Central Annals of Otolaryngology and Rhinology Case Report *Corresponding author Marc Hamoir, Department of Otolaryngology - Head and Neck Surgery, 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 • Airway management 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 tracheal intubation 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 tobe 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 pneumothorax a narrow-bore and cannula-over-needle hypercapnia. This or percutaneous airway access, including cricothyroidotomy outputallows isjet compromised ventilation, butin 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 laryngoscopy and multiple attempts Furthermore, diagnosed and undiagnosed obstructive disease of alarmswhen severely in case ofobstructing overpressure, tumors ventilation are present remains [7]. challengingEven 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 trachea such as subglottic stenosis and voice disorders [9]. frame of emergency situations. Basically, cricothyroidotomy Laryngealmay occur inducingfracture andirreversible bleeding, long secondary term injuries to the of theinsertion 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 in18 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% andin 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 openincluding 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 tosimilarly hematoma encouraging [23], angioedema results [24],with cardiogenic the Griggs technique in different clinical situations including upper airway tracheotomyStudies analyzing and thecricothyroidotomy, outcomes of emergency suggesting surgical that airway both procedures reportare effective comparable and complicationcan be performed rates with safely surgical [5]. asshock safe [25], and alteredfeasible neck and, anatomyin 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 isthat, not withoutan 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 bronchoscopy and ultrasound PT has been reported