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Original Article
Article history: Background: The purpose of this study was to evaluate the efficacy of ultrasound guided
Received 2 February 2014 percutaneous tracheostomy (USPCT) and bronchoscopic guided percutaneous tracheos-
Accepted 26 January 2015 tomy (BPCT) and the incidence of complications in critically ill, obese patients.
Available online 12 March 2015 Methods: Seventy four consecutive patients were included in a prospective study and
randomly divided into USPCT and BPCT. Incidence of complications, ease and efficacy were
Keywords: compared in obese USPCT (n ¼ 38)and BPCT (n ¼ 36). Results are expressed as the median
Percutaneous tracheostomy (25the75th percentile) or number (percentage).
Ultrasound Results: The median times for tracheostomy were 12 min (9e14) in USPCT patients and
Bronchoscopic 18 min (12e21.5) in BPCT (p ¼ 0.05). The overall complication rate was higher in BPCT than
USPCT patient group (75% vs. 321%, p < 0.05). Most complications were minor (hypotension,
desaturation, tracheal cuff puncture and minor bleeding) and of higher number in the
BPCT. Ultrasound-guided PCT was possible in all enrolled patients and there were no
surgical conversions or deaths.
Conclusions: This study demonstrated that real US-guided PCT is a favourable alternative to
BPCT with a low complication rate and ease, thus proving more efficacious. A US exami-
nation provides information on cervical anatomy, vasculature etc. and hence modifies and
guides choice of the PCT puncture site.
© 2015, Armed Forces Medical Services (AFMS). All rights reserved.
* Corresponding author.
E-mail address: parliravi@gmail.com (P.R. Ravi).
http://dx.doi.org/10.1016/j.mjafi.2015.01.013
0377-1237/© 2015, Armed Forces Medical Services (AFMS). All rights reserved.
m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 7 1 ( 2 0 1 5 ) 1 5 8 e1 6 4 159
tracheal cartilage. A saline filled finder needle was introduced ventilation of the patient in both US and Fiberscopic guided
into the trachea and visualised directly by the operator on the PCT, hemodynamic data before and after the completion of
screen attached with a camera to the bronchoscope. A 14 G PCT and complications. The ease of performance of both the
catheter over needle was introduced under bronchoscopic procedures was rated on a simple numerical scale; 1: easy 2: a
vision and guide-wire was passed through the catheter (Fig. 7). few difficulties 3: moderate difficulties 4: very difficult; and 5:
The small dilator was then used to create the initial stoma impossible.
followed by the single-stage Griggs forceps dilator over the Data were expressed as the median (25th to 75th percen-
guide wire. The tracheostomy tube was guided over the guide- tiles) or number (percentage). We compared the group of
wire and passed through the stoma. The placement of tra- USPCT with the group of BPCT patients. A non-parametric
cheostomy tube was confirmed by fibreoptic visualisation of ManneWhitney test was used for intergroup comparisons of
the bifurcation of trachea after fiberscope was passed through continuous variables. Categorical variables were compared by
the tracheostomy tube. using a chi-squared test (and a Yates correction if necessary)
Patient care began with PCT and ended with dec- or a Fisher exact test. A p value of not more than 0.05 was
annulation. Complications were defined as minor, interme- considered statistically significant.
diate, or major. Minor complications were defined as clinically
irrelevant and clearly did not harm the patient. Intermediate
complications were defined as potentially harmful for the Results
patient. Major complications required medical or surgical
intervention. The complications are listed and classified in Seventy four patients were prospectively enrolled between
Table 1.8 March 2012 and December 2013. Twenty-six patients were
The following data were collected: gender, age in years, obese -median BMI of 34 kg/m2 (32e38) e and five of the latter
height in meters, weight in kilograms, body mass index (BMI), were morbidly obese. The median ages were 58 years (50e66)
diagnosis on hospitalization, duration of mechanical venti- (mean 61 yrs, 1.2SD) in the (Bronchoscopic assisted Percuta-
lation prior to PCT (in days), indication for tracheostomy, the neous Tracheostomy (BPCT)) group and 62 years (56e64)
duration of the tracheostomy defined by the time (in mi- (mean 58 yrs, 1.6SD) in the Ultrasound assisted percutaneous
nutes) between the puncture of the trachea and the tracheostomy (USPCT) group (P ¼ 0.62) (Table 2). Of the 74
patients, 60 patients (81%) had been hospitalized for a medical two patients (2.70%). The median times to decannulation was
problem (respiratory failure in chronic obstructive pulmonary 16 days (13e28) (mean 21.6 min 1.4SD) in BPCT group and 21
disease, stroke, seizures, ARDS) and 14 (%) had undergone days (16e29) (mean 24.6 1.8SD) in USPCT group (P ¼ 0.66). It
cardiac, vascular, or digestive surgery or severe trauma. The was possible to carry out all PCTs with US and bronchoscopic
most frequent indication for tracheotomy was difficult guidance. No surgical conversions occurred.
weaning from predictable, prolonged mechanical ventilation In terms of complications, we observed 8 tracheal cuff
(due to COPD in 39% of cases). Indications for PCT in both the punctures (22.2%) in the BPCT group and nil punctures in
groups were comparable since they were allotted randomly. USPCT group which was statistically significant (p < 0.05). The
Table 2 presents profile of the study population. number of multiple puncture were also more in BPCT (4)
Twelve patients (16.2%) had a short neck, and the median against UPSCT (0) (11.11%e0) although was not statistically
cricoid-manubrium distance was 6.2 cm (5.5e7.6) (mean6.4 cm, significant. Intra-procedural complications included desatu-
1.4SD). The prevalence of a short neck was higher in the BPCT ration for less than 5 min in four patients (11.11%) in the BPCT
group than in the USPCT (16.2% and 15.78% respectively; group in comparison to USPCT which had nil incidence of
P ¼ 0.54). hypoxia (p < 0.05). There was 12 cases (32.22%) of minor
The median total time for performing the PCT was 14 min (<5 ml) bleeding and four cases (11.11%) of major bleed
(10e23) (mean 19.4 min, 1.6SD). For BPCT group it was 18 min (<50 ml) in the BPCT group which was statistically significant
(12e21.5) (mean 16.3 min 1.6SD) while for USPCT it was 12 min in comparison to the USPCT (P < 0.05). None of the patients
(9e14) (mean 10.2 min 1.8SD) which was statistically signifi- had severe bleeding. One patient (2.27%) of BPCT group had an
cant. Five cases of the BPCT group had tracheal deviation episode of hypotension for less than 5 min in comparison to
(22.2%) while this was encountered in 9 patients of USPCT two patients in USPCT (5.26%). Post-procedural complications
group (23.68%). Identification of the anatomical structures and included skin infection among two patients (2.70%) among the
the PCT guidance were considered to be easy in 56 patients BPCT group that resolved easily with local care and intrave-
(75.67%), moderately difficult in 16 patients (21.6%), difficult in nous antibiotics.
m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 7 1 ( 2 0 1 5 ) 1 5 8 e1 6 4 163
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