World J Surg (2007) 31:1854–1857 DOI 10.1007/s00268-007-9167-3
A Simplified Technique for Translaryngeal Tracheostomy (TLT). A Preliminary Report S. Katsaragakis Æ D. Theodorou Æ P. Drimousis Æ K. M. Stamou Æ A. Koutras Æ A. Kapralou Æ J. Bramis
Published online: 19 July 2007 Ó Socie´te´ Internationale de Chirurgie 2007
Abstract Objective In this prospective observational study we present preliminary results of a modification of the translaryngeal tracheostomy technique that was introduced by Fantoni in 1997. The study was conducted in a five-bed surgical intensive care unit of a university teaching hospital. Patients and Methods The study included 14 consecutive surgical patients (8 men, 6 women) who underwent a modified translaryngeal tracheostomy in a 6-month period. In our modification of the technique, we keep the basic principle of the inside-to-outside approach of the Fantoni technique, and combine it with a blind needle insertion, as reported in the classic subcricoid retrograde intubation technique. The technique that we use involves two medical doctors and a nurse. Results Mean patient age was 68.9 years (range: 31–85 years) and mean APACHE II score was 15.8 (range: 6–31). Mean operative time for the procedure was 15.2 min (range: 11.5–22 min). Eight of the patients died during the postoperative course in the ICU from causes relevant to their surgical pathology. One patient survived to be discharged from the ICU but died of an acute myocardial infraction later in the same hospital stay. Five patients survived to be discharged from the hospital. Conclusions The modified translaryngeal tracheostomy seems to be as reliable and safe as the original technique. In
S. Katsaragakis D. Theodorou P. Drimousis (&) K. M. Stamou A. Koutras A. Kapralou J. Bramis Surgical Intensive Care Unit, 1st Department of Propaedeutic Surgery, Athens University School of Medicine, Vas. Sofias 114 Ave., Hippocration Hospital, Athens, 11527, Greece e-mail:
[email protected]
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addition, the modified technique is faster and can be performed without the use of an endoscope. Tracheostomy is the most frequent surgical procedure performed in the intensive care unit (ICU) setting. Traditionally, tracheostomies were performed in the operating room by surgeons. Since the introduction of the percutaneous dilational tracheostomy (PDT) by Ciaglia et al. [1] in 1985, there has been an evolving tendency toward more frequent and earlier tracheostomy in critically ill patients requiring prolonged mechanical ventilation. The widespread adoption of PDT has been facilitated by its relatively fewer complications compared to the traditional surgical approach and the ability to accomplish the procedure at the bedside. Today there are four different types of PDT that are clinically used. Three of them use the same outside-toinside perspective with the use of dilators or forceps to create a path from the skin to the tracheal lumen. The fourth technique, the translaryngeal tracheostomy (TLT), employs a specially designed cannula to pass into and dilate the trachea from the inner lumen to the skin. This approach, from the inner lumen of the trachea to the skin eliminates the most serious complication of PDT, perforation of the posterior tracheal wall, as well as the creation of a false route. The basic principle of TLT was introduced by Fantoni in 1992 [2] and since then the technique has undergone some adjustments and improvements. The most recent version of the procedure, as we use it today, was reported in 1997 [3]. The technique emphasizes direct endoscopic control during all necessary steps for the creation of the tracheostomy. In this report, we present preliminary results of a modification of the technique for which we use the same kit for TLT (manufactured by Mallinckrodt), but instead of endoscopic
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control we use laryngoscopic control throughout the procedure.
Materials and methods This observational study was conducted in a five-bed surgical intensive care unit (ICU) in a university teaching hospital. Translaryngeal tracheostomy was introduced in our department in 2003. All the medical and nursing personnel of our surgical ICU attended a short one-day training course on the implementation of TLT in critically ill patients under mechanical ventilation. It should be noted that our department is part of the surgical division, and therefore the medical personnel are skilled surgeons capable of performing a surgical tracheostomy at the bedside. The Fantoni technique was first used in our department in 2004, and it became the procedure of choice for elective tracheostomies. Although we were satisfied with the initial results of the technique in our patients, we encountered some difficulties. The major problem was associated with our use of a fiberoptic bronchoscope. With this bronchoscope, the identification of the exact piercing point by means of transillumination or palpation as described in the original technique was always very difficult. This is because transillumination may prove to be a complicated task in stout necks, and palpation of the tracheoscope from the outside is not always accurate. Therefore, we thought that we should keep the basic principle of the inside-to-outside approach of the Fantoni technique, and combine it with a blind needle insertion as reported in the classic subcricoid retrograde intubation technique [4]. The technique that we use involves two medical doctors and a nurse. The preparation of the patient for the procedure includes cervical extension unless contradicted, and sterilization and draping of the neck. One of the phycisians (A), not necessarily sterilized, moves to the head of the patient, and the second phycisian (B), sterilized, is at the right of the patient. Physician B is the one who manages the tracheostomy kit. The nurse is at the bedside.
