adding percutaneous tracheotomy through Griggs' forceps technique to the failed airway management algorithm

1. Title of Presentation Arial Regular 22pt
Single line spacing
Up to 3 lines long
Date 20pts
Author Name 20pts
Author Title 20pts
Bassem N. Beshey; MD1
, Tamer A. Helmy; MD1
, Hany S. Assaad Khalil; MS1
Emad Ibrahim; MD, FCCP2
1
Critical Care Medicine Dep., 2
Chest Dep.,
Faculty of Medicine, Alexandria University, Alexandria, Egypt.
EMERGENCY PERCUTANEOUS
TRACHEOTOMY
IN
FAILED INTUBATION

2. 2
Emeregencypercutaneoustracheotomy
infailedintubation
B assem B eshey, T am er H elm y, H any A saad, E m ad Ibrahim
E uropean R espiratory Journal 2013 42: P 4919; D O I:

3. 3
ABSTRACT
Objective: Cricothyrotomy is the emergency surgical means of gaining access to the airways.
However it holds a lot of problems to the patient and is only a temporary measure until a definitive
airway is reached. Griggs’ forceps technique for elective bedside percutaneous dilational
tracheotomy (PDT) is safe, fast, and carries fewer complications in expert hands. This study aimed
at comparing between emergency cricothyrotomy and emergency PDT in patients with failed
intubation. Design: a comparative double blind randomized study. Setting emergency room of
Alexandria main University Hospitals. Patients: This study was conducted on failed airway patients
according to the failed airway management algorithm. Total number of patients in need for intubation
was 3785. Those with difficult airway were 365 patients (9.64%), 196 of them were successfully
intubated soon and so were excluded from the study. 169 failed to intubate, and to ventilate patients.
Methods: they were serially randomized into group I (85 patients): percutaneous cricothyrotomy and
group II (85 patients): PDT using Griggs’ forceps technique. Results: success rate was 95.3% in
group I and 97.6% in group II (P=0.452). Procedure duration (in minutes) was 1.85±0.36 in group I
versus 1.46±0.31 in group II (P=0.106). Lung atelectasis occurred to 8.2% of patients in group I only
(P=0.011). Vocal cord injury occurred to 4.7% of patients in group I versus 1.2% in group II
(P=0.074). Subglottic stenosis was recorded in 5.88% of patients in group I versus 1.2% in group II
(P=0.039(P=0.452)). Conclusion: emergency PDT is feasible and safe in expert and trained hands in
patients with failed emergency intubation.

4. • The situation of “can’t intubate, can’t ventilate”
is not a common finding, however it is life
threatening and necessitates immediate
intervention.
• According to the failed airway management
algorithm in most guidelines worldwide,
cricothyrotomy is the most rapid and accepted
means of gaining access to the airways in such
emergency conditions.
Introduction

5. The problem with Cricothyrotomy
• The small sized tube used that can lead to more
▫ incidence of displacement,
▫ difficult suction,
▫ incidence of obstruction,
▫ increased resistance,
▫ incidence of atelectasis,
▫ liability to lower airway infections,
▫ incidence of subglottic stenosis,
▫ only a temporary solution until a definitive airway.
Introduction

6. Percutaneous dilational tracheotomy
• Percutaneous dilational tracheotomy (PDT) has gained
popularity and became a routine practice in most
hospitals worldwide.
• A large number of articles have been published comparing
several techniques of PDT with open surgical tracheotomy
• Majority reported either no statistical difference or lower
complications rate and less procedure time associated
with performing PDT.
Introduction

7. Percutaneous dilatational tracheotomy
Our experience:
• Ciaglia et al modified serial dilations of the trachea using
gradually larger-sized dilators in the mid-1980s.
• Dilating forceps technique for percutaneous tracheotomy
was created by Griggs in 1990.
• Our department was the first one in the Middle East to
introduce Griggs’ forceps dilating tracheotomy kit by
1999.
Introduction

8. Percutaneous dilatational tracheotomy
Our experience:
• This was a surprise to Sir Davidson; chief editor of
Davidson’s principles & practice of medicine, in his visit
to our department in 1999. He encouraged us a lot to
continue.
• Since then, we constituted the first team of PDT in the
Middle East for both interventional & teaching purposes.
• PDT has gained a lot of popularity and totally replaced the
surgical technique nearly in all Alexandria ICUs.
Introduction

9. Percutaneous dilatational tracheotomy
Our experience:
• More than 2000 cases have been successfully operated
and a lot of research work has been accomplished.
• Griggs’ forceps was faster and carried less complications
in expert hands.
• Our hope is to spread our experience to all ICUs with our
collegues allover Egypt, so that all ICU consultants in
Egypt can perform bedside PDT easily. First one in Cairo
university was one of our specialists in 2009.
Introduction

10. Percutaneous dilatational tracheotomy
Our experience:
• Hoping for this, we constructed the:
EASI Course
(Emergency and elective Airway
management Steps in ICU)
Introduction

