undergoing PDT from April 1 to June 4, 2020 at a public tertiary care center. RESULTS: Fifty-five patients met PDT criteria and underwent PDT at a median of 13 days (IQR 10, 18) from intubation. Patient characteristics are found in Table 1. Intravenous midazolam, fentanyl, and cisatracurium equivalents were significantly reduced 48 hours post-PDT (Table 2). Thirty-five patients were transferred from the ICU and liberated from the ventilator. Median time from PDT to ventilator liberation and ICU discharge was 10 (IQR 4, 14) and 12 (IQR 8, 17) days, respectively. Decannulation occurred in 45.5% and 52.7% were discharged from acute inpatient care (Figure 1). Median follow-up for the study was 62 days. Four patients had bleeding complications postoperatively and 11 died during the study period. Older age was associated with increased odds of complication (OR 1.12, 95% CI 1.04, 1.23) and death (OR=1.15, 95% CI 1.05, 1.30). All operators tested negative for COVID-19 during the study period. CONCLUSION: These findings suggest COVID-19 patients undergoing tracheostomy within the standard time frame can improve critical care capacity in areas strained by the pandemic with low risk to operators. Long-term outcomes after PDT deserve further study.

Early percutaneous tracheostomy in COVID19 patients with failed intubation: A case series.

INTRODUCTION: COVID19 and pulmonary dysfunction leading to acute respiratory distress syndrome (ARDS). CASE STUDY PRESENTATION: Herein we presented the cases of failed intubation that was replaced by early percutaneous dilational tracheostomy. The procedure is safe for the patients, doctors and clinical staff. CONCLUSION: Additionally, we report mucormycosis after COVID19 treatment that was potentially due to immunosuppressive drugs.

Percutaneous Dilational Tracheostomy in a Patient With SARS-CoV-2 (COVID-19) Disease: A Case Report With Implications in Staff Safety.

Some patients may need mechanical ventilation support during severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease-2019, COVID-19) infection and may eventually require tracheostomy in the following days. Tracheostomy is considered as a high-risk procedure for surgeons and operative personnel in terms of air contamination. We present a case of percutaneous dilational tracheostomy performed in a patient with COVID-19 pneumonia and the methods we used to reduce contamination risks for the healthcare staff.

A clinical retrospective study of percutaneous dilatational tracheostomy without guide wire for critically ill patients.

OBJECTIVE: This study aimed to introduce a novel tracheostomy method, the non-guide-wire percutaneous dilatational tracheostomy (NGPDT) technique, and evaluate its effectiveness for critically ill patients undergoing neurosurgery under special conditions. METHODS: The clinical data of 48 critically ill patients who underwent NGPDT under special conditions with controlled steps were analyzed retrospectively. The patients' demographic, preoperative state of illness, and diagnosis data were collected. Moreover, their intraoperative and postoperative variables were accessed, e.g., operation times, bleeding, saturation of pulse oxygen (SPO2), and early and late complications related to NGPDT. RESULTS: The mean patient age was 47.7 ± 13.7 years. The mean GCS (Glasgow Coma Scale) was 8.1 ± 2.9, and the mean BMI (Body Mass Index) was 25.2 ± 5.6. There were 38 patients with an endotracheal tube. The mean duration of onset to NGPDT was 4.0 ± 1.3 days. The mean operation time was 4.2 ± 1.9 min. There were 41 patients with mild intraoperative bleeding, 5 with moderate bleeding, and 2 with severe bleeding as well as 46 with mild postoperative bleeding and 2 with moderate bleeding. Additionally, 41 patients required complete extubation after NGPDT. The mean duration of incision healing was 4.8 ± 3.1 days. There was 1 patient with a decrease of SPO2 ≥ 10%. Three patients presented with a transient violent cough at the primary tracheostomy stage; however, no patients suffered from pneumothorax, subcutaneous emphysema, false passage, or surgery-related death during this procedure. CONCLUSION: Overall, NGPDT with controlled steps is a fast, safe, and microinvasive procedure. It mildly stimulates the trachea with a low rate of complications.

Early Percutaneous Dilational Tracheostomy in Trauma Patients After Anterior Cervical Fusion: Propensity-Matched Cohort Study.

