What can go wrong

The principal complications of minitracheostomy are summarized in Tabie.2. Table 2 Principal complications

Misplacement is probably due to inexperience. There are many structures in the neck, and failure to place the patient in the correct position or rushing the insertion can contribute to mistakes; the trick of insertion from above helps to orientate the clinician into the midline. Complications that are described include the loss of the introducer into the pleura, insertion into the mediastinum or the esophagus, and even placement upside down. In one unreported case a pneumothorax was produced. The tube can sometimes kink if the plastic is deformed by too much force on insertion. The use of fiber-optic bronchoscopy ensures that placement is correct, but in practice the tube can easily be seen at direct laryngoscopy if there are any doubts. A lateral neck radiograph may also be helpful.

Surgical emphysema (2 per cent) can be the result of misplacement, an insertion hole which is too large, or repeated attempts at insertion. This was more likely when a scalpel stab was used to insert the tube rather than the Seldinger dilator method. Displacement of the tube during high-frequency ventilation has resulted in emphysema and respiratory distress, leading to recommended safeguards in such usage. Inadvertent penetration of the mucosa by the wire used in the Seldinger technique, producing surgical emphysema, has also been described. The authors concluded that a J-wire would be safer.

Bleeding necessitating surgical intervention (3 per cent) is the other major problem. The thinking behind the midline approach through the cricothyroid membrane is to enter a bloodless field, but this is rarely the case, and it can be frightening to the inexperienced operator when the insertion site is masked by venous bleeding coupled with air bubbling. If there is delay, coughing bouts will ensue as blood is inhaled. Most bleeding stops with compression, but sometimes undersewing or simply large stitches adjacent to the insertion site are required. The bleeding here is from the skin edge. Dramatic life-threatening bleeding necessitating intubation has been described, and complete airway obstruction has been documented in five cases (one fatal).

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