Modified Dilatational Tracheostomy

K. Karvandian^1, Z. Hosainkhan¹, S. A. Tabatabaee¹, S. H. Abtahi¹    & S.Nikou. 

Department of Anesthesia and Intensive Care Unit, Tehran University of Medical Science (TUMS), Tehran Iran (Email:kassramail@yahoo.com)

Abstract

Traditional surgical tracheostomy has its own risks, and complications, i.e. hemorrhage, directional deviation, tracheal rupture, pneumothorax, hypoxia and death. The other method for tracheostomy- Tracheostomy through skin- has contraindications agreed on by all specialists as well. Difficulty in reaching to tracheal cartilages in  ilatational tracheostomy  deviation of tracheal direction and previous manipulation due to tracheostomy are the reasons for not using the so-called percutaneous tracheostomy method, as mentioned by several case reports. Keeping in mind the difficulties and risks of the former method, a new method titled as Modified Dilatational Tracheostomy has been applied by this team on four groups of patients whenever relative contra-indications for percutaneous tracheostomy were the obstacle.

Introduction

“Percutaneous Dilatational Tracheostomy” in spite of its vast application, faces usage limitations in some patients. 6 patients admitted In Intensive Care Unit (ICU) of Imam Khomeini teaching Hospital, who were not suitable cases for usual percutaneous tracheostomy method, beard a new method of tracheostomy to benefit from its advantages. Relative counter-indications of percutaneous tracheostomy, present in these selected patients, were as follows:

A-   Having large thyroid gland

B-   Having short neck

C-   Limitation of  neck movement

D-   Bearing previous tracheostomy

In this new method, the patients were anesthetized and given neuromuscular blockage in operation room, or in Intensive Care Unit (ICU). After incision and exploration of soft tissue, cartilages were reached and passed by, by the guide wire, instead of being incised as done in the usual method. The tracheal tube was inserted after dilatation thereafter.

Case 1

The first patient was a 29-year old man, with brain damage, in vegetative state. Three years ago, he had beard tracheostomy in such condition (Figure 1). After relative improvement and closure of the site of the previous tracheostomy, he had been discharged from the hospital and received care at home. Pneumonia, respiratory distress and homodynamic problems had lead him back to ICU for the second time. Critical condition of the patient and prolonged intubation raised the need for tracheostomy again, where a percutaneous one was contraindicated.

So, based on the new method, the soft tissue in neck area, inferior to the site of previous tracheostomy, was opened via a minimal skin incision. After reaching to the tracheal cartilages by use of needle and dilator, the conductor wire was passed and dilatation was performed by Griggs forceps (Figure 2). Then, a No.8 trcheostomy tube was inserted in the trachea, with least hemorrhage. In mentioned procedure, tracheal tube was pushed through the space between cartilages No.4 and 5 with minimal damage to the soft tissue and no damage to tracheal cartilages. That is to say, this method bears the advantages of percutaneous tracheostomy such as minimal hemorrhage, preservation of tracheal cartilages, rapidity, small size of incision and high accuracy.

In subsequent follow-up by bronchoscope, tracheal condition was investigated. After three days, the patient was separated from ventilator. He was discharged after treatment of Pneumonia in a good general condition.

Case 2

Our second patient was a 24-year old man with a large thyroid gland; another relative contraindication for percutaneous tracheostomy (Figure 3).He had undergone craniotomy due to brain hernia & was a candidate for tracheostomy, on account of prolonged intubation and decreased level of consciousness.

After incising the skin between cartilages No. 2 & 3, the tracheal cartilages were reached by passing of conductor wire. Dilatation by Griggs forceps was performed and a No.8 tracheostomy tube was inserted (figure 4).  After relative improvement, the patient was discharged from ICU.

Case 3

The third patient was a 29-year old man, a case of multiple-trauma, with suspected cervical fracture, another relative contraindication for percutaneous tracheostomy. He was also a candidate for tracheostomy due to prolonged intubation and mechanical ventilation (Figure 5). Using the modified tracheostomy method, after incision and definite access to tracheal cartilage, the conductor wire was passed via the space between cartilage No.2 & 3.Dilatation by Griggs forceps and insertion of a tracheal tube No. 9 were the final steps.

Case 4

And our last patient was a 65-year old man, with chronic bronchitis, broncho-esophageal fistula, and a short neck.  He beard general anesthesia in operating  room (Figure 6).

After bronchoscopic confirmation of bronchial patency and bronchoesophegeal fistula, the patient was transferred to ICU, but on the next day he died.

In post  tracheostomy tracheal investigation, the cause of death was found to be aspiration-induced acute respiratory failure. This patient's condition was one of the relative contra  indications of percutaneouse tracheostomy.

 

Discussion

The tracheostomy by surgical method which has been used for so many years in ENT, Thorax surgery and Neurosurgery Departments for treatment and training purposes, has covered a wide range of patients with small modifications (9). It has also covered the sever cases as well as usual ones, in a way that nearly no patient has been deprived from this method (10).

 Tracheostomy through skin was done by Ciaglia,in 1985 , not welcomed then(11).   In 1990, Griggs dilatational tracheostomy method was initiated by Mr. Griggs and applied worldwide, along with his self-designed forceps that is called after him. (8).Nowadays, different methods of dilatational tracheostomy through skin _including Griggs (1), Ciaglia(2), and Fantony(3)_ are being practiced for many years by using advanced tools rather than the surgical method in many centers around the world(Portex Co)(4).  The main reasons to put forward the tracheostomy through skin in all above mentioned methods are rapidity, precision and lesser complications in both short and long terms (5). The methods have been compared to each other. Among different methods of dilatational tracheostomy, some have advantages in comparison to the others, considering the skill of specialists as the most important factor (6). There are some limitations in this method, in spite of presented advantages however. Some are as follows: ages less than 12  15 years, emergency setting, hyperthyroidism, previous tracheosthomy, invasion of tumors to trachea and neck, short neck, sever limitation of neck movements and neck injuries (7).

Dilatational tracheostomy through skin in IRAN was performed first in Tehran University of medical science (TUMS) during 2005-2006 with cooperation of specialists from Turin University of medical science _Maria Victoria Hospital, Turin ITALY _and representative of Portex Co in IRAN (12). Along with the registration of this method, came the responsibility of training the target groups throughout the country by conducting different workshops in Imam Khomeini Hospital (12). In time, it was beard in mind that there were groups _such as those with previous surgery in the neck area, none-suitable anatomy or pathologies of the neck _who would benefit from the mentioned method in case it could be performed on them as well.  Not only were the conditions of these groups, but also the two methods of tracheostomy assessed precisely by our research team.The result was a new method, applicable to the mentioned groups.

Fortunately, the new method was practiced successfully by our group with minimal complications.

In long term follow-up of the patients with dilatational tracheostomy through skin, it was found that, the injuries to tracheal cartilages were far less than the surgical tracheostomy; reason for which is preserving the tracheal cartilages in this method by using the spaces between tracheal cartilages.

For more precise assessment of the airways in case of deviations, narrowing, previous tracheostomy, tracheomalacia and stenosis, the fiber optic bronchoscope can be used. it will also be of help in tracheal deviation due to hyperthyroidism and tracheal stenosis.

Even the malignant invasion to upper can be excluded.

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