Central Annals of Otolaryngology and Rhinology

Case Report *Corresponding author Marc Hamoir, Department of Otolaryngology - Head and Neck , St. Luc University Hospital and King Percutaneous Tracheotomy in Albert II Cancer Institute, Avenue Hippocrate 10, 1200 Brussels, Belgium, Tel: 32-2-7641974; Fax: 32-2-7648935; Email: Emergency Situation Setting Submitted: 16 March 2015 Sandra Schmitz1, Michel Van Boven2 and Marc Hamoir1* Accepted: 08 April 2015 Published: 13 April 2015 1Department of Otolaryngology - Head and Neck Surgery, St. Luc University Hospital and King Albert II Cancer Institute, Belgium Copyright 2Department of Anesthesiology, St. Luc University Hospital, Belgium © 2015 Hamoir et al.

OPEN ACCESS Abstract Keywords While Percutaneous Tracheotomy (PT) has become a standard procedure to • Percutaneous tracheotomy ensure airway patency in elective indications, it is not yet accepted as standard for • Difficult airway the management of emergency airway situations, despite more and more reports • highlighting its use in this setting. After comparing PT with other emergency airway • Upper airway obstruction access techniques, we report a new approach performed under general anesthesia for the management of patients with major airway obstruction leading to « no ventilation, no intubation » situations.

ABBREVIATIONS (Seldinger) technique [5].The cricothyroid membrane can also be approached surgically through a small incision. PT: Percutaneous Tracheotomy The cricothyroidotomy procedure has been advocated as INTRODUCTION In 2003, the American Society of Anesthesiology (ASA) and simpler than surgical tracheotomy and easier to learn by the emergency airway procedure of choice because it is faster reported that emergency cricothyroidotomy and tracheotomy are defined a difficult airway as a situation in which facemask nonsurgical staff members and paramedics [5,6]. However, it was ventilation or of the upper airway is not adequate or unsuccessful [1,2]. Many new airway devices have morbidityequally effective [5]. with comparable complication rates, suggesting that both procedures can be performed safely with low overall accessbeen created has to to be manage considered these either conditions by emergency safely. However, tracheotomy when both ventilation and intubation are impossible, invasive airway deliveryCricothyroidotomy is essential to avoid with a narrow-bore and cannula-over-needle hypercapnia. This or percutaneous airway access, including cricothyroidotomy outputallows isjet compromised ventilation, but in some appropriate clinical situations, output after particularly each jet and percutaneous tracheotomy (PT). Risk factors leading to a at« no tracheal ventilation, intubation no intubation by an experienced » situation anaesthesiologist include difficult mask[3,4]. ventilation, difficult direct and multiple attempts Furthermore, diagnosed and undiagnosed obstructive disease of alarmswhen severely in case of obstructing overpressure, tumors ventilation are present remains [7]. challenging Even with modern jet ventilation incorporating a cut off system and theWHAT upper ARE airway THE frequently INVASIVE leads to AIRWAY this situation. ACCESS IN A in patients with upper airway obstruction. Ventilation systems “NO VENTILATION, NO INTUBATION” SITUATION? pressurewith larger required diameters, to insert whilst such improvingdevices [8].Furthermore, ventilation, carry as the a Cricothyroidotomy cricothyroidgreater risk ofmembrane posterior istracheal small, damagewall injuries to the due cricoid to the cartilage higher

Cricothyroidotomy is a procedure frequently selected in the such as subglottic stenosis and voice disorders [9]. frame of emergency situations. Basically, cricothyroidotomy Laryngealmay occur inducing fracture andirreversible , long secondary term injuries to the of the insertion upper consists of percutaneous tracheal access through the cricothyroid membrane. The main advantage of this technique is related surgical approach. Moreover, because of the limited ventilation to the easy accessibility of the cricothyroid membrane. As it is possibilitiesof a small tube and (6 potential mm in diameter), complications, are also cricothyroidotomy possible with a should be considered a temporary procedure that often requires minimal dissection is required and the procedure is fastly located superficially to the skin in the middle part of the neck, subsequent conversion to a conventional tracheotomy [5]. Cricothyroidotomy is generally performed in emergency executed. Cricothyroidotomy can be performed by puncture with a narrow-bore cannula-over-needle (≤2mm in diameter), a wide- bore cannula-over-trocar (≥4mm in diameter) or a wire-guided situations, whereas PT is routinely used in selected indications. Cite this article: Schmitz S, Van Boven M, Hamoir M (2015) Percutaneous Tracheotomy in Emergency Situation Setting. Ann Otolaryngol Rhinol 2(3): 1028. Hamoir et al. (2015) Email: Central

