Dr.Ali Bandar, MD, PHD
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DO we need Percutaneous tracheostomy set to be in Emergency Airway trolley? PCT in emergency airway managment
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Dr.Ali Bandar, MD, PHD
- 1. Do we need PCT set to be in Emergency Airway Trolley? Dr.AliBandarMD,PHD
- 2. Case report * 17/02/2018 at 18:30 * 34 years old male, Presented to medical causality with worsening SOB for 3 days, not responding to treatment, sweating, No fever, No chest pain. * Known case of DM on Ins more than 7 years, heavy smoker 2P/D, BA – On Ventolin puffs SOS, previously admitted to ICU with Status asthmaticus 2 month back (intubated and mechanically ventilated during his stay in ICU).
- 3. Clinical examination Conscious, oriented. BP: 130/80 HR:140 SR S1/S2 Breathing Spont, connected to BIPAP( IPAP=18, EPAP=5 RR=20, FIO2=0.5) * Chest auscultation: Reduced air entry, ronchi Abdomen soft, No tenderness. Free voiding. CNS CVS RS GI GU
- 4. Lab * VBG: PH: 7.39 PCO2: 5.7Kpa HCO3: 25.8 PO2: 10.9Kpa * Hb: 15.3 PLT: 235 WBC: 11 * INR: 1.15 APTT: 36 * BS: 11.2 Urea:3.1 Creat. : 34 Na: 13 K: 4.2 * CXR: Prominant vascular markings , hyper inflated lung.
- 5. * Preliminary (Admission ) diagnosis: severe exacerbation of BA under Chest physician care. * Patient was admitted to ICU for close observation, further management and possibility of invasive ventilation. * Treatment: T.Solumedrol 30mg TDS, Ventolin and Atrovent Nebulaization 2hourly, Neb.Pulmicort BD, Syr.Mucolyte TDS, Antbiotic therapy empirically. * VBG 6hrly, but pt refusing any needle prick. * On 18/02/18 at 12.30 am, Pt became agitated, not tolerating BIPAP, with severe respiratory distress.
- 6. * Decision for intubation was taken. * Ketamine, Propofole , Scoline given , 1st trial of intubation failed, although laryngscopy view was Cormack 2, this was followed with multiples trials with different sizes of ETT (8.0, 7.0, 5.0, 4.5) bougie. * All this period, Oxygenation and ventilation were maintained by mask ventilation.
- 7. * Consultant contacted, ENT involved for emergency tracheostomy. * In the presence of gowned and gloved ENT surgeon , Percutaneous Tracheostomy done by our consultant. * Improved and on 19/02/18 transferred to the ward, Spont breathing via TT, with stable vital signs. * Final diagnosis (post intubation subglottic stenosis).
- 11. Journal of the Association of Anesthetists Great Britain & Ireland January 2004
- 12. A Case of resection of a left‐sided carotid body tumour complicated by wound hematoma compromising Airway. Conclusion The technique of PCT in TRAINED HANDS, may be considered as an option when emergency access to the airway is required
- 13. Texas Heart Institute Journal 2004
- 14. Under special circumstances, when application of standard management techniques for a difficult airway were not possible, a PCT can be valuable in an emergency situation to establish airway access and it could replace cricothyroidotomy. CONCUSION
- 15. South Asian Journal of Cancer October-December 2012
- 18. A case of dental abscess complicated by severe facial and neck swelling compromising the airway.
- 19. From the Trauma, Burn, and Surgical Critical Care Program, Methodist Hospital, Michigan. This study was presented at the Advanced Technology Applications for Combat Casualty Care Conference in Florida, August 15Y18, 2011, Journal of Trauma and Acute Care Surgery 2012
- 20. * 18 patients underwent emergency PCT age range was 21 - 86 y. * Indications for PCT included respiratory failure associated with anaphylaxis, supraglottic edema, cardiac arrest, and blood or edema blocking the airway preventing intubation. * PCT was performed in various departments throughout the hospital (ICU, trauma surgery, cardiology, medicine, and neurology). * Tracheostomy tube sizes 6.0, 7.0, 8.0, 9.0. * All PCTs were successfully placed, and there were no complications. * 10 patients had no airway in place at the time of procedure.
