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