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Maria Vargas, MD; Paolo Pelosi, MD; Robert M. Kacmarek, PhD, RRT; Giuseppe Servillo, MD
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From the Department of Neurosciences, Reproductive and Odonthostomatological Sciences (Drs Vargas and Servillo), University of Naples “Federico II”; Department of Surgical Sciences and Integrated Diagnostics (Dr Pelosi), AOU IRCCS San Martino IST, University of Genoa; and the Department of Anesthesiology and Critical Care and Department of Respiratory Care (Dr Kacmarek), Massachusetts General Hospital.

CORRESPONDENCE TO: Giuseppe Servillo Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples “Federico II”, via Pansini 16, via pansini, 80100 Naples, Italy; e-mail: servillo@unina.it


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;148(1):e27-e28. doi:10.1378/chest.15-0511
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To the Editor:

We read with interest the comments by Dr Ferraro and colleagues about our recent article in CHEST.1 The double-lumen endotracheal tube (DLET) is a new device tested during percutaneous dilatational tracheostomy (PDT).1 We agree with Dr Ferraro and colleagues that the current DLET design cannot be used for Fantoni translaryngeal tracheotomy (TLT), but future design modifications may make it more useful during TLT. TLT is not frequently used in Italy, and it is used even less frequently in other parts of Europe,2 but we appreciate the need to improve ventilation during TLT.3

The primary end point of our study was to report the feasibility of PDT with DLET.1 Specifically, our focus was on successful completion of the PDT (levels 1 and 2) without shifting from DLET to a conventional endotracheal tube.1 Accordingly, we categorized the kinking of the guidewire that occurred in one PDT with DLET as a complication not limiting the technique, since the procedure was successfully completed with the DLET. Thus, the primary end point was achieved in 100% of the patients. Furthermore, our study reached a power of 0.86 for Pao2 data and 0.99 for plateau airway pressure data, with an α level of 0.05, indicating that our sample size was adequate to make statistically sound conclusions.1

Patients eligible for PDT are already intubated with a conventional endotracheal tube, so the infantile glottis is not an unexpected problem. The replacement of the DLET may be safely performed with a proper tube exchanger.3 We recommended caution in the presence of a difficult airway,3 as during any airway manipulation.

We respectfully do not agree that DLET might limit the vision of anatomic structures. The DLET correctly positioned at the level of vocal cords allows endoscopic vision from this point to the carina. The DLET is made of transparent polyvinyl chloride, allowing endoscopic vision of mucosal lesions and avoiding endoscopic tip flexure. In our opinion, the technique proposed by Ferraro et al4,5 has some limitations: (1) It negatively affected ventilation, since Paco2 increased 4.5 (3.7 SD) mm Hg and Pao2 decreased 75 (33 SD) mm Hg during PDT; and (2) it is likely to interfere with endoscopic vision and procedural maneuvers. In fact, since the uncuffed endotracheal tube is not adequately secured and fixed in the trachea, like DLET, it may be abruptly displaced by the pressure exerted during the PDT maneuvers. Additionally, at cannula insertion, the DLET may be partially withdrawn, but the flexible fiber-optic bronchoscope can remain in place, ensuring continued endoscopic vision.

We believe that DLET is the sole device that both protects the posterior tracheal wall and is not associated with any variation in gas exchange, acid-base balance, or airway pressure during PDT. Future studies are warranted to better identify the optimal indications and contraindications of DLET during PDT.

References

Vargas M, Pelosi P, Tessitore G, et al. Percutaneous dilatational tracheostomy with a double-lumen endotracheal tube: a comparison of feasibility, gas exchange, and airway pressure. Chest. 2015;147(5):1267-1274. [CrossRef] [PubMed]
 
Vargas M, Servillo G, Arditi E, et al. Tracheostomy in intensive care unit: a national survey in Italy. Minerva Anestesiol. 2013;79(2):156-164. [PubMed]
 
Vargas M, Servillo G, Tessitore G, et al. Double lumen endotracheal tube for percutaneous tracheostomy. Respir Care. 2014;59(11):1652-1659. [CrossRef] [PubMed]
 
Ferraro F, Capasso A, Troise E, et al. Assessment of ventilation during the performance of elective endoscopic-guided percutaneous tracheostomy: clinical evaluation of a new method. Chest. 2004;126(1):159-164. [CrossRef] [PubMed]
 
Ferraro F, Marfella R, Petruzzi J, Torino A, d’Elia A, Lettieri B. Translaryngeal open ventilation for percutaneous endoscopic tracheostomy. Br J Anaesth. 2014;113(1):189-190. [CrossRef] [PubMed]
 

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References

Vargas M, Pelosi P, Tessitore G, et al. Percutaneous dilatational tracheostomy with a double-lumen endotracheal tube: a comparison of feasibility, gas exchange, and airway pressure. Chest. 2015;147(5):1267-1274. [CrossRef] [PubMed]
 
Vargas M, Servillo G, Arditi E, et al. Tracheostomy in intensive care unit: a national survey in Italy. Minerva Anestesiol. 2013;79(2):156-164. [PubMed]
 
Vargas M, Servillo G, Tessitore G, et al. Double lumen endotracheal tube for percutaneous tracheostomy. Respir Care. 2014;59(11):1652-1659. [CrossRef] [PubMed]
 
Ferraro F, Capasso A, Troise E, et al. Assessment of ventilation during the performance of elective endoscopic-guided percutaneous tracheostomy: clinical evaluation of a new method. Chest. 2004;126(1):159-164. [CrossRef] [PubMed]
 
Ferraro F, Marfella R, Petruzzi J, Torino A, d’Elia A, Lettieri B. Translaryngeal open ventilation for percutaneous endoscopic tracheostomy. Br J Anaesth. 2014;113(1):189-190. [CrossRef] [PubMed]
 
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