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 Table of Contents  
Year : 2019  |  Volume : 17  |  Issue : 3  |  Page : 227-232

Guidance for percutaneous tracheostomy: ultrasonography, fiberoptic bronchoscopy, or no guidance at all

1 Department of Anesthesiology & Intensive Care, Al-Azhar Faculty of Medicine, New Damietta, Egypt
2 ENT Department, Al-Azhar Faculty of Medicine, Cairo, Egypt
3 Pulmonologist & Intensivist, Armed Forces Hospital, Jazan, Saudi Arabia

Date of Submission28-Oct-2018
Date of Decision09-Mar-2019
Date of Acceptance04-Aug-2019
Date of Web Publication26-Nov-2019

Correspondence Address:
Ibrahim Fadl Mahmoud
Department of Anesthesiology & Intensive Care, Al-Azhar Faculty of Medicine, New Damietta
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/AZMJ.AZMJ_116_18

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Background Percutaneous tracheostomy is widely practiced in intensive care units. It had lower rate of complications. However, serious adverse events still liable to occur. Guidance is proposed to decrease such events.
Aim of the work To examine the effect of ultrasound or bronchoscopy guidance on the clinical outcome and complication rate of percutaneous tracheostomy.
Patients and methods Sixty patients were prospectively randomized to underwent bronchoscopy, ultrasound, or combined guidance (20 patients each) and data sheets of 20 patients were retrospectively analyzed. Then clinical outcome and rate of major or minor complications were document.
Results Total rate of minor complications was significantly increased in none-guidance group (50.0%) when compared to ultrasound guided (25%) or combined guidance (20%) groups. But the difference was non significant when compared to bronchoscopy-guided group (40.0%). Individually, no complication showed significant difference between any of studied groups. The total procedure time was significantly prolonged in non-guided group when compared to each of guided groups, and in combined-guidance group when compared to other groups.
Conclusion The combined guidance by both bronchoscopy and ultrasound was associated with significant reduction of overall complications rate. Ultrasound-guided is superior to bronchoscopy guided although the difference was non-significant.

Keywords: bronchoscopy, intensive care unit, percutaneous, tracheostomy, ultrasound

How to cite this article:
Mahmoud IF, Abdelmottaleb NA, El-Shiekh AM, Erwi SM. Guidance for percutaneous tracheostomy: ultrasonography, fiberoptic bronchoscopy, or no guidance at all. Al-Azhar Assiut Med J 2019;17:227-32

How to cite this URL:
Mahmoud IF, Abdelmottaleb NA, El-Shiekh AM, Erwi SM. Guidance for percutaneous tracheostomy: ultrasonography, fiberoptic bronchoscopy, or no guidance at all. Al-Azhar Assiut Med J [serial online] 2019 [cited 2020 Dec 3];17:227-32. Available from: http://www.azmj.eg.net/text.asp?2019/17/3/227/271674

  Introduction Top

Percutaneous tracheostomy (PT) has become a routine maneuver in many of the ICUs [1]. PT is usually associated with a low rate of complications. However, serious adverse events still occur [2]. Therefore, there is a need for guidance by either ultrasound or bronchoscopy [3].

Bronchoscopy can be used as an adjunct for guidance in PT. It helps in defining the suitable site for puncture in trachea, as a real-time guidance of the needle entrance into the trachea. This could avoid injuries to the posterior tracheal wall and confirm the endotracheal tube (ETT) placement [4]. However, bronchoscopy might not exactly recognize the cervical anatomical structures and prevent complications such as vascular injuries or thyroid punctures [5].

Ultrasonographic guidance was well established as a guidance for venous access and regional anesthesia in the daily practice of anesthesia and intensive care [6]. In the tracheostomy, ultrasound is able to visualize superficial anatomical structures like thyroid gland and vasculature of the neck. Thus, it is proposed to prevent complications related to these structures such as injury of thyroid and neck vessels [5].

In addition, ultrasound could help in determination of the tube size and length [7]. Furthermore, it could help in identification of the most appropriate puncture site of the trachea and help in insertion of needle in the trachea [3].

