The Laryngoscope VC 2010 The American Laryngological, Rhinological and Otological Society, Inc.

Suspension Laryngoscopy-Assisted Percutaneous Dilatational Tracheostomy in High-Risk Patients

Hilliary N. White, MD; Dawn B. Sharp, MD; Paul F. Castellanos, MD

Objectives/Hypothesis: To describe the out- This is most useful when T-PDT is considered unten- comes of bedside percutaneous dilatational tracheos- able or when transport to the operating room for a tomy (PDT) extended to the care of high-risk patients standard open tracheostomy is considered too cum- in the intensive care unit (ICU) by the use of suspen- bersome or potentially dangerous. sion laryngoscopy (SL) to secure the airway. Key Words: Percutaneous dilatational Study Design: Retrospective chart review. tracheostomy, suspension laryngoscopy, high risk. Methods: The records of 117 consecutive Level of Evidence:2c patients who underwent suspension laryngoscopy- Laryngoscope, 120:2423–2429, 2010 assisted percutaneous dilatational tracheostomy (SL- PDT) between April 2006 and May 2009 at our insti- tution were reviewed. Data gathered included patient INTRODUCTION demographics, anatomical conditions, ventilator set- tings, intraoperative findings, presence of coagulop- Tracheostomy, as a means of airway access, is one athy or anti-coagulation, and outcomes. of the oldest surgical procedures documented, dating Results: One hundred seventeen patients back approximately 4,000 years. As technology continues underwent SL-PDT. Eighty (68%) were considered to advance, there has been an increasing interest in high risk by virtue of one or more of the following: minimally invasive techniques over the years. Since the morbid obesity, coagulopathy, prior neck surgery or introduction of percutaneous dilatational tracheostomy head and neck trauma, laryngotracheal stenosis or (PDT) over 24 years ago by Ciaglia et al., the adaptation tracheomalacia, a high-riding innominate artery, or into most clinical spheres has been rather slow.1 The high ventilator demands. Thirty-five patients (30%) most common method for tracheostomy in critically ill had two or more of these risk factors. A total of 11 patients still remains open tracheostomy performed in (13.7 %) complications occurred in the high-risk 2 group. Two major and nine minor complications the operating room (OR). PDT was initially introduced occurred during the study. There were no adverse as an alternative method of airway management for sequelae. those patients in intensive care units (ICU) that was Conclusions: SL-PDT is a safe and effective unrelated to factors such as availability of the consulting means of bedside airway management in critically ill surgeon, OR time, and transportation assistance, but patients. This new technique offers several advan- rather to minimize perioperative complications of the tages over traditional percutaneous dilatational tra- standard tracheostomy procedure.1 cheostomy (T-PDT) and can be safely employed by A number of studies have been published compar- otolaryngologists, especially in high-risk patients. ing several techniques of PDT with the open surgical tracheostomy, and most suggest lower complication rates From the Department of Surgery, Division of Otolaryngology–Head or no statistical differences between the two methods. and Neck Surgery, University of Alabama at Birmingham, Birmingham, Recent meta-analyses have shown that PDT is easier to Alabama, U.S.A. perform, requires shorter operative times, produces less Editor’s Note: This Manuscript was accepted for publication March intraoperative and postoperative bleeding than the open 16, 2010. This work was an oral presentation at the 2010 Triological Society surgical technique, and results in fewer overall postoper- 3–5 Combined Sections Meeting, Orlando, Florida, U.S.A., February 5, 2010. ative complications. It has also been reported that Paul F. Castellanos, MD, is a consultant for Cook Critical Care, PDT in the intensive care unit ICU costs significantly Inc. The authors have no other funding, financial relationships, or con- less than surgical tracheostomy performed in the OR flicts of interest to disclose. 4,6–11 Send correspondence to Paul F. Castellanos, MD, University of Ala- and can be performed in less time. bama at Birmingham, BDB 563, 1530 3rd Avenue South, Birmingham, Despite the rapid evolution and improvements in AL 35294-0012. E-mail: [email protected] technique of PDT, there continues to be apprehension in DOI: 10.1002/lary.21019 the medical community about its applicability to the