- 21. CONCLUDED • PCT provided a safe, effective emergency airway in adult patients who presented with a variety of indications, in varying locations throughout the hospital. * PT performed by appropriately trained personnel may be a potential adjunct for emergent airway control in diverse settings. * 6 patients had emergency esophageal-tracheal airways in place. * 2 patients had a cricothyroidotomy that was not functioning adequately. * 9 patients had body mass indexes ranging from 30 kg/m2 to 112 kg/m2
- 22. 抽象 バックグラウンド： 近年、短頸、肥満、凝固障害または緊急時のような悪条件の患者に経皮的気管切開術 が行われている。 方法： 喉頭腫瘍、喉頭浮腫、頸部がんまたは頸部傷害のために気道が困難な5人の患者にお いて、またはの技術を用いて経皮的気管切開術を行った。 結果： 十分に訓練された麻酔医はすべての処置を行った。 4人の患者において、経皮的気管 切開術は合併症なしに迅速に完了した。 残りの患者は、緊急事態のために準備され た経皮気管切開セットを用いて気管挿管を成功裡に受けた。 この設定を「スタンバ イPCT」と呼びます。
- 23. CONCLUSIONS: * We believe that PCT in well-trained hands can be used safely for the management of the patient with a difficult airway. * PCT set prepared for an emergency situation. We call this setting "Stand-by PCT" Anesthesia and Critical Care Service, Chiba Aoba Municipal Hospital, Chiba, Japan
- 25. A case of severely burned patient, smoke injuries and acute respiratory and Circulatory Arrest Although not widely investigated for urgent airway access, the feasibility of the PCT technique in experienced hands as opposed to emergency cricothyroidotomy is suggested in selected cases, even in arrested patients. Conclusions
- 26. Recomendation * Add PCT set to your Emergency Airway trolley. * Train your doctors for elective PCT to gain skill and experience. * Greater consideration should be given to PCT use. * When relative contraindication are encountered .. Consider risk/benefit while taking decision.
- 27. Conclusion * PCT may prove to be a safer, more efficient method than the open route as a procedure can be performed outside of the operating theatre, at the bed side, All of the necessary instruments are pre‐packaged in one kit. * PCT as a further option available to the anesthetist in airway management. * With experience the PCT can be performed without a bronchoscopy. * Emergency PCT is a safe alternative method for providing a definitive airway in an emergency, in TRAINED HANDS.
- 28. Why not Cricothyroidotomy? * An emergency Cricothyroidotomy carries high complication rate up to 40%. * Easily injures adjunct structure of Cricothyroid membrane(conus elasticus cricothyroid muscles, central cricothyroid arteries). * Damage to the Cricoid cartilage , thyroid cartilage and vocal cords. * Subcutaneous emphysema, hemorrhage, extra- tracheal tube placement, pneumothorax, laceration of the esophagus or trachea. * Tracheal stenosis/ Tracheomalacia. * Its not definitive airway, its only temporary solution & requires often conversion to a formal tracheotomy during a second step
- 32. ▪ Difficult Airway socity guidelines for critical ill patient intubation 2018 ▪ Australian New Zealand Intensive Care Society (ANZICS). Percutaneous Dilatational Tracheostomy – Consensus Statement. Carlton, South Victoria: Australian New Zealand Intensive Care Society; 2014. ▪ American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013 ▪ Ciaglia P, Firsching R, Syniec C. Elective percutaneous dilatational tracheostomy. A new simple bedside procedure; preliminary report. Chest 1985;87:715-9. ▪ Schachner A, Ovil J, Sidi J, Avram A, Levy MJ. Rapid percutaneous tracheostomy. Chest 1990;98:1266-70. ▪ Byhahn C, Wilke HJ, Halbig S, Lische V, Westphal K. Percutaneous tracheostomy; Ciaglia Blue Rhino versus the basic Ciaglia technique of percutaneous dilatational tracheostomy. ▪ Frova G, Quintel M. A new simple method for percutaneous tracheostomy: controlled rotating dilatating: a preliminary report. ▪ Fantoni A, Ripamonti D. A non derivative, non-surgical tracheostomy: the translaryngeal method. ▪ Szmuk P, Ezri T, Evron S, et al. A brief history of tracheostomy and tracheal intubation, from the Bronze Age to the Space Age. Intensive Care Med 2008 34:222-8. ▪ McGarvey JM, Pollack CV. Heliox in airway management. Emerg Med Clin North Am 2008;26:905-20, viii. ▪ Grillo HC, Donahue DM. Post intubation tracheal stenosis. Semin Thorac Cardiovasc Surg 1996;8:370-80. ▪ Hsiao J, Pacheco-Fowler V. Videos in clinical medicine.Cricothyroidotomy. N Engl J Med 2008;358:e25 Refrences
Editor's Notes
- Good evening The ability to secure an airway emergently in most cases can make a difference between life and death. Orotracheal intubation is the predominate method of choice. Unfortunately, there are occasions when this is not possible. Under such circumstances an open tracheostomy or a cricothyroidotomy has been the procedure of choice. Percutaneous tracheostomy (PCT) in experienced hands is gradually being added to a limited number of lifesaving emergency procedures. Over the next few minutes I will share with you our local experience in ASH regarding the using PCT in emergency airway management Starting by a case report, then going through literature review Many suggested contraindications are not adequately supported with published data, and are merely suggestions. It appears that the list of contraindications may decrease depending on the sitting of the intensive care unit, type of kits, bronchoscopic assistance and skill of the operators
