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.