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Correspondence
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Double-Lumen Endotracheal Tube Device for Percutaneous Dilatational Tracheostomy An Inventor’s Perspective To the Editor:
I read with great interest the article by Vargas et al1 in this issue of CHEST (see page 1267). A double-lumen endotracheal tube (DLET) for percutaneous dilatational tracheostomy (PDT) was first described by me in 2011.2 The tracheostomy technique used by Vargas et al1 is exactly the same as I described in Figure 4 on page 371 of my article. The original patented design of my tube is seen in US patent 20120260921 A1. Interested readers might go through my patent and see the extensive similarity between our double-lumen tubes down to the asymmetric balloon at the distal end. Having invented a device like the DLET, I question the practical need for such a device. The DLET-assisted PDT procedure begins with a tube exchange, which can itself cause airway loss and should ideally be performed by experts in critical airway management.3 Accidental airway loss during conventional PDT is uncommon and is dependent on operator skill and experience.4,5 The DLET technique appears easy when performed by experts and will likely encourage operators relatively inexperienced in critical airway management to perform PDT. The incidence of airway complications during the easy-looking tube exchange3 may then exceed the incidence of airway complications if conventional PDT4-6 had been performed. If an operator can safely perform an airway exchange in a critically ill patient then he/she can also manage the occasional accidental airway loss during PDT. The impairment of gas exchange, arising from the presence of the bronchoscope inside the endotracheal tube, is well tolerated by the majority of patients. Conventional PDT has an excellent safety profile.4-6 For the few patients who would not tolerate the impairment of gas exchange, one can use intermittent bronchoscopy4 or no bronchoscopy.5 PDT can also be delayed in such patients as there is no compelling proof in literature that
e192 Correspondence
PDT helps critically sick patients in terms of mortality or length of stay. In the final version of my device,2 I had added a proximal fixating balloon to allow a single operator to perform PDT with continuous bronchoscopy guidance. In my mind, removing one physician operator from the PDT procedure would justify the cost of the device. But, realizing the complexity involved in using the DLET, I decided not to move ahead with the invention. The two-operator PDT procedure using the DLET adds nothing to conventional PDT except cost and complexity. Yashvir Sangwan, MD Salisbury, MD AFFILIATIONS: From Pulmonary and Critical Care, Peninsula Regional Medical Center. FINANCIAL/NONFINANCIAL DISCLOSURES: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. CORRESPONDENCE TO: Yashvir Sangwan, MD, Pulmonary and Critical Care, Peninsula Regional Medical Center, 100 E Carroll St, Salisbury, MD 21804; e-mail: [email protected] © 2015 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.14-2946
References 1. Vargas M, Pelosi P, Tessitore G, et al. Percutaneous dilatational tracheostomy with a double-lumen endotracheal tube: a comparison of feasibility, gas exchange, and airway pressures. Chest. 2015;147(5): 1267-1274. 2. Sangwan YS, Koveleskie J, Palomino J, Simeone F. A new endotracheal tube designed to enable a single operator to perform percutaneous dilatational tracheostomy while maintaining the airway, providing continuous bronchoscopic guidance, and minimizing procedural complications: demonstration of feasibility on a mannequin and a cadaver. J Bronchology Interv Pulmonol. 2011; 18(4):368-373. 3. McLean S, Lanam CR, Benedict W, Kirkpatrick N, Kheterpal S, Ramachandran SK. Airway exchange failure and complications with the use of the Cook Airway Exchange Catheter®: a single center cohort study of 1177 patients. Anesth Analg. 2013;117(6): 1325-1327. 4. Kornblith LZ, Burlew CC, Moore EE, et al. One thousand bedside percutaneous tracheostomies in the surgical intensive care unit: time to change the gold standard. J Am Coll Surg. 2011;212(2): 163-170. 5. Dennis BM, Eckert MJ, Gunter OL, Morris JA Jr, May AK. Safety of bedside percutaneous tracheostomy in the critically ill: evaluation of more than 3,000 procedures. J Am Coll Surg. 2013;216(4): 858-865. 6. Simon M, Metschke M, Braune SA, Püschel K, Kluge S. Death after percutaneous dilatational tracheostomy: a systematic review and analysis of risk factors. Crit Care. 2013;17(5):R258.
