Percutaneous Tracheostomy And Gastrostomy

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Two basic supportive therapies frequently necessary for neurotrauma patients are mechanical ventilation and enteral nutrition. Patients with (TBI requiring early endotracheal intubation include those with altered sensorium resulting in respiratory depression, hypoventilation, apnea, or inability to maintain or protect the airway. Patients with agitation or disorientation requiring sedative medications may also require mechanical ventilatory support. In those patients with spinal cord injury, high cervical lesions may result in respiratory dysfunction, may manifest as an inability to initiate adequate breaths, and typically require early endotracheal intubation. Finally, patients with multisystem trauma and hemorrhagic shock benefit from early airway control.

In critically ill trauma patients, enteral nutritional support is typically begun soon after admission to promote anabolism. Nasogastric or orogastric intubation is the usual early access route for feeding. Prolonged nutritional support provided by tube feeding may be necessary in those patients with TBI requiring prolonged ventilator support or those suffering from dysphagia.

Long-term mechanical ventilatory support in patients with respiratory failure and long-term airway control in comatose patients ultimately require tracheostomy. In these same patients and those with prolonged dysphagia, definitive enteral access with a gastrostomy tube is necessary for long-term nutritional support. These procedures are often essential to continue caring for those patients entering the rehabilitation phase of their injuries (6). The following sections describe the minimally invasive techniques of percutaneous tra-cheostomy and percutaneous gastrostomy and their practical applications to neurotrauma patients.

Percutaneous Tracheostomy

Early tracheostomy in the critically injured trauma patient has been shown to facilitate patient management and reduce morbidity. There are many advantages of converting the translaryngeal endotracheal tube to tracheostomy. The shorter tube length decreases overall airway flow resistance compared with an endotracheal tube of the same internal diameter. It also allows easier tracheal suctioning of secretions and has a reduced risk of air flow obstruction by intraluminal concretion deposits. Easy exchange or cleaning of the disposable tra-cheostomy inner cannula may be routinely performed, in those models equipped with an inner cannula. Suturing of the tracheostomy flange to the skin of the patient's neck, in addition to ties around the neck, provides more secure airway stabilization compared with simply tying or taping endotracheal tubes to the patient's lips and face. In patients requiring prolonged ventilator support, removal of an orotracheal or nasotracheal tube markedly enhances patient comfort, improves oral hygiene, and reduces the risk of sinusitis.

Mechanical ventilator weaning may assume a more aggressive approach in patients with tracheostomy whereby patients may be liberated from the ventilator and placed on supplemental humidified oxygen by collar. In those patients with marginal respiratory function, mechanical ventilation may be easily resumed at scheduled and intermittent durations or when the patient exhibits any signs of fatigue. The neurotrauma patient with persistent altered sensorium may have specific needs for an artificial airway separate from the delivery of mechanical ventilation. The neurologically impaired patient no longer requiring ventilator support may have a poor spontaneous cough and may have poor oropharyngeal tone. These patients are at risk for atelectasis, mucus plugging, and airway obstruction. Tracheostomy provides access for endotracheal suctioning to maintain a patent airway.

Studies have reported reduction of complications and economic advantages of tracheostomy. Early tracheostomy, within 72 h of injury, has been shown in a randomized trial to reduce the incidence of ventilator-associated pneumonia (57). Tracheostomy has also been associated with reduction in ventilator days, intensive care unit (ICU) length of stay, hospital length of stay, and reduced hospital and patient costs (58).

The modern technique of surgical tracheostomy has been performed since the 1900s and is one of the most frequently performed operative procedures required of critically ill patients. Although the method of percutaneous tra-

Table 1

Abbreviated Instructions for Use of the

Ciaglia Blue Rhino™ Percutaneous TracheostomyIntroducerSet

1. After local anesthesia, make a vertical skin incision from the lower edge of the cricoid cartilage downward, in the midline, for a distance of 1-1.5 cm.

2. Use a curved clamp to dissect gently down to the anterior tracheal wall.

3. Place the tube at the level between the first and second tracheal cartilages or between the second and third tracheal cartilages.

4. After the endotracheal tube is withdrawn slightly, direct the syringe and introducer needle assembly in the tracheal midline, posterior and caudad.

5. When advancing the needle forward, verify entrance into the tracheal lumen by aspiration with air bubble return.

6. When free flow of air is obtained with no impalement of the endotracheal tube, advance the outer sheath and remove the inner needle.

7. Remove the syringe and needle, introduce the j-wire guide into the sheath, and remove the sheath.

8. Advance the short, 14-Fr introducing dilator over the wire guide to dilate the initial access site into the trachea.

9. Advance and pull back the Ciaglia Blue Rhino dilator and the guiding catheter as a unit several times over the wire guide.