Laryngoscope 120: December 2010 White et al.: PDT in High Risk Patients 2423 high-risk patient.12 What constitutes absolute and rela- ing blood pressure, pulse, respiratory rate, oximetry, and tive contraindications has become a matter of debate. electrocardiography. Most published articles consider cervical injury, pediatric A Dedo laryngoscope, a Pilling-Weck Louie arm suspen- < sion apparatus (model 502245FF9; Pilling-Weck Surgical, Fort age 8 years, gross distortion of the neck anatomy, and emergency airway necessity as absolute contraindica- Washington, PA), a 5-mm 30 Storz rigid endoscope (Hopkins II, model 2604613A; Karl Storz Endoscopy Ltd., Tuttlingen, Ger- tions, whereas obesity with a short neck, coagulopathy, many), a Storz camera and light cord (IMAGE1, A3, model need for positive end-expiratory pressure (PEEP) of HF618406-H; Karl Storz Endoscopy Ltd.), and a modified 9.0 more than 20 cm of water, and evidence of infection in Mallinckrodt oral endotracheal tube (ETT) (model 86454; Mal- the soft tissues of the neck at the prospective surgical linckrodt Co., Juarez, Mexico) were used for the site are relative contraindications. However, several laryngotracheal examination and control of the airway. A single reports have recently emerged suggesting safety and fea- dilator Ciaglia Blue Rhino Percutaneous Tracheostomy Intro- sibility of performing PDT in patients with the ducer Kit (Cook Critical Care, Inc., Bloomington, IN) was used previously described contraindications.12–17 in all cases. Patient ventilation was maintained throughout the Suspension laryngoscopy-assisted percutaneous entire procedure, with only very brief intervals of apnea during dilatational tracheostomy (SL-PDT) is a blending of two ETT exchange and airway evaluation. The Dedo laryngoscope is placed just into the laryngeal techniques developed by the senior author (P.F.C.) to ac- inlet within the aperture of the false vocal folds. The airway is complish two important goals: airway evaluation and then trapped into place while the Louie arm apparatus is tracheostomy simultaneously, while maintaining the engaged and the patient is placed in suspension from the bed- highest level of patient safety. The first preliminary side table that is positioned over the patient’s chest. The ETT is report of this technique and patient clinical outcomes then removed and a rigid airway evaluation is performed dur- showed great promise in adopting this to all critically ill ing a short period of apnea. The airway evaluation is a careful patients with rare complications. Over the last several and quick visual inspection with the 30 Storz endoscope. We years, SL-PDT was offered to all critically ill patients establish whether or not there is a clear view of the larynx, the regardless of body habitus, coagulopathy, increased ven- presence and depth of arytenoid and cricoid ulcers, signs of pos- tilator requirements, or difficult airway anatomy, sible tracheoesophageal fistula formation or innominate artery fistula formation, and obstructing secretions. Secretions that internal or external. We have retrospectively investi- might obstruct the airway during the PDT procedure are com- gated the implementation of this procedure in all monly encountered and removed either via rigid suction or with patients, highlighting those with high-risk features. We the assistance of grasping forceps. A shortened 9.0 ETT placed present the outcomes of a consecutive series of patients over a 30 optical telescope is then used to reintubate the in whom SL-PDT was performed in the context of the patient