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Communications to the Editor |

A Modified Percutaneous Tracheostomy Technique Without Bronchoscopic Guidance: A Note of Concern FREE TO VIEW

Giulio Melloni, MD; Lidia Libretti, MD; Monica Casiraghi, MD; Piero Zannini, MD, FCCP
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Affiliations: Scientific Institute H. San Raffaele, Milan, Italy,  Tel Aviv University School of Medicine, Tel Aviv, Israel

Correspondence to: Giulio Melloni, MD, Unità Operativa di Chirurgia Toracica, Ospedale San Raffaele, Via Olgettina, 60, 20132 Milan, Italy; e-mail: giulio.melloni@hsr.it



Chest. 2005;128(6):4050-4051. doi:10.1378/chest.128.6.4050
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To the Editor:

We read with interest the article in CHEST by Paran and colleagues (September 2004)1 on a modified percutaneous tracheostomy (PcT) technique performed without bronchoscopic guidance. Although their initial results seem to match those reported in the literature following conventional PcTs, we think that some points need to be addressed.

An important technical detail in avoiding PcT-related complications, such as tracheo-innominate artery fistula and late postintubation cricoid stenosis, is the site for the surgical incision. The authors performed a midline, vertical 2-cm incision just above the sternal notch with subcutaneous dissection in order to enter the airway between the second and third tracheal rings. This maneuver is more effectively achieved if the incision is made 1 to 1.5 cm below the cricoid cartilage as this gives direct access to the required point of entry to the airway with minimal subcutaneous dissection. It is advisable to locate the incision with reference to the cricoid and not to the sternal notch because the larynx and the trachea move independently of the sternum when the neck is flexed or extended.2

The second point regards the issue of stomal bleeding and/or local soft-tissue infection following PcT. The low rate of stomal bleeding and infection associated with conventional PcT34 is mainly ascribable to certain features of the PcT stoma. Following conventional PcT, the stoma fits snugly around the cannula, and the absence of dead space serves to both tamponade bleeding vessels and to prevent infection.3 Because of the relatively wide skin incision proposed by the authors and the subsequent blunt dissection of the subcutaneous tissue needed to manually assess the level of the entry into the airway, the stoma is likely to fit loosely around the cannula, without any compression effect on the surrounding tissue and, therefore, with an increased potential risk of stomal bleeding and/or infection. Under such conditions, the risk of bleeding is further increased by potential injury to the highly vascularized thyroid isthmus, which lies over the second and third tracheal rings.

In conclusion, although the type of modified PcT proposed by Paran and colleagues1 has the advantage of being performed without bronchoscopic guidance, it may expose patients to the unnecessary risk of serious complications that would inevitably entail increased hospital costs and fails to match the positive results achieved by conventional PcT performed under bronchoscopic guidance in larger series of patients.

Paran, H, Butnaru, G, Hass, I, et al (2004) Evaluation of a modified percutaneous tracheostomy technique without bronchoscopic guidance.Chest126,868-871
 
Grillo, HC Surgery of the trachea and bronchi.2004,499-506 BC Decker. Hamilton, ON, Canada:
 
Freeman, BD, Isabella, K, Lin, N, et al A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients.Chest2000;118,1412-1418
 
Melloni, G, Muttini, S, Gallioli, G, et al Surgical tracheostomy versus percutaneous dilatational tracheostomy: a prospective-randomized study with long-term follow-up.J Cardiovasc Surg2002;43,113-121
 
To the Editor:

Melloni and colleagues expressed their concern regarding possible complications following the modified technique of percutaneous tracheostomy. They hypothesize that the skin incision using the sternum as a reference point could result in wrong placement of the cannula. Since the technique described in our report is primarily based on limited blunt dissection of the subcutaneous tissues, it allows accurate positioning in insertion of the cannula. We believe that the surface landmark should serve only as a guideline, as opposed to the strict percutaneous tracheostomy, which relies entirely on surface landmarks and thus necessitates bronchoscopic guidance.

The second point of the letter addresses the potential complication of bleeding from subcutaneous tissues. Based on our experience in > 100 cases, the careful blunt dissection down to the pretracheal fascia allows careful navigation and displacement of blood vessels and the thyroid isthmus. This technique, therefore, when performed by a surgeon, actually prevents inadvertent damage to local blood vessels, which sometimes may occur when blindly inserting a cannula from the skin surface directly into the trachea. In our series, we had only one case of small but persistent bleeding from subcutaneous tissues that required revision in the operating theater. We did encounter in two cases a larger blood vessel that was detected while performing blunt dissection. This finding led us to abort the procedure and continue by conventional surgical tracheostomy. In these cases, performance of the conventional percutaneous tracheostomy would most probably have led to significant bleeding.

As for the theoretical danger of infection, we believe that infection in this setting usually originates from the contaminated airway and not from skin. A larger incision allows for adequate drainage, while snug closure of the skin around the cannula may actually even predispose to infection. Indeed in our series there were no cases of soft tissue infection that required additional drainage.


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References

Paran, H, Butnaru, G, Hass, I, et al (2004) Evaluation of a modified percutaneous tracheostomy technique without bronchoscopic guidance.Chest126,868-871
 
Grillo, HC Surgery of the trachea and bronchi.2004,499-506 BC Decker. Hamilton, ON, Canada:
 
Freeman, BD, Isabella, K, Lin, N, et al A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients.Chest2000;118,1412-1418
 
Melloni, G, Muttini, S, Gallioli, G, et al Surgical tracheostomy versus percutaneous dilatational tracheostomy: a prospective-randomized study with long-term follow-up.J Cardiovasc Surg2002;43,113-121
 
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