- On arrival in casuality pt was con
- CT: Subglottic significant stenosis, maximal airway diameter measures about 3mm seen at level of C7 with related edema of the tracheal wall
- Failure of noninnvasive ventelation declaired and disicioun for invasive intubation was taken This was a turning point in our management as we started to think that pateint has subglotic stenosis rather than actual bronchospasm, and we realized that securing the pt airway will be only accomplished by FONA
- In the presence of gowned and gloved ENT surgeon , Given that PCT has a better safety profile, prognosis, and that pt is young with reassuring anatomy ENT surgeon suggested to proceed for PCT
- This Glydiscope view after securing the airway by TS
- This case trigered me to review laterature Looking for similar cases searching for an evedince supports PCT on emergency basis
- I found in laterature 68 cases repoted from different countries I choose 4 interesting cases to share with you 2 cases 2004 London 9 cases 2003 LOS angelus 1 case 2004 Texas 10 cases 2004 Palestine 1 case 2005 France 2 cases 2008 UAE 5 cases 2008 Japan 2 cases 2012 India 18 cases 2012 Mechigan 4 cases 2013 India 13 cases 2015 Belgium 1 cases 2017 South Africa Total= 68 cases
- Failed intubation and emergency Percutaneous tracheostomy published in Association of Anesthetist great britain and Irland in 2004 they
- A 55‐year‐old man underwent resection of a left‐sided carotid body tumor. Tracheal intubation was performed without difficulty (Cormack and Lehane Grade II). After an uneventful procedure he was extubated and transferred to the HDU. Two hours later, he complained of difficulty breathing and his neck was becoming very swollen. Over a period of minutes he developed complete airway obstruction. The wound was opened and an attempt made to evacuate haematoma. Attempts to maintain ventilation with a mask and breathing system were unsuccessful and he rapidly became severely hypoxic and unrousable. An attempt was then made to intubate the trachea but there was gross oedema. It was impossible to identify the epiglottis. The neck anatomy grossly distorted. The trachea was pushed over to the right. With desating SPO2 less than 50% the trachea was cannulated and a guide wire inserted.. The trachea was dilated and a tracheostomy tube was introduced. The time taken to secure an airway was estimated to be less than 90 s. Saturation improved, pt tooke to OT for hemostasis, after controle of bleeding shifted to ICU On next day started weaning process, downsizing the tracheostomy tube and decanulation On day5 post op transferred to the word
- Artickle published in texas heart institute journal 2005 : a case of emergency PCT after unsuccessful orotracheal intubation in a patient with an A MI 41-year-old woman had an acute myocardial infarction, followed by pulmonary edema and respiratory failure necessitating emergency airway access. Four unsuccessful attempts intubation were complicated by a pharyngeal hemorrhage and glottic edema;. The patient was given tissue plasminogen activator and heparin to treat her myocardial infarction. patient was semiconscious and in respiratory distress. An ambulatory breathing unit and mask were applied, and 100 mg of succinylcholine was administered. The patient was ventilated with the breathing unit, and the oxygen saturation was maintained in the 90% to 93% range. On laryngoscopy, no glottal structures were visible. The supraglottal tissues were edematous, and hemorrhage was noted with gross blood in the pharynx, presumably from previous intubation attempts. Use of a laryngeal mask airway was not deemed possible. Because of the patient’s obesity, a cricothyroidotomy or conventional tracheostomy would have been difficult in this anticoagulated patient and would have prevented further definitive emergency cardiac intervention. She was hemodynamically unstable, so an intra-aortic balloon pump (IABP) was inserted. During IABP placement, a percutaneous sequential dilational tracheostomy was performed. The patient was taken to the cardiac catheterization laboratory, where blood flow was reestablished through her occluded left anterior descending artery. Her hemodynamic condition improved, and she was transferred to the intensive care unit later the same night. During the next week, she recovered smoothly and was weaned from the IABP and mechanical ventilator. Her tracheostomy was sequentially downsized, and decannulation was performed before she was discharged on the 14th postoperative day.