and examine the relevant airway landmarks to guide consultant request for tracheostomy alone. accurate needle placement. This is shown in Figure 1. The re- mainder of the procedure is conducted exactly as already described in the literature. The SL-PDT technique is described MATERIALS AND METHODS in further detail in the previous paper by Sharp and Castella- Approval was obtained from the institutional review board nos titled, ‘‘Clinical Outcomes of Bedside Percutaneous for data collection. A list of 117 consecutive patients who under- Dilatational Tracheostomy With Suspension Laryngoscopy for went SL-PDT at the University of Alabama at Birmingham Airway Control.’’ A streaming video of the procedure can be Hospital from April 2006 to May 2009 was considered for the viewed at be at: www.pdtsurgeon.com/sl-pdt.mp4.2 study. All patients were included in our retrospective analysis. All patients received standard Shiley cuffed cannulas Recorded data consisted of patient age, sex, weight and except for two of each gender; number 6 cannulas in females height, admission diagnosis, indication for tracheostomy, and and number 8 in males. Two male patients in this series perioperative complications. Also, ventilator settings at the time received an 8.0 proximal Shiley Extended-Length Tracheostomy of procedure, history of prior neck surgeries, intraprocedural (XLT) tube. One was required secondary to morbid cervical obe- findings on direct laryngoscopy, and recent lab values, including sity and the other secondary to a large, locally invasive thyroid platelet count and international normalized ratio (INR) were malignancy and postradiation fibrosis causing his airway to be recorded. Body mass index (BMI) was calculated from the deeply located in his neck. Two female patients received a 6.0 patient’s height and weight. This allowed patients to be classi- proximal Shiley XLT tracheostomy cannula. These were both fied as high risk based on these different findings. Each secondary to modest cervical obesity. patient’s record was followed throughout hospitalization. Inpa- tient outcomes and decannulation data were obtained. Standard statistical methods were used to analyze data. All procedures were performed either at the bedside in an RESULTS ICU setting or in the OR with the senior author present. Nearly One hundred seventeen patients underwent SL- all cases were performed with the assistance of an ear, nose, PDT from April 2006 to May 2009. One hundred nine of and throat (ENT) resident. The intensivist administered general these procedures were performed bedside in the ICU anesthesia using a combination of intravenous vecuronium bro- and eight in the OR. Table I lists basic patient demo- mide, fentanyl citrate, propofol, and/or midazolam maleate. The graphics including mean BMI and age. Eighty patients intensivist remained readily available, if not at the bedside, were considered high risk by virtue of one or more of the throughout the procedure. Particularly brittle patients were managed very closely by the intensivist team. The patient’s ICU following: morbid obesity, coagulopathy, prior neck sur- nurse and a respiratory therapist were present. Patients were gery or head and neck trauma, laryngotracheal stenosis mechanically ventilated with 1.0 fraction of inspired oxygen for or tracheomalacia, a high-riding innominate artery, or approximately 5 minutes before the start of the procedure. high ventilator demands. Thirty-four (29%) patients had Throughout the procedure, vital signs were monitored, includ- two or more of the above risk factors (Table II).