10. Advance the preloaded lubricated tracheostomy tube over the wire guide/guiding catheter assembly as a unit into the trachea.

cheostomy was first introduced by Sheldon in 1957, it was not popularized until Ciaglia described percutaneous dilatational tracheostomy (PDT) using a modified Seldinger technique in 1985 (59,60). The dilatational technique revolutionized bedside tracheostomy for its simplicity, ease of performance at the ICU bedside by physicians in various specialties, and low incidence of complications. PDT allows tracheostomy to be performed without surgical exposure of the tracheal landmarks and may be ideal in those patients in whom tracheal dissection would be a challenge, including patients with thick, short necks and those with substantial pretracheal edema from anasarca. Furthermore, those trauma patients with cervical spine injury requiring immobilization and patients with an uncleared cervical spine, in which neck extension is prohibited, represent the population with potentially more difficult tracheal dissection. Intensivists from surgical critical care, anesthesiology critical care, and pulmonary critical care, along with general surgeons, trauma surgeons, thoracic surgeons, otolaryngologists, and neurosurgeons have all been reported to perform this technique.

Table 1 and Fig. 7 briefly describe the most current version of the PDT technique. A commercial kit (Ciaglia Blue Rhino™ Percutaneous Tracheostomy Introducer Set with EZ Pass Hydrophilic Coating, Cook Critical Care, Bloom-ington, IN) is available that contains all the materials needed to perform the procedure. The typical tracheostomy tube size inserted is either a #8 or #7 (8-or 7-mm internal diameter equivalent).

Percutaneous Trach

Fig. 7. Four essential steps during the percutaneous dilatational tracheostomy (PDT) procedure using the Ciaglia Blue Rhino™ Percutaneous TracheostomyIntroducerSet. See Table 1 for details. (A) After the endotracheal tube is withdrawn slightly, direct the syringe and introducer needle assembly in the tracheal midline. (B) Remove the syringe and needle and introduce the J wire guide into the sheath. (C) Advance and pull back the dilator and the guiding catheter as a unit several times over the wire guide. (D) Advance the preloaded lubricated tracheostomy tube over the wire guide/catheter assembly as a unit.

Fig. 7. Four essential steps during the percutaneous dilatational tracheostomy (PDT) procedure using the Ciaglia Blue Rhino™ Percutaneous TracheostomyIntroducerSet. See Table 1 for details. (A) After the endotracheal tube is withdrawn slightly, direct the syringe and introducer needle assembly in the tracheal midline. (B) Remove the syringe and needle and introduce the J wire guide into the sheath. (C) Advance and pull back the dilator and the guiding catheter as a unit several times over the wire guide. (D) Advance the preloaded lubricated tracheostomy tube over the wire guide/catheter assembly as a unit.

In 1992, Ciaglia and Graniero (61) reported results and long-term follow-up of their 165 patients undergoing their procedure. The most frequent perioperative complication was inability to insert a #8 tracheostomy tube. This problem has since been corrected by addition of a 36-F dilator and subsequently the Ciaglia Blue Rhino dilator. Three patients were noted to have postoperative bleeding, one patient requiring one suture and the other two patients achieving hemostasis with topical Gelfoam. Of the 52 patients followed to decannulation, only one patient had stomal infection, and one had a voice change. No patient was noted to have laryngotracheal stenosis.

Several improvements to the original PDT technique have been adopted, with two being particularly significant. In 1989, Paul et al. (62) reported the addition of bronchoscopic monitoring by an assistant instead of the "blind" insertion technique. Subsequently other reports described the use of video-assisted bron-choscopy during percutaneous tracheostomy, allowing the operator to view the intraluminal events during the performance of the procedure. This monitor facilitated confirmation of adequate central, rather than lateral or paratracheal, needle entry into the tracheal lumen and reduced the risk of posterior tracheal wall injury by the needle or dilator. Another improvement to the method was the introduction of the Ciaglia Blue Rhino dilator. The original method utilized seven semirigid dilators of increasing caliber from 12 to 36 Fr. The Ciaglia Blue Rhino set utilizes a single dilator that is a 38-Fr flexible cone tapering down to a point. This dilator simplifies and speeds up the dilatation step by requiring only one single dilator rather than multiple passes of sequential dilators of increasing size.

Many others have reported good results with percutaneous tracheostomy. Chen et al. (63) reported their experience with PDT, all performed by neurosurgeons, in 22 neurosurgical coma patients with no complications requiring intervention. Borm and Gleixner (64) reported that bedside PDT under bronchoscopic control was safe and effective in 54 neurosurgical patients, with no increase in ICP occurring. Moore et al. (6) reported a review of 27 patients with brain injuries undergoing PDT and percutaneous endoscopic gastrostomy (PEG), with three patients having transient ICP elevation.