- Emergency PCT in two cancer pateint with dificult airway: An alternative to Cricothyroidotomy?
- A 48-year-old male, a known case of carcinoma buccal mucosa stage III and had already undergone commando procedure followed by chemotherapy and radiotherapy 3 months back, presented to triage with complaints of breathlessness, cough, difficulty in speaking of 1 day duration. On evaluation, there was an inspiratory stridor and labored respiration along with hypoxemia on room air (oxygen saturation (SpO2) 77% ). After an initial stabilization, he was immediately shifted to the (ICU). He was managed conservatively and urgent surgical consultation. in next few minutes, patient’s condition worsened with increasing stridor, respiratory distress, and hypoxemia followed by cardio-respiratory arrest, and resuscitation was started. The call for definitive airway protection was taken as there was no improvement with the primary resuscitation. Orotracheal intubation was tried thrice,, it was unsuccessful. A rapid decision for PCT was taken by the critical care team along with on-call surgeon and was performed. The time taken to secure an airway was less than 2 minutes, and position was confirmed with capnography. After tracheostomy, there was improvement in ventilation and SpO2. He was successfully resuscitated with the return of spontaneous circulation in approximately 11-12 minutes. Patient showed gradual recovery, vasopressors and ventilatory support were subsequently tapered off, and the patient was transferred out, neurologically alert and oriented, with T-piece on day 5
- Awake PCT as an alternative to open emergensy tracheostomy in threatened airway 2017 published in southern journal of anesthesia and analgesia
- A case of dental obcess complicatd by sever facial and neck swelling compromising the airway A 42-year-old male presented with a threatened airway as a consequence of complicated dental abccess extending into the neck. Extensive head and neck swelling was assessed as severe enough to make bag-mask ventilation, direct laryngoscopy and rescue with a supraglottic airway (SGA) impossible. Critical narrowing of the pharynx, identified on CT scan, made fibre-optic intubation risky in terms of completely obstructing the airway during the attempt. The airway was secured by a percutaneous tracheostomy technique with local anaesthetic with the patient awake and spontaneously breathing in the upright position.
- Clinical research from the trauma, burn, and Surgical Critical care program, Methodist hospital Michigan 2012
- 18 patients underwent emergency PCT; 61% were male, and age range was 21 years to 86 years. Indications for PCT included respiratory failure associated with anaphylaxis, supraglottic edema, cardiac arrest, and blood or edema blocking the airway preventing intubation. PCT was performed in various departments throughout the hospital. Admitting services ncluded critical care intensivist (44.4%), trauma surgery (27.7%), cardiology (11.1%), medicine (11.1%), and neurology (5.5%). Most of the tracheostomy tube sizes were no. 8 (61.1%), followed by no. 7 (22.2%), no. 6 (5.5%), and no. 9 (5.5%). All PCTs were successfully placed, and there were no complications. Ten of our patients had no airway in place at the time of procedure. Six patients had emergency esophageal-tracheal airways in place. Two patients had a cricothyroidotomy that was not functioning adequately. Nine patients had body mass indexes ranging from 30 kg/m2 to 112 kg/m2
- At this point the logic question would be ( why not Cricothyrotomy ? )
- Japanese article published in 2008, performed PCT in 5 patients with difficult airways due to laryngeal tumors, a laryngeal edema, a neck cancer or a cervical injury without any complications.
- Now after sharing with you these case reports and artickles about using PCT in emergency airway management comes the question why not cricothyiotomy ?