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the deflated cuff is visible through the mouth. This occurs when the cuff is approximately at the level of the vocal cords. This maneuver facilitates the advance of the guidewire and at the same time permits the ventilation of the patient. Next, physician B palpates the tracheal rings and inserts the curved needle of the kit just below the second tracheal cartilage. The needle should point cephalad (Fig. 1). When the needle is in the trachea, physician B inserts the guidewire and advances it through the trachea to the mouth of the patient. When the wire is visible, physician A places the tracheal tube back in its original position and pulls the guidewire out through the mouth. From this point the procedure progresses as shown in Figure 2. Briefly, physician B removes the curved needle and threads the mouth end of the guidewire from the central hole of the cone of the cannula and the cannula is prepared for traction as described by the manufacturer. When the cone cannula is ready, physician A removes the tracheal tube and intubates the trachea with the thin temporary tracheal tube supplied in the kit (Fig. 2A). The nurse then inflates the cuff of the thin tracheal tube and connects the patient to the ventilator. The patient will be ventilated through this tube for the rest of the procedure. When the temporary tracheal tube is in place and the patient is connected to the ventilator, physician B passes the cone cannula from the oral cavity, through the vocal cords, to the trachea and by means of pull-handle traction, extracts it from the tracheal lumen to the skin. When the cone appears at the skin, physician B performs a skin incision, 0.5–1 cm long to reduce tissue resistance and to facilitate traction. Counter pressure by positioning the fingers around the guidewire at the skin above the trachea as described by Fantoni is helpful. When the cone cannula
Technique Five minutes before the scheduled start of the procedure the patient is ventilated with 100% oxygen. At the beginning of the procedure, physician A suctions the pharynx and evaluates the position of the existing tracheal tube in the trachea within the use of a laryngoscope. The nurse removes the strap of the tracheal tube and deflates the cuff. At this point, physician A withdraws the tracheal tube under laryngoscopic control until
Fig. 1 The cuff is deflated and, under laryngoscopic control, the tube is withdrawn to the level of the vocal cords. Physician B palpates the trachea and inserts the curved needle in the second tracheal cartilage. The guidewire is advanced through the needle
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Results
Fig. 2 A. A. A knot has been made as needed in the guidewire and the cone cannula is prepared for the traction. The guidewire is connected to the core cannula in the same way as described by Fantroni in the original technique. There is a thin hole at the tip of the cannula and the wire is passed through that hole. Once the wire is through, a knot is made to avoid backtrack of the wire. B. The tracheal tube is removed. C. The patient is intubated with the thin tracheal tube provided by the manufacturer. The role of the thin endotracheal tube is to reassure that the patient with be ventilated and oxygenated through the procedure. The tube is of standard size of 4 mm in diameter. B. A. The cone cannula is pulled through the oral cavity and by hand traction it is extracted to the skin above the trachea. B. Ts in the tracheal lumen. C. The cannula is rotated as the cuff is inflated and the patient is connected to the ventilator
penetrates the skin above the trachea, the tracheostomy tube points cephalad and therefore it must rotate 180 degress. For this purpose, the manufacturer provides a plastic obturator. Moreover, the extent of the rotation is anticipated by a black line in the cone cannula. After the rotation of the cannula, physician A deflates the cuff of the thin tracheal tube and removes the tube. A plastic anchoring device is adjusted to the tube and the patient is connected to the ventilator (Fig. 2B).
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Fourteen consecutive surgical patients (8 men, 6 women) in our ICU underwent modified translaryngeal tracheostomy in the 6-month period December 2004–July 2005. Eleven of them were critically ill patients under ventilatory support at the time of the tracheotomy. They were surgical patients, and eventually in their postoperative course they developed abdominal sepsis and septic shock, requiring prolonged mechanical ventilation. One patient was tracheotomized after a total thyroidectomy that led to recurrent nerve palsy. The mean age of the 11 patients was 68.9 years (range: 31– 85 years), and the mean APACHE II score was 15.8 (range: 6–31). Mean operative time for the procedure was 15.2 min (range: 11.5–22 min). Eight of these patients died during the postoperative course in the ICU from causes relevant to their surgical pathology. One patient survived to be discharged from the ICU but died of an acute myocardial infraction later in course of the same hospital stay. Five patients survived to be discharged from the hospital. There were no postoperative complications, blood loss or blood transfusion requirements. In all patients there was no stoma infection and no tracheal ring fracture. In the five patients who survived to be decannulated, the stoma closed uneventfully within 7 days. During one procedure, we experienced some difficulties in rotating the cannula in the tracheal lumen. This patient was intubated with a 7.0 French tracheal tube and had a very short neck. Incorrectly, we had chosen a 7.5 F cone cannula instead of a 7.0 or a 6.5 F tube, which would have been more appropriate. The 7.5 F cannula proved very hard to manipulate in the tracheal lumen. When we encountered the problem, we looked for a way to create more intraluminal space for the rotation of the cannula. To do so, we completely removed the thin tracheal tube that was being used to ventilate the patient. That maneuver proved to be adequate, and complete rotation was accomplished in less than 60 s.