  Aim Top

The aim of this study was to evaluate the possible role of using preprocedure ultrasound versus bronchoscopy alone or bronchoscopy use to complete the procedure after prior ultrasound mapping for neck structures. In addition, these methods were compared with a retrospective outcome of patients who underwent PT without guidance at all.

  Patients and methods Top

The present study was conducted at Al-Azhar University Hospital (New Damietta) and Armed Forces Hospital (Jazan, Saudi Arabia) within 3 years (March 2015 till March 2018). It included 60 patients who were randomly allocated to one of three groups: the first included 20 patients who underwent tracheostomy with bronchoscopy guidance without prior ultrasound of the neck; the second included 20 patients who underwent ultrasound examination of the neck before PT with no use of bronchoscopy; and the third included 20 patients who underwent PT after ultrasound examination of the neck and with bronchoscopy. Randomization was carried out immediately before the procedure, as soon as all of the equipment and the PT team were ready. Randomization was done by closed envelop method, where closed envelops were prelisted with the procedure number (1 for bronchoscopy alone, 2 for ultrasound alone, and 3 for combined approaches; each number was assigned for 20 envelops). All were kept with a nurse not involved in the study, and one envelope was picked up blindly and opened just after the procedure.

Data of another 20 patients who underwent PT without ultrasound or bronchoscopy were included for comparison. We found that, it is unethical to do PT without any guidance, especially with the availability of instrument. Thus, we retrospectively analyzed medical records of patients who underwent PT without guidance (either before introduction of instrument or owing to inability to use guidance).

Ethical consideration

An informed consent form was signed by the patient guardian before inclusion in the study and after full explanation of the procedure. In addition, the right to withdraw and confidentiality of data were ascertained. Finally, the study protocol was approved by the local research and ethics committee of Al-Azhar Faculty of Medicine (New Damietta) and that of Armed Forces Hospital (Jazan, Saudi Arabia).

In all patients, PT was carried out by the Ciaglia method using a PT introducer set (C-PTIS-100-HC, Ciaglia Blue Rhino; COOK Medical Inc., Bloomington, Indiana, USA) as described by Ambesh et al. [8]. In brief, 100% oxygen was applied for each patient for 10–15 min, just before the procedure in a trial to decrease intraoperative hypoxia. A transverse incision of 1 cm was made in midline between the first and second (or second and third) tracheal rings. Just below the vocal cords, the tip of the ETT was retracted. A puncture needle of 15 G with a saline-filled syringe was introduced in a perpendicular manner to the skin and advanced till the needle was seen to pass the anterior tracheal wall during aspiration of air. Then, the guide wire was introduced, and once done, the needle was removed. A 14-Fr dilator was used to create the initial stoma followed by the single-stage curve dilator over the guide wire. A tracheostomy tube of different sizes was placed over a lubricated dilator for tracheal insertion.

In the bronchoscopy group, a flexible fiberoptic video bronchoscope (Karl Storz-C-MAC produced by Karl Storz Gmbh & Co., KG, Tuttlingen, Germany) was used by the co-operator to withdraw the ETT under visual control of the bronchoscope and transilluminate for assistances in determination of the site of intended skin incision. Then gentle pressure by operator’s finger was applied to improve tracheal puncture by the appearance of endoscopic indentation of the anterior tracheal wall.

In the ultrasound group, and before PT, ultrasound was used by the co-operator. Longitudinal sections were done to recognize the cricoid cartilage, tracheal rings, and the puncture site. This was followed by a transverse section to assign the location of arteries, veins, thyroid, trachea, and ETT and to estimate the depth of the anterior tracheal wall from the skin. Finally, an ‘out-of-plane’ mode was used to visualize the needle. This mode is best described by the determination of needle path by the existence of a distinct acoustic shadow ahead of the needle on a transversal section of the neck.

In the combined group, both described techniques were used, whereas in nonguidance group, none of them was used.

