Ipct tracheo roma 2001

Grigg’s Percutaneous
tracheostomic technique :why?
How?
C.Melloni
Servizio di Anestesia e Rianimazione
Ospedale di Faenza(RA)
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Indications for PCt’s
Upper airway obstruction
» trauma
» burns & corrosive chemicals
» laryngeal dysfunction
» foreign bodies
» infections
» inflammatory conditions
» neoplasms
» postoperative
» obstructive sleep apnea

access for pulmonary toilet


Contraindications for PCT
Coagulopathy
copious secretions….
Unstable ARDS
elevated ICP
deep trachea/difficult neck….


Advantages of PC vs surgical
tracheostomy
Smaller skin incision
less dissection and tissue trauma
less hemorrhage
fewer infection
fewer tracheal problems
fewer cosmetic deformities
procedure performed at the bedside
» decreasing the risk and cost of patient transportation to OR.
» Faster procedure
» easier to perform
» requires less personnnel

Cervical spine & PCT
Mayberry et al. Cervical spine clearance
and neck estension during
percutaneous tracheostomy in trama
patients. CCM.2000;28:3436-3440
“cleared(60) and non cleared(28)”
stabilized(collar.halo.operative fixation)
simult.FBS

Lesioni della trachea
Ciaglia
Kaiser et al.Ann
Fr.Anesth.Reanin.19
97;16:925-6
Rx immediato ok
3 ore dopo pnx bilat

Griggs
Bourlon et al.Ann
Fr.nesth.Reanim.
1998;17:1156-9
Rx
immediato;cannula
disassata a sn
10 ore dopo
pneumomediast ed
emfis cut.


Complications of
tracheostomy
Early:periprocedural…

late complications

» paratracheal insertion,false
» tracheal
passage,tube
erosion:tracheoesophageal or
misplacement
trcaheoinnominatae fistula
» pneumothorax
» laringeal or subglottic
stenosis
» subcutaneus emphysema
» voice changes
» aspiration
» deglutition problems
» bleeding
» loss of airway
» transient
hypoxia/hypercapnia
» death

Genesi delle lesioni tracheali
Pneumomediastino
La forma ovoidale dell’orifizio
tracheale non si adatta a quella
della cannula;aria attorno alla
cannula……

Lesione della parete
tracheale:
Da parte di:
ago
guida metallica
della pinza
dilatatrice(Schachner…)
leader della cannula
scambiatore del tubo
sondini di aspirazione


Malposizionamento della
tracheostomia
Dexter A cadaver study appraising accurarcy of blind placement of
percutaneous tracheostomy.Anaesthesia 1995;;50:863-4….solo 4
posizionamenti corretti!!!
Sun KO.Barotrauna during percutaneous dilational
tracheostomy.Anaesthesia 1996;51:1076-7
Crofts et al.A comparison of percutaneous and operative
tracheostomies in intensive care patients.Can.J.Anaesth. 1995;42:7759.
Caldicott et al.An evaluation of a new percutaneous tracheostomy
kit.Anaesthesia 1995;50:49-51.

Incidenza globale 6%
Citata una frequenza del 18% dopo Ciaglia(Winkler,71
paz,ICM 1994;20:476-9)

Emorragia
rottura della vena tiroidea inferiore:
Buguet-Brown et al.Hemorrhagie aigue
cataclysmique par lesion de la veine
thyroidienne inferiure au cours d’une
tracheostomie percutane.Ann.Fr
Anesth.Reanim.2001;20:304-305.
griggs,paz,cirrotico con bil.coag alterato….


Ciaglia P.Percutaneous

tracheostomy is really
better –if done
correctly.Chest 1999;116:1138-9.
No comments??

Per evitare la puntura del
tubo endotracheale….
Ritrarlo prima di iniziare la procedura,in
visione laringoscopica diretta,con cuffia subito
sotto/tra le corde vocali:
Muoverlo in alto e in basso dopo puntura della
trachea con ago per vedere che l’ago non
abbia penetrato il tubo e quindi non sia
solidale con esso….
Visione diretta FBS:ago oltre il lume del
tubo…

Dulguerov et al.Percutaneous or surgical
tracheostomy:a meta analysis.Crit.Care
Med 1999;27:1617-25.