Laryngoscope 120: December 2010 White et al.: PDT in High Risk Patients 2424 TABLE II. High-Risk Factors.

Risk Factor Total No. % Obesity 36 30.7 Coagulopathy 35 30 INR > 1.5 9 7.7 CVVHD 18 15.4 Platelets < 50,000 8 6.8 Previous neck surgery/trauma 18 15.4 Laryngotracheal stenosis/tracheomalacia 9 7.7 High-riding innominate artery 2 1.7 High ventilator demands 18 15.4

INR ¼ international normalized ratio; CVVHD ¼ continuous venove- nous hemodialysis.

sure. No major complications occurred in the morbidly obese group. Patients were considered at increased risk of intra or postprocedure bleeding if they had one or more of the Fig. 1. SL-PDT instrument setup on a morbidly obese patient. > < Patient is placed in rigid suspension and intubated through the la- following features: INR 1.5, platelet count 50,000, ryngoscope with a shortened 9.0 endotracheal tube over a 5 mm or were receiving continuous venovenous hemodialysis telescope. The patient is ventilated throughout the procedure via (CVVHD). A total of 35 patients, approximately 30% of the side port. [Color figure can be viewed in the online issue, the patient population, met one or more of these criteria. which is available at wileyonlinelibrary.com.] Table II lists the detailed categorization. One major com- plication occurred in this group, a patient with end- Morbid obesity was defined as BMI 30, which is stage leukemia and multiorgan failure on CVVHD with consistent with National Institutes of Health standards. an INR > 2.0. On day 7 after surgery, the patient devel- In our series, 36 patients or approximately 30% were oped distal tracheobronchial airway obstruction with included in that category. The BMI of our male patients blood clots and mucous plugs. These were successfully ranged between 13.5 and 57.2 with an average BMI of removed with SL and rigid instrumentation. Within 24 27.8. The female patients had an average BMI of 29.8 hours of this event, the patient went into cardiopulmo- with a range from 16.7 to 48.6. Early in the series, one nary arrest and subsequently died. This outcome was patient required open tracheostomy because of unfavora- thought to be a manifestation of multisystem failure ble laryngotracheal visualization and difficult landmarks rather than airway obstruction. Of this group, only two secondary to morbid obesity (BMI 40). Later in the se- patients had moderate bleeding at the skin edges and ries, however, patients with higher BMIs and more only one required intervention. The first patient had obscure landmarks were routinely treated at the bedside heparin-induced thrombocytopenia and was receiving with SL-PDT without difficulty. CVVHD at the time of the procedure; the bleeding was Four minor complications occurred in this group. mild and ceased with compression after tracheostomy Moderate skin edge bleeding occurred in two patients, insertion. The second patient was also on CVVHD and one resolved with pressure and Surgicel (an absorbable had a history of a previous tracheostomy. Moderate brisk hemostatic agent) and the other required suture ligation bleeding was encountered at the skin edges requiring of a small arterial blood vessel. One episode of endotra- suture ligation of a vessel. cheal bleeding occurred, which was controlled with Eighteen patients had a history of previous head endotracheal topical epinephrine. Transient desaturation and neck trauma or surgery. This placed them in the to 60% occurred in one patient, which corrected to above high-risk group secondary to scar formation, alteration 90% with endotracheal albuterol and lidocaine and with in external landmarks, and because they are tradition- temporary increase in the positive end expiratory pres- ally more difficult to place in rigid suspension secondary to decreased neck extension. Patients who have had pre- vious tracheostomies performed by either open or TABLE I. percutaneous techniques were included in this category. Patient Demographics. The types of surgeries included thoracotomy for thymic Total Mean BMI Mean Age, yr High Risk mass excision, anterior cervical disc fusion, partial lar- yngectomy, anterior neck soft tissue reconstruction with Male 62 27.8 55.2 35 local flaps and grafts, and thyroidectomy. Female 55 29.8 56.8 45 The second major complication during this study Total 117 28.1 57.6 80 occurred in this patient group in a patient with severe la- BMI ¼ body mass index. ryngeal edema (remote history of base of tongue cancer