Study outcome

The primary outcome was failure of the procedure, which was defined as conversion to open surgical tracheostomy, bronchoscopy use in the case of ultrasound-guided PT, ultrasound use in the bronchoscopy-guided PT, or the occurrence of a major complication. These major complications included death related to the procedure, cardiac arrest, injury of tracheal wall, false passage, pneumothorax, pneumomediastinum, obstruction of cannula, injury of esophagus, tracheoesophageal fistula, persistent hypotension (systolic pressure <90 mmHg for >5 min with intervention to increase blood pressure by fluids or vasopressors), persistent hypoxemia of acute onset (peripheral SO2<90% for >5 min), major bleeding, or tracheostomy-related sepsis. The secondary outcomes were incident minor complication, number of punctures, and procedure length. Minor complications included transient hypotension (systolic blood pressure below 90 mmHg for <5 min and use of intravenous fluids or vasopressors as a single bolus), transient acute hypoxemia (SO2<90% for <5 min), atelectasis, stoma infection, accidental decannulation, and minor bleeding (stomal or intratracheal self-limiting bleeding or bleeding successfully treated by a local compression or by instillation of topical vasoconstrictors). Patients were followed up for 7 days (the end point of the study).

Statistical analysis of data

The statistical package for social science (SPSS) version 20 (SPSS, IBM Inc., Chicago, USA) was used for analysis of data. Mean and SD were calculated for numerical data, whereas frequency and percent distribution were calculated for categorical variables. For numerical data, one-way analysis of variance with post-hoc least significant differences was used for comparison between groups, whereas χ2 or Mann–Whitney test was used for comparison between categorical variables. P value less than 0.05 was considered significant for interpretation of data.

  Results Top

Patient characteristics and indications for PT are presented in [Table 1]. There was no significant difference between studied groups regarding sex, age, weight, height, BMI, or indications. The most common indications were traumatic brain injury (24 patients), intracerebral hemorrhage (15 patients), ischemic stroke (15 patients), respiratory failure (13 patients), postarrest (nine patients), and maxilla-facial injury (four patients).
Table 1 Patient characteristics and indications for percutaneous tracheostomy

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Outcome is presented in [Table 2]. The number of puncture was mainly one in most patients (two punctures were reported in just five (6.25%) of 80 patients, whereas three punctures were reported in four (5.0%) patients, and there was no significant difference between studied groups. The insertion time was significantly longer in the nonguided group (5.70±1.26 min), when compared with bronchoscopy group (4.95±1.14 min), ultrasound-guided group (4.65±1.26 min), or combined-guidance group (4.90±0.64 min). However, no significant difference was found among the three guidance groups when compared with each other. In addition, the total time of the procedure was significantly longer in nonguided group (12.80±2.14 min) when compared with each of the guided groups and in the combined-guidance group (11.05±1.90) when compared with the bronchoscopy-guided group (7.45±0.68 min) or ultrasound-guided group (6.65±0.58 min). However, the difference between bronchoscopy-guided and ultrasound-guided groups did not reach statistical significance. Finally, there was no significant difference between studied groups regarding failure rate or minor complications. The total rate of minor complications was significantly increased in nonguidance group (50.0%) when compared with ultrasound-guided (25%) or combined-guidance (20%) groups. However, there was no significant difference when compared with bronchoscopy group (40.0%) or between bronchoscopy, ultrasound, and combined-guidance groups.
Table 2 Outcome among studied populations

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  Discussion Top

The results of the present study revealed that the use of either bronchoscopy or ultrasound guidance led to reduction of minor complications and increased the rate of procedure success than nonguidance approach. However, the difference did not reach statistical significance. In addition, some complications were more common in certain procedures, such as minor bleeding and hypoxemia in bronchoscopy-guided group and atelectasis in ultrasound group. However, no statistically significant differences were found. These results are comparable to those reported by Gobatto et al. [5] who reported that ultrasound-guided PT in critically ill patients had a relatively equal result as bronchoscopy-guided PT. In addition, the profile of major and minor complications was comparable between both the techniques. In addition, Helmy et al. [3] concluded that each of ultrasound-guided and bronchoscopy-guided PT is effective and safe, and both had similar incidences of complication and clinical outcome. They added the use of both techniques together as a guidance was associated with significant increase of procedure duration without addition of any benefit on the clinical outcome. These results are comparable to that of the present work.

On reviewing the literature, we encountered trials that evaluated the role of ultrasound guidance in the assistance of PT [9],[10]. In addition, practice guidelines have advocated the use of ultrasound to hasten the safety of the procedure [11]. Furthermore, many trials have addressed the role of ultrasound guidance in comparison with traditional landmark technique in bronchoscopy. All these trials addressed the safety and efficacy of ultrasound guidance in reduction of procedure-related complications when compared with the landmark technique. Moreover, the use of ultrasound guidance was associated with significant reduction of total time of the procedure (as found in the present work) [12],[13],[14].