All publications(Medline)
english language
human studies
addressing complications
65 papers
heterogeneity………..


Perioperatuve mortality of pct vs surgical
techniques

100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%

pct
surg 85-96
surg 60-85

periop

postop

tot


Serious perioperative complications of
tracheostomies.

120
100
80
per 10.000 60
40
pneumediast

pnx

cardiopulm
arrest

0

death

20


surg 60-85
surg 85-96
pct

Intermediate perioperative
complications of tracheostomies
90
80
70
60
surg 60-85
surg 85-96
pct

50
40
30
20
10
0

Desat/
hypotens

Post trach. Cannula
wall lesion displac

aspiration. Switch to
surg.techn.


Minor perioperative complications of tracheostomies

subcut
emphysema

false passage

difficult tube
placement

surg 60-85
surg 85-96
pct
haemorrhage

350
300
250
200
per 10.000
150
100
50
0


Serious postoperative
complications
300
250
200
per 10.000

150
surg 60-85
surg 85-96
pct

100

trach stenosis

cannula displac

cannula
iobstruct

pnx

haemorrhage

sepsis

mediastnitis

tracheoesoph.fist

0

death

50


Postoperative intermediate
complications of tracheostomies
700
600
500
per 10.000

400

surg 60-84
surg 85-96
Pct

300
200
100
0

pneumonia

atelectasis

aspiration

tracheal
cartil.lesion


Postoperative minor complications of
tracheostomies
3500
3000
2500
per 10.000

2000

surg 60surg 85Pct

1500
1000


total KO

unesthetic
scar

keloid

delayed
cutaneous
closure

tracheitis

wound
infection

0

ext
hemorrh

500

Comparison of surgical vs pct
techniques:I
Overall Ko rate lower with Pct’s,but
periop KO higher with Pct’s(
» tracheostomy tube placement(false
passage,operative difficulty)
» subcut emphysema
» post trach wall lesions
» TEF
» mortality
» cardioresp arrest


Comparison of surgical vs pct
techniques:II
Postop KO lower with Pct’s:
» less hemorrhage
» less wound infection


comparing percutaneous with surgical tracheostomy
in critically ill patients.
Crit Care Med 2001 May;29(5):926-30
OBJECTIVE: To determine the relative costeffectiveness of percutaneous dilational tracheostomy
(PDT) and surgical tracheostomy (ST) in critically ill
patients. DESIGN: Prospective randomized study.
SETTING: Medical, surgical, and coronary intensive
care units at Barnes-Jewish Hospital, a tertiary care
medical center.
PATIENTS: Eighty critically ill mechanically ventilated
patients requiring elective tracheostomy.
INTERVENTIONS: Randomization to either PDT
performed in the intensive care unit or ST performed
in the operating room.

percutaneous with surgical tracheostomy
MEASUREMENTS AND MAIN RESULTS: Treatment groups were well matched with
respect to age (PDT, 65.44 +/- 2.82 [mean +/- se] years; ST, 61.4 +/- 2.89 years, p =
Ns), gender (PDT, 45% males; ST, 47.5% males, p = NS), severity of illness (Acute
Physiology and Chronic Health Evaluation II score: PDT, 16.87 +/- 0.84; ST, 17.88 +/0.92, p = NS), and principle diagnosis. PDT was performed more quickly (PDT, 20.1
+/- 2.0 mins; ST, 41.7 +/- 3.9 mins, p < .0001) and was associated with lower patient
charges than ST (total patient charges: PDT, 1,569 dollars +/- 157 dollars vs. ST,
3,172 dollars +/- 114 dollars; equipment/supply charges: PDT, 688 dollars +/- 103
dollars vs. ST, 1,526 dollars +/- 87 dollars; professional charges: PDT, 880 dollars +/54 dollars vs. ST, 1,647 dollars +/- 50 dollars; p < .0001 for all). There were no
differences in days intubated before tracheostomy (PDT, 12.7 +/- 1.1 days; ST, 15.6
+/- 1.9, p = .20), intensive care unit length of stay (PDT, 24.5 +/- 2.5 days; ST, 28.5 +/3.1 days, p = .33), or hospital length of stay (PDT 49.7 +/- 4.2 days; ST, 43.7 +/- 3.5
days, p = .28) when we compared these two techniques. CONCLUSIONS: PDT is a
cost-effective alternative to ST. The reduction in patient charges associated with PDT
in this study resulted from the procedure being performed in the intensive care unit,
thus eliminating the need e Rianimazione Ospedale and personnel. PDT may
Servizio di Anestesia for operating room facilities di Faenza(RA)