12. Percutaneous dilatational tracheotomy
Our experience:
Introduction

13. • These findings encouraged us to
highlight the possible role of PDT in
providing a definitive airway if applied
on emergency basis with special look
to:
• duration of the procedure
• rate of complications.
Introduction

14. • This study aimed at comparing between
emergency cricothyrotomy and emergency
percutaneous dilational tracheotomy
(PDT) using Griggs’ forceps technique in
patients with failed intubation as regard:
• success rate
• duration of the procedure
• rate of complications.
Aim of the Work

15. Inclusion Criteria
• Adult Patients,
• Admitted to Alexandria University Hospitals,
• At the period from 1st
of January till the 31st
of December, 2011,
• Who failed intubation and necessitated invasive emergency
airway access according to the failed airway management
algorithm.
Patients &
Methods

16. Exclusion Criteria
• Patients under 10 years of age,
• Those not accompanied by first degree relatives,
• Pregnant women,
• Patients with known laryngeal pathology.
Patients &
Methods

17. Ethical Approval
• Ethical committee of Alexandria Faculty of
Medicine approved this randomized
interventional clinical study.
Patients &
Methods

18. Patients &
Methods
Patient admitted to the ER indicated for endotracheal intubation was
assessed for characteristics predictive of difficult laryngoscopy
and intubation using the LEMON mnemonic scoring
No difficult intubation predicted
Difficult intubation predicted
ICU admission
Successful Intubation
•Bag Valve Mask (BVM) ventilation
•Using 100% oxygen was applied
•Cricoid pressure
•Manual-in-line stabilization of the cervical spine
•Re-insertion of the oro/naso-pharyngeal airway
•Awaken attempt for endotracheal intubation
•Using another laryngoscope blade
•Flexible stylet
•Ensuring patient’s optimum position.
•Intubating laryngeal mask (ILMA-FastTrackTM
).
(SpO2 ≤ 90%)(SpO2 ≥ 90%)
Failed airway management algorithm
Successful Intubation
Unsuccessful Intubation
Unsuccessful Intubation

19. Failed airway management algorithm
Group I:
Percutaneous cricothyrotomy
•using the Seldinger 4-step
cricothyrotomy technique
•with insertion of a suitable
sized tube to connect to the
ventilator
•If failed, percutaneous
dilational tracheotomy was
performed as a definitive airway
(cross group drop-out was not
allowed after randomization).
Group II:
Percutaneous dilational
tracheotomy (PTD)
•using the Griggs’ forceps dilator
technique
•with insertion of a suitable
sized tube to connect to the
ventilator
•If failed, surgical tracheotomy
was performed as a definitive
airway (cross group drop-out
was not allowed after
randomization).
Patients &
Methods

20. All patients in both groups
• Were mechanically ventilated using BI-PAP mode
• A plain A-P chest X-ray was performed
• Fiberoptic bronchoscopic examination of the upper
airways was conducted within a time window of 1 hour
post-intubation.
• Routine laboratory investigations were recorded shortly
after airway establishment.
Patients &
Methods

21. Airway management data were recorded:
▫ Success rate of establishing an artificial airway that
improved and maintained SpO2 ≥ 90%,
▫ Time elapsed between needle insertion till the end of
procedure.
▫ Incidence of early complications.
▫ Late airway complications were reported either soon post
extubation, or 30 days after procedure completion which
ever came first.
Patients &
Methods

22. • Patients in the percutaneous cricothyrotomy group who
failed to receive their needed ventilation requirements were
switched to percutaneous tracheotomy as a definitive airway
after bronchoscopic examination and within 24 hours
• However this was not calculated in the rate of failure in this
group.
Patients &
Methods

23. Group homogeneity
• 169 patients with failed intubation were included.
• Serially randomized into
▫ 85 patients (50.3%) in group I:
The percutaneous cricothyrotomy group
▫ 84 patients (49.7%) in group II:
The percutaneous dilational tracheotomy group.
• Both studied groups were matched in age and sex with no
statistical significant difference.
Results

24. • Selective laboratory findings: p=N.S
Results
(P=0.52) (P= 0.62) (P= 0.98)
(P= 0.77)(P= 0.25)

25. • Success rate:
95.3 97.6
2.44.7
P=0.452
Results

26. Results

27. • Early complications:
P= 0.011 P= 0.074 P= 0.65 P= 0.99
Results

28. • Late complications:
P= 0.039 P= 0.103
Results

29. Real time procedure of PDT performed by Dr. Bassem BESHEY
(1:20 min)
Results

30. • Although success rate and time to complete both
procedures were comparable; however
performing PDT to patients on emergency basis
in such short time is much superior in providing
a definitive airway rather than the temporary
solution of cricothyrotomy with all its known
possible complications and ventilatory obstacles.
Conclusion

31. • We have a very promising future expectation for
the emergency PDT using Griggs’ forceps
technique, hoping to highlight its encouraging
role in any future alterations in the algorithm of
failed airway management with lower early and
late complications in critically ill patients.
Conclusion

32. Thank You
Egyptian Revolution, 28th
of January 2011, Alexandria, Egypt