Laryngoscope 120: December 2010 White et al.: PDT in High Risk Patients 2425 TABLE III. The last group classified as high risk in this study Incidence of Complications in High-Risk Patients. included those patients with high ventilator demands at the time of their procedure. Eighteen patients met the Complication No. % criteria of PEEP >10 mbar. Two patients experienced a Extratracheal bleeding 4 5 transient desaturation to 70% during the airway evalua- Endotracheal bleeding 2 2.5 tion portion of the procedure, which returned to normal Desaturation 3 3.8 once the patient was reintubated and ventilated during Arrhythmia 1 1.3 the remainder of the SL-PDT. Airway obstruction 1 1.3 A total of 11 (13.7%) complications occurred in the high-risk group, two (2.5%) major and nine (11.3%) minor (Table III). One patient without high-risk features experi- enced a brief episode of moderate skin edge bleeding that treated with irradiation and a radial neck dissection). was tamponaded by insertion of the tracheostomy tube. The patient presented to the hospital in acute respiratory Refer to Table IV for a comparison of SL-PDT and tradi- distress and underwent an urgent open cricothyrotomy tional percutaneous dilatational tracheostomy (T-PDT) in because of a very low-lying cricoid cartilage and inability management of common complications. to expose the proximal trachea. Within 2 days, the patient was brought back to the OR for elective SL-PDT conversion. Upon neck extension and tongue compres- sion, he experienced severe bradycardia, requiring DISCUSSION emergent cardiopulmonary resuscitation and cessation of Bedside PDT within an ICU setting has been shown the procedure. He subsequently underwent left heart to be safe and effective in the hands of surgeons and catheterization, percutaneous transluminal coronary nonsurgeons alike.2–5,7–10,18 The range of patients angioplasty, and pacemaker placement. Once his condi- offered this option has been limited by multiple factors. tion stabilized, we successfully performed SL-PDT One factor is the reluctance of otolaryngology as a spe- without any complications. cialty to accept PDT as a reasonable option for airway One minor complication occurred in this group, management irrespective of the venue, secondary to which was an episode of endotracheal bleeding with tem- early reports of grave complications.19 There appears to porary desaturation to 70%. This was corrected be a variety of practice patterns and prejudice issues immediately with suctioning directly on the opening of contributing to this as well that were previously the tracheostomy cannula with removal of a large endo- described in an earlier publication.2 The second factor is tracheal clot. This was in a patient with a history of based on an array of relative contraindications to T-PDT severe burns to the head and neck who had undergone that include obese body habitus, difficult neck anatomy, reconstruction with local muscle flaps and skin grafts. prior neck surgery and increased ventilator settings Airway abnormalities, such as laryngotracheal ste- among others. Table V lists the benefits of performing nosis and tracheomalacia, placed patients in the high- SL-PDT over T-PDT in high-risk patients. This case se- risk group as well. There were a total of nine patients ries enabled us to demonstrate that SL-PDT can be with these findings. They all underwent successful SL- offered to virtually all comers. Patients with one or more PDT without any complications. Two patients with high- of the above-listed contraindications to PDT underwent riding innominate arteries were also included in the SL-PDT with minimal significant morbidities and with- high-risk group secondary to decreased dissection capa- out procedure-related mortality in our study. This leads bilities and decreased visualization in the soft tissues of to the conclusion that the current paradigm of airway the anterior neck with the percutaneous technique. No care for critically ill patients might need to be rethought complications were encountered. in several important ways.

TABLE IV. Comparison of T-PDT and SL-PDT in Management of Potential Complications.

Complication T-PDT SL-PDT Extratracheal bleeding Neck in neutral position with limited visualization Neck is extended with greater visualization of of operative field operative field at all times Endotracheal bleeding Suctioning is difficult with limited visualization Able to clearly visualize entire tracheal lumen while through a 2 mm port of flexible scope suctioning with rigid suction catheter; can utilize grasping forceps to remove organized blood clot if needed Desaturation Procedure performed through a 7.0 or 8.0 ETT; difficult Minute ventilation is nearly fully maintained to maintain adequate PEEP and/or minute ventilation throughout the procedure with use of a 9.0 ETT Airway obstruction Difficult anatomy of high-risk patients make extubation Patient easily extubated and reintubated quickly and reintubation difficult under direct visualization with airway trapped in rigid suspension

T-PDT ¼ traditional percutaneous dilatational tracheostomy; SL-PDT ¼ suspension laryngoscopy-assisted percutaneous dilatational tracheostomy; ETT ¼ endotracheal tube; PEEP ¼ positive end-expiratory pressure.

Laryngoscope 120: December 2010 White et al.: PDT in High Risk Patients 2426 TABLE V. Comparison of T-PDT and SL-PDT in High-Risk Patients.

High-Risk Factor T-PDT Approach SL-PDT Approach Morbid obesity Limited neck extension; difficult reintubation if necessary; Greater extension of neck with improved landmarks not palpable ability to palpate landmarks High ventilator volumes Loss of minute ventilation and PEEP common with use ETT upsized; minimal loss of PEEP and and/or pressures of flexible bronchoscope through original smaller ETT minute ventilation throughout the procedure Tracheal stenosis/ Airway visualization with flexible scope can make it Improved direct optical visualization with malacia difficult to distinguish landmarks rigid telescope; decreased risk of posterior wall injury Coagulopathy Oozing of blood into the airway with limited suctioning Superior visualization; image is bright and ability causes decreased visualization; very difficult optical; may use a large bore suction to suction secretions cannula to evacuate thick secretions or blood Previous neck Harder to dissect the anterior tracheal wall; requires Airway in rigid suspension; increased surgery significant force to dilate through scar tissue causing pressure on anterior tracheal wall decreased or lost visualization; compression of the does not hinder visualization or trachea causes decreased ventilation ventilation

T-PDT ¼ traditional percutaneous dilatational tracheostomy; SL-PDT ¼ suspension laryngoscopy-assisted percutaneous dilatational tracheostomy; PEEP ¼ positive end-expiratory pressure; ETT ¼ endotracheal tube.