The latter is therefore generally preferred by medical staff. Failure to identify the cricothyroid membrane occurs frequently and is the principal cause of failed cricothyroidotomy [10]. choice when PT is to be performed as an emergency procedure Different cricothyroidotomy techniques have been tested on [19].Furthermore, in a meta-analysis, Powell et al described a 1.2% perioperative complication rate and a 2.0% postoperative complication rate for the Griggs method which is lower than the human cadavers with the finding that anatomical-surgical complication rate induced by other PT techniques (7.6% - 22.9% andThe 5% largest- 6.5% respectively)retrospective [20].study on the use of PT in emergency puncturetechniques techniques were associated in inexperienced with a higher health success care rate, personnel, a faster conditions involved 18 patients. Indications for emergency underscoringtracheal tube theinsertion impact time, of operator and a lower experience complication on the success rate than of

PT included respiratory failure associated with anaphylaxis, aTracheotomy specific technique [11]. supraglottic edema, cardiac arrest, and blood ²or edema blocking². The Surgical tracheotomy has the advantage of providing a authorsthe airway described preventing successful intubation. placement Among of thePT in 18 all patients, patients. nine No had body mass indexes ranging from 30 kg/m to 112 kg/m definitive and stable airway and is still considered to be the and relies on the surgical expertise of the medical staff. In a didcomplications not function were adequately documented [21]. after the procedure. Of interest, golden standard. This technique is, however, time consuming two patients had previously undergone cricothyroidotomy which The second largest retrospective study of emergency PT large retrospective study of 1175 tracheotomy procedures, the [12].Ofoverall note,complication a retrospective rate was study 14.1% recently (intraoperative, reported that early surgical and using a modified Griggs technique involved 10 patients with tracheotomylate complication performed rates of by 1.4%, residents 5.6% and in training 7.1% respectively) supervised cervical spine fractures, maxillofacial trauma, head and neck burns and inhalation injuries [22].The mean time from skin complications [13]. Because the complication rate is reported to by experienced surgeons was not associated to increased complications,incision to intubation and no conversionwas 5.5 minutes to an open including technique. the oxygen Long insufflations period. There was no failure, no procedural related be two to five times higher in an emergency than in an elective situation,[5,7] surgical tracheotomy is, therefore, not considered term follow-up did not reveal any other complications. Smaller as the best option for rapid airway control. This is controversial. obstructionreports showed due to similarly hematoma encouraging [23], results [24], with cardiogenic the Griggs technique in different clinical situations including upper airway tracheotomyStudies analyzing and the cricothyroidotomy, outcomes of emergency suggesting surgical that airway both procedures report are effective comparable and complication can be performed rates with safely surgical [5]. asshock safe [25], and altered feasible neck and, anatomy in experienced due to hands, severe emergencyburn [26] and PT cancer of the upper airway [27]. The technique is described method of emergency PT is safe and rapid, some centers have tracheotomy,It should however surgical be tracheotomy emphasized is that, not without an option knowledge [6]. The of the exact surgical procedure and sufficient practice with is faster than open tracheotomy [28]. Given that the Griggs access [29]. the last decades, PT has become a procedure largely used in implemented it as the procedure of choice for emergency airway role of emergency PT is not currently well established. During Percutaneous Tracheotomy to ensure airway patency of patients with an expected “no ventilation, no elective situations and is an acknowledged attractive alternative intubation” situation to a surgical approach, being significantly faster and more cost- effective [14,15].The list of contraindications for PT has shrunk progressively over the last few years as users have gained more imaging, have increased the safety of the procedure. The use of Recently, we reported a modified PT technique used in a experience and adjuncts, such as and ultrasound PT has been reported in clinical conditions initially described series of 13 patients with major upper airway obstruction [30]. Briefly, we combined the Griggs dilatation technique with as relative contraindications - obese patients, patients with designedthe insertion, to be inside inserted the through trachea, the of a cricothyroid narrow-bore membrane. cannula-over- The needle (Ravussin catheter, VBM Medizintechnik GmbH, Germany), injuries to the head and neck area and in emergency airway Asituations [16,17]. The most used PT technique described in the emergency setting was the Griggs wire-guided forceps method. Ravussin catheter was placed under local anesthesia just below laboratory comparison of the Ciaglia wire-guided dilators the through the first ring of the trachea and its method versus the Griggs wire-guided forceps method showed correct placement was confirmed by the presence of air bubbles (by aspirating into a syringe filled with water), and capnograph abenefits prospective in terms trial ofincluding time of 53 placement patients randomized in favor of to the undergo Griggs technique: mean 217 seconds versus 89 seconds, respectively. In CO2 readings taken directly out of the catheter (Figure 1). PT was then performed under general anesthesia by introducing the more recent Ciaglia single dilator technique (so-called Ciaglia performedthe guide wire in less through than the1 minute. Ravussin This cannula. technique After is removing particularly the Ravussin cannula, the classical Griggs dilatation technique was surgicalBlue Rhino) duration or the or Griggs procedural technique, complications the investigators [18]. were not able to show any differences between both techniques regarding ventilationuseful in patients and no intu withbation” major status. airway obstruction secondary to advanced head and neck tumors leading to a predictable “no Accordingly, the Griggs technique should be a technique of Ann Otolaryngol Rhinol 2(3): 1028 (2015) 2/4 Hamoir et al. (2015) Email: Central