Discussion Since the introduction of percutaneous tracheostomy in 1985 by Ciaglia [1], many studies have shown that PDT is at least as safe as surgical tracheostomy. As a result of the comparable complication rate, the relatively undemanding technique, and the opportunity to perform the procedure at the bedside, PDT has gained favor among intensivists. Today, it is considered to be the procedure of choice for elective tracheostomy in the ICU in appropriately selected patients [5]. Nevertheless, several complications associated with PDT, but not typically encountered in the traditional surgical approach, have been reported. Of these complica-
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tions, perforation of the posterior tracheal wall is the most serious [5]. In all types of PDT and its modifications in clinical use today, the basic principle is progressive dilation of the trachea by whatever means (dilators or forceps), via an outside-to-inside approach; i.e., the physician dilates from the skin of the neck to the tracheal lumen. In all these techniques that use the outside-to-inside approach, the risk of perforating the posterior tracheal wall remains. The main cause of this complication is the pressure applied to the anterior tracheal wall, which remains a necessary element of the procedure regardless of the utensil employed. Moreover, in cases with high tissue resistance, there is a substantial risk of lesions in the tracheal wall and of false passage in the trachea [6]. Translaryngeal tracheostomy (TLT) was developed by Fantoni to improve conventional PDT and to reduce the risk of the complications encountered in all the percutaneous techniques. Thus Fantoni developed a completely novel approach, in which the stoma is advanced from within the tracheal lumen to the cervical skin, thus eliminating the chance of pressure-related complications. The TLT procedure proved to be safe, fast, and related to fewer complications than the conventional percutaneous tracheostomies [7]. However, the technique did not meet widespread approval and to our knowledge there are limited reports in the literature on the use of the Fantoni technique for percutaneous tracheostomy. In our opinion, the main reason for this is related to the use of the rigid bronchoscope. As described by Fantoni, TLT requires the use of a rigid bronchoscope not only for direct endoscopic control of the maneuvers performed but also for identification of the piercing point via transillumination or palpation. Fantoni performed almost all of the tracheostomies in his series with the use of a rigid endoscope, and this fact is outlined in his original report. In our ICU we use a fiberoptic bronchoscope (FOB), and our experience has been different than the original technique as described by Fantoni. Moreover, rigid bronchoscopes are not available in all ICUs and intensivists are not familiar with their use. For all these reasons we tried to preserve the main principle of TLT and to develop a technique that would be more easily applied. We maintained the inside-to-outside perspective because it is our belief that this is the major breakthrough of the Fantoni technique. We then combined
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it with blind piercing of the trachea, as in the retrograde intubation method [4]. The omission of the use of a bronchoscope in favor of laryngoscopic detection of the guidewire made the technique even faster and easier to perform without a notable difference in safety and complication rate. Fantoni in his original report did not provide data on time. The technique has a learning curve that is not negligible. As with all dilatational tracheostomies, operative time continues to decrease after the first 20–25 procedures. In our institution we were not that experienced with the original Fantoni technique, but in the 4–5 that we attempted before developing the modification, we observed times between 20 and 25 min. Furthermore, our time with the modification is still decreasing as we get more and more experienced in the use of the technique. Although time is not as important as safety, we believe that time around 5–7 min is a realistic objective once the team is well experienced and coordinated. In conclusion, the modified translaryngeal tracheostomy technique seems to be as reliable and safe as the original procedure. Additionally, the modified technique is faster and can be performed without the use of an endoscope. A prospective randomized study is needed to compare the techniques in terms of safety and timing, and we are planning to organize such a study in our department.
References 1. Ciaglia P, Firshing R, Syniec C (1985) Elective percutaneous dilational tracheostomy. A new simple bedside procedure: preliminary report. Chest 87:715–719 2. Fantoni A, Ripamonti D, Favero A (1992) Percutaneous tracheotomy in infants. Intensive Care Med 18(Suppl 12):237 3. Fantoni A, Ripamonti D (1997) A non-derivative, non-surgical tracheostomy: the translaryngeal method. Intensive Care Med 23:386–392 4. Shantha TR (1992) Retrograde intubation using the subcricoid region. Br J Anaesth 68:109–112 5. Freeman BD, Isabella K, Lin N, et al. (2000) A meta analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients. Chest 118:1412–1418 6. Frova G, Quintel M (2002) A new simple method for percutaneous tracheostomy: controlled rotating dilation. A preliminary report. Intensive Care Med 28:299–303 7. Freeman BD, Isabella K, Cobb P, et al. (2001) A prospective, randomized study comparing percutaneous with surgical tracheostomy in critically ill patients. Crit Care Med 29:926–930
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