One specific way of rethinking is to propose that all Bedside PDT is currently performed in a minority of in- ICU airway care can and should be provided entirely at tensive care units across the United States and only the bedside. This enables point-of-service benefits, such offered to a select group of patients who are considered as the elimination of transport related risks and the low risk. The logistics of scheduling a tracheostomy diminution of transport and OR costs. There are several would immediately be simplified if they all were per- well-known risks of transport to the OR that are avoided formed bedside. The deciding factor of when a patient when a tracheostomy is performed at the bedside. For gets a tracheostomy would then be dependent on medi- example, complex ventilation needs make the transport cal management, rather than OR availability or safety of process more difficult, if not hazardous, by having to transporting the patient to the OR. include the mechanical ventilator itself as part of the A third feature of the old paradigm worthy of recon- necessary entourage along with various intravenous (IV) sideration is the value of performing an airway medication pumps providing critical medications contin- evaluation as part of the tracheostomy procedure. This uously. Transporting a critically ill patient typically is not traditionally part of an open tracheostomy per- requires the assistance of several care team members, formed in the OR, most likely because the open including a respiratory therapist and anesthesia pro- procedure has no endoscopic component. Setting up for vider, to safely manage the patient’s oversized ICU bed, two distinct types of care, endoscopic and open/sterile, is ventilator apparatus, numerous IV poles, and frequently cumbersome. Even when the indication for the tracheos- a CVVHD machine, while continuously monitoring the tomy is a failed extubation, most ENTs do not do a rigid patient’s tenuous vital signs. airway exam prior to performing the tracheostomy. The Multiple studies have already demonstrated the sig- downside to neglecting this component is that the nificant cost savings of performing tracheostomies at the patient might be lost to follow-up and/or transferred to a bedside rather than the OR.4,7,9,10 Transportation of the facility where no airway care is available. By incorporat- patient to the OR is not only risky, but it also increases ing an airway evaluation as part of the initial surgical the cost. Multiple personnel are being paid for simply airway care, specific plans for post-tracheostomy care transporting the patient. This includes all of the team can be made. Also, potentially dangerous tracheal dis- members accompanying the patient, as well as those ease, such as impending fistula formation, can be who are available to cross-cover while they are in discovered in time to avoid the tracheostomy all to- transit. The OR itself is commonly prepared for the case gether. The use of flexible scopes with limited optical and on hold well before the patient arrives, and it expe- capabilities in T-PDT hinders this critical portion of the riences a significant amount of down time when it is not procedure. being utilized. This is perhaps the greatest cost burden Given that we propose that SL-PDT enables bedside for the hospital. The liability of taking a critically ill tracheostomy in patients with high-risk features, it is patient from the care of the ICU, however, is perhaps important to elaborate on some specific care issues. the greatest risk. A second specific way of rethinking the old para- digm relates to the very process of ICU airway care. If The Morbidly Obese Patient bedside PDT is made available to all ICU patients, there Most morbidly obese patients have very short, thick will likely be a major impact on the time-to-trach metric. necks, for reasons related to their body habitus and the This measure of efficient care delivery refers to the height of the clavicles. Obesity makes for challenging amount of time between the tracheostomy consult and airway access regardless of the technique used. Palpa- when the patient actually has the procedure performed. tion of anatomic landmarks often reveals the thyroid