The most important postoperative complication that has been reported involves subglottic tracheal stenosis. One theory suggests that the extent of the cartilaginous and mucosal injury to the anterior trachea owing to the procedure determines the risk for subsequent stenosis (65). Another theory suggests that the nidus for stenosis is the displacement of tracheal cartilage into the tracheal lumen surrounding the tracheotomy. Subsequent chronic irritation by the tra-cheostomy tube leads to scar and granulation tissue formation (66). Although tracheal stenosis should be recognized as a potential long-term complication in all patients with tracheostomy, no satisfactory method of prevention has been proposed. Instead, efforts should be directed toward monitoring and post-decannulation tracheoscopy surveillance to identify these patients.

Percutaneous Gastrostomy

Early enteral nutritional support has increasingly been advocated following critical illness and trauma. Many studies have reported the benefits of the enteral feeding route rather than the parenteral route, citing promotion of gastrointestinal trophism, improved anabolic outcome, and reduction of central venous access mechanical complications and bloodstream infections. Trauma patients and surgical patients without a contraindication for enteral feeding should be provided with enteral nutrition as early as hospital d 1 or postoperative d 1.

Patients requiring long-term enteral access include those requiring prolonged ventilator support and those with traumatic brain, head, or neck injury. Patients with dysphagia or anorexia from neurological or pharyngeal dysfunction also benefit from gastrostomy tube feeding to prevent aspiration pneumonia and malnutrition. A gastrostomy tube has several advantages over the nasogastric or orogastric tube. Removal of the nasogastric or orogasstric tube results in enhanced patient comfort and reduces the risk of sinusitis. Frequent accidental tube withdrawal and need for reinsertion is essentially eliminated with a gastrostomy tube. One disadvantage with most commercially available gastrostomy tubes is that they lack an associated sump suction port. Patients with a greater volume of gastric secretions, gastric dysmotility, or gastric outlet obstruction may benefit from continuous suction. Gastrostomy tubes without sump ports are only amenable to intermittent suction or straight gravity drainage, and those patients requiring gastric drainage may benefit from a post-pyloric or jejunal position of a feeding tube.

The percutaneous method for gastrostomy placement was popularized earlier than that for tracheostomy placement. The first reported PEG was performed in 1979 by Gauderer, with Ponsky as the endoscopist (67). PEG has since become the method of choice for gastrostomy insertion. The surgical gastros-tomy method is reserved for those patients in whom inadequate light transillumination has prevented PEG from being completed or those in whom upper endoscopy cannot be performed or is contraindicated, such as those with pharyngoesophageal injury, stenosis, or obstruction and those with portal hypertension, esophageal or gastric varices, and ascites. Therefore current controversies do not involve whether to perform percutaneous or "open" gastros-tomy but instead involve the ethical nature of whether to perform PEG at all to sustain life (68). An increasing number of elderly patients with chronic diseases and terminal illnesses are undergoing PEG as an adjunct to the prolongation of life.

Table 2 and Fig. 8 briefly describe Ponsky's pull-type technique for PEG. Several commercial kits (MIC-PEG, Medical Innovations, Draper, UT, and EndoVive™ Standard PEG Kit, Boston Scientific, Natick, MA) are available that contain all the materials needed to complete the procedure. The standard com-

Fig. 8. Four essential steps during the pull-typepercutaneousendoscopicgastros-tomy (PEG) procedure. See Table 2 for details. (1) When the introducer cannula is observed in the stomach, remove the internal piercing stylet. (2) Place the looped wire through the cannula into the stomach, and grasp with a retrieval snare. (3,4) Connect the looped wire with the tube loop. (5,6) Apply traction to pull the loop and tube back through the oropharynx, esophagus, stomach, and abdominal wall.

Table 2

Abbreviated Instructions for Pull-Type Percutaneous Endoscopic Gastrostomy Kits

1. Perform gastric endoscopy, insufflate the stomach with air, and transilluminate the abdominal wall.

2. Select the gastrostomy site in the upper left quadrant, free of major vessels, viscera, and scar tissue.

3. Prepare and drape the skin at the selected insertion site, and, following local anesthesia, make a 1-cm incision through the skin.

4. Insert the introducer cannula through the incision, advancing through the peritoneum and the stomach wall.

5. When the introducer cannula is observed in the stomach, remove the internal piercing stylet, leaving the blunt-end cannula within the stomach.

6. Place the looped placement wire through the cannula into the stomach, and grasp with a retrieval snare.

7. Remove the endoscope and the looped placement wire through the oropharynx.

8. Connect the looped placement wire with the tube loop.

9. Apply traction to pull the placement loop and the tube back through the oropharynx and esophagus and into the stomach.

10. Repeat the endoscopy and visually follow the gastrostomy tube as it exits the stomach until the internal bumper rests against the stomach wall.

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Responses

  • ilkka
    Is percutaneous tracheostomy a minimally invasive surgery?
    1 year ago
  • Sonja
    Is trach peg permenant?
    5 months ago
  • terhi
    Is peg tube required with tracheostomy?
    2 months ago

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