comparing percutaneous with surgical tracheostomy
70

1569 $

60
50
40
30

PDT

20

Surg
days
intub
before

APACHE
2

0

age

10


3172$

Ann Fr Anesth Reanim 2001
Mar;20(3):260-81
..the learning curve for percutaneous
dilational tracheostomy
significant decrease of complication
incidence with the operator's experience
continuous endoscopic guidance seems
to increase the safety of the
percutaneous procedure.
There is a trend to replace the surgical
procedure byRianimazione Ospedale di Faenza(RA)
the percutaneous one.
Servizio di Anestesia e

with endoscopically guided
percutaneous dilational tracheotomy.
Laryngoscope 2001 Mar;111(3):494-500
» OBJECTIVES: Objectives of the study were
1) to analyze the complication incidence
and resource utilization of two methods of
bedside tracheostomy and 2) to define
selection criteria for bedside tracheostomy.
STUDY DESIGN: Prospective randomized
trial in the setting of a tertiary care center at
a university hospital. METHODS: One
hundred sixty-four consecutive intubated
patients selected for elective tracheostomy
were enrolled. One hundred patients met


endoscopically guided percutaneous
dilational tracheotomy.
Laryngoscope 2001 Mar;111(3):494-500
“Patients meeting our selection criteria for bedside tracheostomy had a
significantly reduced perioperative complication rate compared with
those who failed to meet these criteria, and subsequently underwent
tracheostomy placement in the operating room (5% vs. 20%... No
statistically significant difference was found in the perioperative
complication incidence between the two methods of bedside
tracheostomy. However, percutaneous

tracheostomy
placement at the bedside resulted in a significant
increase in postoperative complication incidence
(16% vs. 2%, P <.05) and incurred an additional
patient charge of $436 per bedside procedure.

and Fantoni techniques World
J Surg 2001 Mar;25(3):296-301
» techniques according to Griggs (guidewire
dilating forceps, or GWDF) and to Fantoni
(translaryngeal tracheostomy, or TLT). The
aim of the study was to evaluate these two
techniques in terms of perioperative
complications, risks, and benefits in
critically ill patients. A series of 100 critically
ill adult patients on long-term ventilation
underwent elective percutaneous
tracheostomy, either according to the
Griggs (n = 50) or Fantoni (n = 50)


GWDF (Griggs) vs Fantoni(TLT)
operating times:
4.8 +/- 3.7 vs
9.2 +/- 3.9
Perioperative complications
4% of patients during either TLT or
GWDF
» and included :massive bleeding,
mediastinal emphysema, posterior tracheal
wall injury, and pretracheal placement of
the tracheostomy tube.

progressive dilatational and forceps dilatational
tracheostomy.
Intensive Care Med 2001 Jan;27(1):292-5
progressive dilatational tracheostomy (PDT)vs forceps dilatational tracheostomy (FDT).

35
30
25
20

PDT
FDT

15
10
5
0

duration of proc.(min)

Ko % Difficult or false insertion of the c
in 8 patients after FDT the most


tracheostomy.
Am Surg 2001 Jan;67(1):54-60
» Tracheostomy continues to be a standard
procedure for the management of long-term
ventilator-dependent patients. Traditionally
the procedure has been performed by
surgeons in the operating theater using an
open technique. This routine practice has
recently been challenged by the
introduction of bedside percutaneous
dilatational tracheostomy (PDT), which has
been reported to be a cost-effective
alternative. The purpose of this study is to