In the present work, major complications (excluding failure of the procedure) were absent. The major complication rate reported in the previous studies ranged between 0.38 and 1.4% [2],[15].

In the present study, the total rate of minor complications in nonguidance group was 50.0%, whereas it was 40, 25, and 20% in bronchoscopy, ultrasound, and combined-guidance groups, respectively. This is comparable to the results reported by Gobatto et al. [5] who revealed that minor complications related to the procedure were reported for 20 (33.3%) patients in the ultrasound group and 12 (20.7%) patients in the bronchoscopy group. However, they reported higher rate of complication in ultrasound-guided group than bronchoscopy-guided group (the reverse situation in the present work). They attributed the higher rate of complications in ultrasound-guided group to elevated Simplified Acute Physiology Score 3 score in this group or to less experience of team with ultrasound guidance. Comparable results were also reported by Delaney et al. [16] and Higgins and Punthakee [17]. In addition, Guinot et al. [18] observed 33.0% as an overall complication rate in 50 obese and nonobese patients who underwent ultrasound-guided tracheostomy, with bleeding accounting for 6%, surgical site infection for 2%, desaturation for 6%, and hypotension for 6%. In another study that included 120 patients who underwent bronchoscopy-guided PT, 15% of patients had minor blood loss, 2.5% had transient hypoxemia, and 15% had the ETT punctured [19].

Complication rates presented in previous work are quietly variable. For example, in randomized controlled trails that evaluated ultrasound-guidance versus bronchoscopy or landmark PT, the total minor complication rates were from 11.52 to 56.75% [12],[13],[14], and there was no significant difference between groups. The reported rate of minor complications in the present work lies within these range. In addition, other retrospective analysis revealed a complication rate of 30% in both ultrasound-guided and bronchoscopy-guided groups [20].

An interesting, unexpected finding of the present study is the total rate of overall complications in bronchoscopy-guided group (40.0%), which is just lower than that of nonguided group (50.0%). This suggests that the bronchoscopy use should not set as a routine in PT. Otherwise, it should be confined to selected patients. This opinion was previously advocated by Jackson et al. [21] and Abdulla et al. [22].On the contrary, ultrasound guidance gained wider acceptance since its introduction as an adjunctive tool for PT. This could be attributed to different reasons: first it is readily available in emergency settings and ICUs when compared with bronchoscopy; second, it needs less staff for operation and cleaning; and third, the steep learning curve of PT-guided ultrasound and confidence for new technology over time [23],[24],[25].

In the present work, the lowest complication rate was documented in the combined-guidance group. These results advocate the use of both techniques in guidance of PT, irrespective of long duration of the procedure, to improve the safety profile in the PT procedure. This conclusion was also advocated by Gobatto et al. [5], but Helmy et al. [3] were against this combination as they found no clinical benefit in reduction of complication rate, irrespective of longer duration of the procedure.

  Conclusion Top

Ultrasound-guided and bronchoscopy-guided PT is a safe and effective procedure when compared with nonguided maneuver. Ultrasound itself is superior to bronchoscopy. However, the difference was statistically nonsignificant when rate of complications and clinical outcome were considered. However, when both techniques were combined, the complications rate was significantly reduced, but it was associated with longer duration of the procedure. This difference in duration (about 4–5 min) is clinically relevant as it was associated with lower complication rates.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Helmy T, Beshey B, Megahed M, Hamdy E. Fiberoptic bronchoscopic guided versus ultrasound guided percutaneous tracheostomy in critically ill patients. Biolife 2017; 5:201–206.  Back to cited text no. 3
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Gobatto AL, Besen BA, Tierno PF, Mendes PV, Cadamuro F, Joelsons D et al. Ultrasound-guided percutaneous dilational tracheostomy versus bronchoscopy-guided percutaneous dilational tracheostomy in critically ill patients (TRACHUS): a randomized noninferiority controlled trial. Intensive Care Med 2016; 42:342–351.  Back to cited text no. 5
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