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147#5 CHEST MAY 2015
]
Correspondence
]
Double-Lumen Endotracheal Tube Device for Percutaneous Dilatational Tracheostomy An Inventor’s Perspective To the Editor:
I read with great interest the article by Vargas et al1 in this issue of CHEST (see page 1267). A double-lumen endotracheal tube (DLET) for percutaneous dilatational tracheostomy (PDT) was first described by me in 2011.2 The tracheostomy technique used by Vargas et al1 is exactly the same as I described in Figure 4 on page 371 of my article. The original patented design of my tube is seen in US patent 20120260921 A1. Interested readers might go through my patent and see the extensive similarity between our double-lumen tubes down to the asymmetric balloon at the distal end. Having invented a device like the DLET, I question the practical need for such a device. The DLET-assisted PDT procedure begins with a tube exchange, which can itself cause airway loss and should ideally be performed by experts in critical airway management.3 Accidental airway loss during conventional PDT is uncommon and is dependent on operator skill and experience.4,5 The DLET technique appears easy when performed by experts and will likely encourage operators relatively inexperienced in critical airway management to perform PDT. The incidence of airway complications during the easy-looking tube exchange3 may then exceed the incidence of airway complications if conventional PDT4-6 had been performed. If an operator can safely perform an airway exchange in a critically ill patient then he/she can also manage the occasional accidental airway loss during PDT. The impairment of gas exchange, arising from the presence of the bronchoscope inside the endotracheal tube, is well tolerated by the majority of patients. Conventional PDT has an excellent safety profile.4-6 For the few patients who would not tolerate the impairment of gas exchange, one can use intermittent bronchoscopy4 or no bronchoscopy.5 PDT can also be delayed in such patients as there is no compelling proof in literature that
e192 Correspondence
PDT helps critically sick patients in terms of mortality or length of stay. In the final version of my device,2 I had added a proximal fixating balloon to allow a single operator to perform PDT with continuous bronchoscopy guidance. In my mind, removing one physician operator from the PDT procedure would justify the cost of the device. But, realizing the complexity involved in using the DLET, I decided not to move ahead with the invention. The two-operator PDT procedure using the DLET adds nothing to conventional PDT except cost and complexity. Yashvir Sangwan, MD Salisbury, MD AFFILIATIONS: From Pulmonary and Critical Care, Peninsula Regional Medical Center. FINANCIAL/NONFINANCIAL DISCLOSURES: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. CORRESPONDENCE TO: Yashvir Sangwan, MD, Pulmonary and Critical Care, Peninsula Regional Medical Center, 100 E Carroll St, Salisbury, MD 21804; e-mail: [email protected] © 2015 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.14-2946
References 1. Vargas M, Pelosi P, Tessitore G, et al. Percutaneous dilatational tracheostomy with a double-lumen endotracheal tube: a comparison of feasibility, gas exchange, and airway pressures. Chest. 2015;147(5): 1267-1274. 2. Sangwan YS, Koveleskie J, Palomino J, Simeone F. A new endotracheal tube designed to enable a single operator to perform percutaneous dilatational tracheostomy while maintaining the airway, providing continuous bronchoscopic guidance, and minimizing procedural complications: demonstration of feasibility on a mannequin and a cadaver. J Bronchology Interv Pulmonol. 2011; 18(4):368-373. 3. McLean S, Lanam CR, Benedict W, Kirkpatrick N, Kheterpal S, Ramachandran SK. Airway exchange failure and complications with the use of the Cook Airway Exchange Catheter®: a single center cohort study of 1177 patients. Anesth Analg. 2013;117(6): 1325-1327. 4. Kornblith LZ, Burlew CC, Moore EE, et al. One thousand bedside percutaneous tracheostomies in the surgical intensive care unit: time to change the gold standard. J Am Coll Surg. 2011;212(2): 163-170. 5. Dennis BM, Eckert MJ, Gunter OL, Morris JA Jr, May AK. Safety of bedside percutaneous tracheostomy in the critically ill: evaluation of more than 3,000 procedures. J Am Coll Surg. 2013;216(4): 858-865. 6. Simon M, Metschke M, Braune SA, Püschel K, Kluge S. Death after percutaneous dilatational tracheostomy: a systematic review and analysis of risk factors. Crit Care. 2013;17(5):R258.
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