Moore MM.Am Surg 2001
Jan;67(1):54-60
7
6

requiring emergent operative
exploration of the neck

5
4

PDT
SURG

3
2
1
0

KO

major Ko


Neurosurg Anesthesiol 2000
Oct;12(4):307-13
effects of different tracheostomy techniques on intracranial pressure
(ICP), cerebral perfusion pressure (CPP), and cerebral extraction of
oxygen. We attempted to identify the main mechanisms affecting
intracranial pressure during tracheostomy. To do so we conducted a
prospective, block-randomized, clinical study which took place in a
neurosurgical intensive care unit in a teaching hospital. The patients
studied consisted of thirty comatose patients admitted to the intensive
care unit because of head injury, subarachnoid hemorrhage, or brain
tumor. Ten patients per group were submitted to standard surgical
tracheostomy, percutaneous dilatational tracheostomy or translaryngeal
tracheostomy. In every technique a significant increase of ICP (P < .05)
was observed at the time of cannula placement. Intracranial
hypertension (ICP > 20 mm Hg) was more frequent in the percutaneous
dilatational tracheostomy group (P < .05). Cerebral perfusion pressure

Intensive Care Med 2000
Oct;26(10):1428-33
♥ Open questionnaire,48 ICUs (70 %),1995 & 1996:90,412 patients
for a total of 243,921 ICU days.
♥ prevalence of tracheostomy: 10% in the long-term ventilated
patients (defined as > 24 h), or 1.3 % of all patients.
♥ Most tracheostomies were performed during the 2nd week of
ventilation.
♥ frequency of tracheostomy varied widely (0-60 %) slightly
associated with the different language regions of our country
and with the policy of hospitals to accept or refuse intubated
patients on their normal wards.
♥ Most units offered either conventional surgical tracheostomy
(69 %) and/or percutaneous procedures (57 %).

Crit Care Med 2000
Nov;28(11):3734-9
: One hundred critically ill patients with
an indication for PDT.
INTERVENTIONS: PDT with the Ciaglia
technique using the Ciaglia PDT
introducer set and the Griggs technique
using a Griggs PDT kit and guidewire
dilating forceps. MEASUREMENTS
AND MAIN RESULTS: Surgical time,
difficulties, and surgical and anesthesia
complications were measured at 0-2

comparison of Ciaglia and
Griggs techniques. Kost KM.


Preparazione
paziente:consenso,monitoraggio,O2,anest
esia…...


Anestesia
(Midazolam 2-3 mg)
Fentanile 100-150 microgr
Propofol 1 mg/kg,poi 6 mg/kg/hr
atracurium 0.3-0.4 mg/kg
FiO2 0.80
IPPV volumetric….
Slight hyperventilation…..

Preparazione campo
chirurgico:strumenti & accessori...


Verifica del materiale,lubrificazione...


Anatomia topografica


Individuare punto di
incisione:locale


Posizione del paziente...


Trucchi del mestiere di endoscopista….


Penetrazione della trachea,direzione
caudale,perdita di resistenza….


Conferma aspirazione aria..


Rimuovere ago e siringa,lasciare in situ
ago cannula e inserire il filo guida...


Rimuovere camicia del filo guida
,lasciare 25-30 cm esterni...


Il filo guida deve entrare
liberamente……..


Pro e contro dell’allargamento della
incisione...


Passare il dilatatore lungo il filo
guida;avvitamento……..


Inserire la pinza di Griggs chiusa
seguendo il filo guida con i rebbi
scanalati...


Far procedere la pinza fino alla parete
anteriore...


Aprire la pinza con entrambe le mani...


Dilatazione dei tessuti tracheali


Introdurre nuovamente la pinza chiusa
lungo il filo guida …..


Penetrare nuovamente in trachea,aprire
la pinza a due mani ,dilatare le pareti
tracheali e retrarla aperta...


Inserire il mandrino lungo il filo guida ...


Avanzare la cannula in trachea..


Rimuovere otturatore e filo guida….


Cuffiare ,aspirare la trachea...


Collegare al mount,riprendere
ventilazione,controllare….


Punti per eccesso stomico...


Sedation with propofol 3 mg/kg/hr
maintained at least until the return of a
sufficient Spont.resp.


Ipct tracheo roma 2001

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