- Case report from france published in Elsevier as Emergency percutaneous tracheostomy in a severly burned pateint with upper airway obstruction and circulatory arrest in 2006 A 54 year old patient was admitted to the intensive care unit with severe burns, smoke injuries, and acute respiratory and circulatory failure. Seventy percent of the total body surface area was burned and the respiratory tract was affected by smoke inhalation, resulting in severe acute respiratory distress syndrome. He had been intubated for 36 days, was reintubated three times, but nevertheless, successful weaning from the ventilator was achieved following the standard weaning guidelines. The tracheal tube was removed after careful evaluation for upper airway obstruction. Mild laryngeal and tracheal injuries following tracheal intubation and smoke inhalation were noticed, without relevant stenosis, and were treated by antibiotics and corticosteroids. Two weeks later, the clinical condition worsened dramatically with the occurrence of a life threatening acute respiratory failure, resulting in arterial desaturation SpO2 75% The following actions were undertaken consecutively taken by the first physician, who had no specific experience in percutaneous techniques: 1. High concentration oxygen therapy using a highflow nonrebreathing mask-reservoir bag (non effective, duration 1 min, SpO2 75%). 2. Manual ventilation using a facial and a laryngeal mask with pure oxygen (non effective with leaks, duration 1 min, oximetry 70%). 3. A rapid sequence intubation attempt using fentanyl and succinylcholine (oximetry 70%), orotracheal intubation using a variety of laryngoscopes proved impossible, due to complex airway obstruction (duration 2 min, oximetry <70%). 4. Cardiac arrest occurred, CPR was initiated. The overall time interval between the onset of respiratory failure and cardiac arrest was <4 min. A second physician, experienced in difficult airway management, reached the arrested patient at this stage. The altered surface anatomy of the neck allowed no possible visual or palpable recognition of the cricoids cartilage. He therefore decided to perform a bedside percutaneous tracheostomy blindly during cardiac resuscitation. Each step of the procedure was achieved during a short interruption of external chest compressions of about 5 s, and guided and secured by aspirating air during trans-tracheal puncture and trans-tracheal catheter insertion. The time taken to perform the percutaneous procedure and achieve efficacious oxygenation, ventilation, and return of spontaneous circulation was about 1 min. The overall time interval for definitive airway establishment from the onset of respiratory failure was 6 min, the total duration of the cardiac arrest 2 min. The patient recovered normal neurological status within 1 day. A new evaluation of the airway under sedation using both flexible and rigid fiberscope confirmed complex and, close to complete, upper airway obstruction, due to laryngeal and tracheal damage, with an additional tracheal ring fracture cranial to the stoma. The tracheostomy tube was kept in place for 1 month while complementary tracheal dilatation and laser therapy were done. The patient was referred to the rehabilitation team breathing air, and removal of the tracheostomy tube finally
- The failed intubation and the need for subsequent cricothyrotomy is a rarity, but most practitioners are unfamiliar with this life-saving technique. All emergency airway access techniques are potentially dangerous and present a high complication rate, especially if performed by unskilled personnel. Training is very similarly the most difficult problem to solve in cricothyrotomy because a formal training on a regular basis is rarely done in most hospitals As they will need the skill and expirience in emergency situation Loosing the airway is life threatening
- The failed intubation and the need for subsequent cricothyrotomy is a rarity, but most practitioners are unfamiliar with this life-saving technique. All emergency airway access techniques are potentially dangerous and present a high complication rate, especially if performed by unskilled personnel. Training is very similarly the most difficult problem to solve in cricothyrotomy because a formal training on a regular basis is rarely done in most hospitals Emergency percutaneous tracheostomy is a safe alternative method for providing a definitive airway in an emergency, in trained hands. A general anaesthetic is not required allowing the procedure to be performed outside of the operating theatre. All of the necessary instruments to perform the percutaneous tracheostomy are pre‐packaged in one kit. With experience the percutaneous tracheostomy can be performed without a bronchoscopy. Percutaneous tracheostomy can be utilised in a variety of emergency clinical situations requiring rapid access to the airway.
- We all know DA algorithm by heart starting from failed trials of intubation, passing through trial of SGD insertion and mask ventilation till the nightmare of CICV, where the last resort will be FONA. At this point according to (DAS, ASA) guidelines we all think about cricithyroidotomy, but how many of us did crico before or even attended one, so how do you expect your performance under maximum stress doing some procedure you never did before!! Apart from lack of experience emergency Crico caries high complication retae