Figure 1

Percutaneous tracheotomy combining use of the Ravussin catheter with the Griggs dilatation technique A: Local anesthesia of the skin, the subcutaneous tissue and the trachea B: Air bubbles observed into the syringe after aspiration confirm the position in the airway C. The capnograph also confirms the position of the transtracheal catheter in the airway F.D. Insertion of the canulaguide wire into the transtracheal catheter E. Use of the dilating forceps after first dilatation (not shown)

CONCLUSION REFERENCES Cricothyroidotomy is a procedure classically used in 1. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of emergency situations. However, because this procedure is often conversion to a formal tracheotomy during a second step. the difficult airway: an updated report by the American Society of potentially associated with long term complications, it requires Anesthesiologists Task Force on Management of the Difficult Airway. 2. Anesthesiology. 2003; 98: 1269-1277. Surgical tracheotomy is a safe and effective way to securing the Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich airway even in an emergent setting, but it is more time consuming DG. Practice guidelines for management of the difficult airway: an and requires knowledge of the exact surgical procedure involved updated report by the American Society of Anesthesiologists Task selected indications and is the procedure generally preferred by Force on Management of the Difficult Airway. Anesthesiology. 2013; and sufficient practice and experience. Typically, PT is used in 3. 118: 251-270. not traditionally used in emergency situations, emergency PT Kheterpal S, Han R, Tremper KK, Shanks A, Tait AR, O’Reilly M, et al. the medical staff who feels more comfortable with it. Although Incidence and predictors of difficult and impossible mask ventilation. 4. hands, PT can be performed as rapidly as cricothyroidotomy Anesthesiology. 2006; 105: 885-891. using the Griggs technique is feasible and safe. In experienced Langeron O, Masso E, Huraux C, Guggiari M, Bianchi A, Coriat P, et al. Prediction of difficult mask ventilation. Anesthesiology. 2000; 92: and has the major advantage of providing a definitive approach 5. 1229-1236. open surgical tracheotomy. PT can be performed as rapidly as to the airway. Besides, it may be even easier and faster than Gillespie MB, Eisele DW. Outcomes of emergency surgical airway procedures in a hospital-wide setting. Laryngoscope. 1999; 109: cricothyroidotomy and has the major advantage of providing 6. 1766-1769. a definitive approach to the airway. There are several factors Dillon JK, Christensen B, Fairbanks T, Jurkovich G, Moe KS. The that influence the choice of technique to manage the emergency emergent surgical airway: vs. tracheotomy. Int J Oral Maxillofac Surg. 2013; 42: 204-208. airway including anatomical, user experience and available AM. Preemptive vessel dilator cricothyrotomy aids in the management devices. All techniques should be first performed and practiced 7. Boyce JR, Peters GE, Carroll WR, Magnuson JS, McCrory A, Boudreaux onditions. in non-emergency settings so that medical teams can learn to of upper airway obstruction. Can J Anaesth. 2005; 52: 765-769. rapidly and successfully manage emergency airway c Ann Otolaryngol Rhinol 2(3): 1028 (2015) 3/4 Hamoir et al. (2015) Email: Central

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Cite this article Schmitz S, Van Boven M, Hamoir M (2015) Percutaneous Tracheotomy in Emergency Situation Setting. Ann Otolaryngol Rhinol 2(3): 1028.

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