BACKGROUND: Patients with cervical spinal cord injuries (CSCIs) may be required to undergo tracheostomy. However, in patients undergoing anterior cervical fusion (ACF), percutaneous dilational tracheostomy (PDT) may be delayed given the risk of cross-contamination. We aimed to evaluate the risk of surgical site infection (SSI) in early PDT in patients with traumatic CSCI after ACF. METHODS: All trauma patients admitted to the intensive care unit from 2008 to 2018 were retrospectively analyzed. Patients with CSCIs who underwent both ACF and PDT were identified, with or without posterior cervical fusion. Cases were classified as having undergone early PDT (≤4 days after ACF) versus late PDT (>4 days after ACF). Propensity scores were matched, and outcomes were compared between matched groups to reduce confounding by indication. RESULTS: From a total of 133 enrolled patients, a well-balanced propensity-matched cohort of 68 patients was defined. On the basis of the comparison of outcomes after matching, no significant difference in SSI was observed between both groups. There was no patient with SSI in the early PDT group (0%), whereas there were 2 SSI patients (5.9%) in the late PDT group (P = 0.493): The tracheostomy site was involved in 1, and the posterior approach site was involved in the other. Early PDT was associated with a shorter duration of mechanical ventilation (P = 0.042). There were no significant differences in the length of intensive care unit stay and hospital mortality between groups. CONCLUSIONS: Early PDT within 4 days after ACF did not increase the risk of SSI compared with late PDT in patients with traumatic CSCIs.

Application Value of Minimally Invasive Percutaneous Dilational Tracheostomy for ICU Critical Patients.

OBJECTIVE: To find out the application value of minimally invasive percutaneous dilational tracheostomy in critically ill patients in intensive care unit (ICU). METHODS: One hundred and forty critically ill patients who underwent tracheostomy in ICU of our hospital were included in the study from August 2016 to December 2017. They were divided into an observation group and a control group by random number table method, 70 in each group. The control group received conventional tracheotomy, while the observation group received percutaneous dilational tracheostomy. The operation time, incision length, amount of intraoperative bleeding and healing time of incision were compared between the two groups, and the changes of vital signs and complications after operation were recorded. The family members of the patients signed the informed consent. RESULTS: The operation time, healing time and incision length of the observation group were (9.92±4.13) min, (1.31±0.21) cm and (6.91±0.72) d respectively, shorter than (24.09±6.82) min, (3.40±0.65) cm and (67.48±0.61) d in the control group, and the differences were statistically significant (P<0.05). The amount of intraoperative bleeding of the observation group was (7.81±1.83) mL, less than (16.34±2.83) mL in the control group; the difference was statistically significant (P<0.05). The heart rate and oxygen saturation of the observation group before and during the operation were not significantly different (P>0.05). The heart rate of the control group during the operation was significantly higher than that before the operation (P<0.05); the oxygen saturation of the control group before and during the operation had no significant difference (P>0.05). The incidence of complications in the observation group was 24.3%, which was significantly lower than that in the control group (55.7%, X2=8.279, P=0.014). CONCLUSION: Minimally invasive percutaneous dilational tracheostomy has advantages of small trauma, less infection and beautiful incision, and it will not increase postoperative complications. It is of great value in the treatment of ICU critical patients.

Antiplatelet agents and anticoagulants increased the bleeding risk of bedside percutaneous dilational tracheostomy in critically ill patients.

