Discussion

Major indications for minitracheostomy are listed in Tab.!.®.. 3. Table 3 Major indications for insertion

The role of minitracheostomy is principally to provide cough stimulation, enhance secretion removal, improve oxygenation, and prevent atelectasis. In this respect there is good evidence of efficacy (70-85 per cent) in prospective randomized trials. The technique is not without risk. In one prospective study of 152 cases, serious complications were reported in 5.4 per cent. Aueta./ (1989) studied 144 minitracheostomies using a 20 French silver tube and recorded complications in 5.5 per cent.

One study used surgical cricothyroidotomy and a larger tube than currently available as an alternative to tracheostomy and had a complication rate of 6.1 per cent.

Pederson... eta/ (1991). found one serious bleed, five less serious bleeds and two cases of surgical emphysema in 73 patients, giving a complication rate of 11 per cent. Tracheostomy, by comparison, is a more major undertaking and is used for a much more varied range of serious conditions. Immediate problems are similar, with severe bleeding at around 5 per cent and surgical emphysema at 1 per cent, and an overall complication rate varying from 6 to 51 per cent.

Minitracheostomy has been used as a means of overcoming significant airway obstruction and to help treatment of acute respiratory failure. It is clearly not a technique for the inexperienced in these circumstances, but it can provide an alternative short-term solution to upper airway obstruction. The use of positive-pressure ventilation is also not without potential danger, but the narrowness of the tube means that either high-frequency ventilation or continuous positive airway pressure will be necessary to ensure that an adequate airflow is achieved in the obstructed upper airway. A recent case describes the management of weaning a flail chest injury after 8 days of ventilation using positive controlled ventilation with a minitracheostomy tube over the next 12 days. Because of the dangers of misplacement of the tube, resulting in serious surgical emphysema and respiratory obstruction, careful supervision of the method is required, notably to ensure placement and patency of the tube.

The administration of longer-term oxygen via a percutaneous tracheal catheter has been described in patients with hypoxemia and continuous positive airway pressure. In appropriate cases, notably intensive care patients where combined sputum removal and oxygenation are necessary, minitracheostomy can provide a solution.

Arguably, the development of percutaneous tracheostomy to enable the intensive care clinician to provide an earlier and safer insertion technique could make minitracheostomy redundant. This would be the case if the complication rate of a tracheostomy was much reduced and the indications for insertion overlapped. Minitracheostomy has very specific indications and limitations which can only benefit the patient if the insertion occurs at an early phase of deterioration.

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