Laryngoscope 120: December 2010 White et al.: PDT in High Risk Patients 2427 tion needs. These patients are an excellent example of how safety is maintained by remaining in the ICU with the necessary equipment for complex ventilation strat- egies and eliminating transport risk. They are in the greatest danger if partial extubation should occur, caus- ing loss of minute ventilation and positive pressure, which is a documented risk of the T-PDT technique.21 The SL-PDT technique appears to be superior in main- taining the requisite ventilatory needs throughout the procedure that are critical in preventing derecruitment. The short period of apnea at the start of the SL-PDT technique during the airway evaluation takes only a few seconds to accomplish and is easily tolerated by most patients. Another technique we have found useful in the most brittle of these patients is to prevent the egress of air from the tracheostomy site while the cannula is being introduced. The assistant essentially reaches under the drapes and pushes the sterile towel onto the Fig. 2. Note the position of the laryngotracheal complex in this wound to tamponade the airflow. This was rarely morbidly obese patient. It is positioned more anteriorly in the neck by rigid suspension laryngoscopy and excessive chest wall soft needed. tissue is retracted distally using tape to further improve access to his neck. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] Program Building Issues The ideal ICU airway program provides comprehen- notch of the larynx to be near or at the thoracic inlet. sive care to patients and offers a full spectrum of Neck extension might not help and/or prove to be lim- interventions including rigid endoscopy and tracheos- ited. Open procedures in these patients are notoriously tomy. By adding SL-PDT to the spectrum of available difficult with the trachea oriented obliquely and posteri- care, virtually all patients needing tracheostomy can orly within the thorax. This makes direct visualization undergo T-PDT or SL-PDT at the bedside for airway of the airway, which is needed for open surgery, limited management. Additionally, it is reasonable to offer place- at best. Some surgeons commonly perform a Bjork flap ment of a percutaneous endoscopic gastrostomy tube at in these situations. Although this surgical approach the time of PDT, if warranted, saving them the risks of might reduce the risk of inadvertent decannulation, in transport and minimizing the risks of anesthesia to that the opinion of the senior author, it can produce an of a single episode. unstable tracheal lumen and might lead to post-trache- This report substantiates a compelling need to ostomy A-frame stenosis.20 include the otolaryngology service as part of an ICU bed- Although SL-PDT is certainly more challenging in side airway program. Specifically, SL-PDT is a technique obese patients, it is far easier and safer than an open that would allow otolaryngologists at all institutions to operation in the opinion of the senior author (Fig. 2). We offer a safe and effective means of bedside tracheostomy have found that it might require the use of an extended- to nearly all critically ill patients at the bedside. This length tracheostomy cannula, such as the Shiley XLT should not inhibit other specialties from providing air- system, which is not specifically designed to fit the intro- way care by the T-PDT method. With an all- ducer system of the Blue Rhino kit manufactured by encompassing team, the majority of patients could have Cook Medical. The distal tip of the extra length cannula their bedside tracheostomy either by intensivists via T- is not tapered to match the contour of the introducer. PDT or by ENT surgeons via SL-PDT, with the intensiv- This is accommodated for by overdilating the tracheal ists’ assistance for the management of the anesthesia opening (inserting the dilator past the black indicator and/or the procedure itself. Patients with absolute con- line by 3–4 mm). This was helpful in four of our patients traindications to SL-PDT, including severe trismus, a in this series, three of whom were morbidly obese. It potentially unstable cervical spine, or those unable to should be noted that while doing this, the surgeon tolerate general anesthesia could potentially undergo T- should always be prepared to introduce an endotracheal PDT with deep sedation and local anesthesia in the tube, either through the laryngoscope from above or hands of the ICU team with or without ENT assistance. directly into the wound itself, in the event that passage of the XLT cannula is not initially successful. Although CONCLUSION the SL-PDT team at our institution has been ready for In summary, SL-PDT has proven to be a safe and this possibility, thus far it has not been necessary. effective method in providing bedside tracheostomy to a consecutive series of high-risk patients within an ICU setting. In addition, it incorporates an airway evaluation High Ventilator Settings prior to proceeding with the tracheostomy. This allows SL-PDT is particularly useful in patients with high identification of any contraindications to tracheostomy ventilator pressure settings and brittle minute ventila- and possibly even pre-emptive treatment of potential

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