BACKGROUND: The main objective of this study was to investigate the safety of bedside percutaneous dilational tracheostomy (PDT) by pulmonologists in critically ill patients, and the factors associated with complications resulting from PDT. METHODS: We retrospectively enrolled critically ill patients who had undergone bedside PDT in the intensive care units (ICUs) and respiratory care center from February 2016 to December 2018. RESULTS: A total of 312 patients were included for analysis, with a mean age of 69.6 ± 17.7 years. Two hundred and eight of the patients were male (66.7%). The mean acute physiology and chronic health evaluation II score was 25.3 ± 6.3, and the mean body mass index was 22.4 ± 4.2. Most of the patients were intubated due to respiratory disorders (51.3%). Fifty-six patients (17.9%) received antiplatelet agents or an anticoagulant regularly prior to PDT. All enrolled patients were undergone bedside PDT successfully. The total complication rate of PDT was 14.4%. Patients who took antiplatelet agents or anticoagulants regularly before PDT had a higher risk of bleeding than patients who went without (26.8% versus 7.0%, adjusted odds ratio 4.93 [95% f 2.16-11.25], p < 0.001). Finally, a longer length of intubation resulted in a higher probability in the length of ICU stay being ≧28 days (adjusted odds ratio 1.11 [95% CI 1.08-1.14], p < 0.001). CONCLUSION: Our study demonstrated that it was feasible for pulmonologists to perform bedside PDT in critically ill patients. However, antiplatelet agents and anticoagulants use increased the risk of bleeding in PDT patients.

Percutaneous Dilational Tracheostomy.

Tracheostomy tubes can be inserted surgically or percutaneously via percutaneous dilational tracheostomy (PDT). Tracheostomy is performed for upper airway obstruction, though more often to allow prolonged mechanical ventilation in place of endotracheal tubes. Preparation, performance, and postoperative management for PDT are best provided by a multidisciplinary team. Although PDT is a safe procedure in the hands of experienced operators, both early and late complications can arise. Caution must also be taken during early tracheostomy tube exchange given that immaturity of the stomal tract can risk loss of the airway.

Tracheostomy Update: When and How.

Tracheostomy remains one of the most commonly performed surgical procedures in the setting of acute respiratory failure. Tracheostomy literature focuses on 2 aspects of this procedure: when (timing) and how (technique). Recent trials have failed to demonstrate an effect of tracheostomy timing on most clinically important endpoints. Nonetheless, relative to continued translaryngeal intubation, studies suggest that tracheostomy use is associated with less need for sedation and enhanced patient comfort. Evidence likewise suggests that percutaneous dilational tracheostomy is advantageous with respect to cost and complication profile and should be considered the preferred approach in appropriately selected patients.

The role of cricothyrotomy, tracheostomy, and percutaneous tracheostomy in airway management.

Cricothyrotomy, percutaneous dilation tracheostomy, and surgical tracheostomy are cost-effective and safe techniques employed in the management of critically ill patients requiring insertion of an artificial airway. These procedures have been well characterized and studied in the surgical, emergency medicine, and critical care literature. This article focuses on the role of each of these modalities in airway management, specifically comparing the data for each procedure in regard to procedural outcomes. The authors discuss the techniques available and the relevant background data regarding choice of each method and its integration into clinical practice.

Percutaneous tracheostomy at the bedside: 13 tips for improving safety and success.

We have developed a set of routines and practices in the course of performing a large series (n = 70) of percutaneous dilational tracheostomy (PDT). The 13 tips discussed in this review fall into 4 categories. System factors that facilitate training, patient safety, and avoidance of crises including the use of appropriate personnel, importance of timing, use of premedication, and the utility and content of a preprocedure briefing. Suggestions to prevent loss of the airway include tips on airway assessment, preparation of airway equipment, and use of exchange catheter techniques. Strategies to avoid and manage both microvascular and large-vessel bleeding are discussed. We also discuss the management of common postprocedure problems including tracheostomy tube obstruction, malposition requiring tube exchange or replacement, and air leak. The practical considerations for successful execution of PDT involve common sense, thorough planning, and structured approaches to prevent adverse effects if the procedure does not go as smoothly as expected. These strategies will aid anesthesiologists and intensivists in improving their comfort level, safety, and competence in performing this beside procedure.

Percutaneous dilational tracheostomy.

Tracheostomy is a commonly performed intervention with several benefits in the treatment of patients with chronic respiratory failure. Percutaneous dilational tracheostomy techniques have allowed bedside tracheostomy placement in the modern intensive care unit. Percutaneous dilational tracheostomy can be safely performed by interventional pulmonologists, medical intensive care physicians, and surgical specialists. When performed with the assistance of adjuncts, such as flexible bronchoscopy, the percutaneous dilational method has a favorable complication rate, efficiency, and cost profile compared with surgical tracheostomy.