Cases descriptions:
All tracheostomies were percutaneous.
Case 1: A 54-year-old morbidly obese male, known hypertensive and diabetic, presented with a short history of severe respiratory distress and persistent hypoxemia not responding to oxygen therapy and required intubation and ventilation. Multiple attempts to wean the patient off the ventilator failed. After a multi-disciplinary discussion PCDT was performed after 31 days of intubation.
Case 2: A 60-year-old morbidly obese male and known case of HTN & DM presented with severe hypoxemia, hypotension and required urgent intubation and mechanical ventilation. Following multiple failed weaning trials from the mechanical ventilator, the decision was made to proceed for tracheostomy at Day 27.
Case 3: A 64-year-old female, with the background history of HTN, DM, severe cervical ankylosing spondylitis and limited neck mobility, presented with severe hypoxemia and ARDS. The patient required intubation and ventilation. After multiple failed attempts to wean, the decision to proceed with PCDT was also made at Day 27.
Procedure: Percutaneous tracheostomy was performed with the number of people in the operating room restricted to four; three experienced anaesthetists (one bronchoscopist, one operator and one assistant) and an ICU nurse. Every member of the team had proper personal protective equipment. To decrease the airway secretions and reduce the risk of aerosolization, each patient received 2 aliquots of 200mcg glycopyrrolate intravenously, 60 minutes and 30 minutes prior to the procedure. Patients received 100% Fio2 ten minutes prior to the start of the procedure which was continued till the end of the procedure. After ensuring full muscle relaxation and adequate sedation, the patients’ position was optimised by neck extension and by the placement of a rolled towel under the shoulders. A neck ultrasound was performed to visualise the positions of the trachea, tracheal rings and blood vessels. 5 ml of Local anaesthetic (2 % lignocaine with 1/200000 adrenaline) was infiltrated at the site of incision. Ventilator was then put on standby and a brief bronchoscopy was performed using a swivel connector attached to an endotracheal tube. The endotracheal tube was pulled back till the cuff was visualised at the glottis. Ventilation was then resumed.
PCDT was performed with guidewire dilator technique following a stepwise approach starting with puncture of the anterior tracheal wall, seldinger technique, dilatation and cannula positioning. Ventilation was paused during the insertion of the dilator and insertion of the tracheal tube. All steps were monitored by bronchoscopy. The assistant covered the tracheostomy site during dilation of tracheostomy stoma insertion site to minimise aerosolization. The position of the tracheostomy tube was confirmed with bronchoscope, chest rise and capnography and the endotracheal tube was subsequently removed with clamp still on. We ensured minimum gas flows and PEEP during performance of per cutaneous tracheostomy.
Case 1 required placement of a PORTEX® UniPerc® Adjustable Flange Extended-Length tracheostomy Tubes as the Portex percutaneous tracheostomy tube didn’t have enough length to reach the trachea, as patient was morbidly obese. The other two patients were successfully managed with Portex® ULTRAperc® tracheostomy tube.