Journal of Critical Care 30 (2015) 425–426
Contents lists available at ScienceDirect
Journal of Critical Care journal homepage: www.jccjournal.org
Ultrasound-guided percutaneous dilatational tracheostomy: Stated advantages are just the tip of the iceberg Since its first description by Ciaglia et al [1], percutaneous dilatational tracheostomy (PDT) has been used as an effective method to maintain the airway patency especially for many intensive care unit (ICU) patients in whom the necessity of prolonged ventilation support is considered. Increasing number of studies demonstrating the advantages of peroperative and/or preoperative ultrasound (US) guidance in PDT protocol have been reported; however, the available data from most of these studies were limited to case series instead of randomized control trials. Only a few recently published works were constructed as including control groups; thus, the advantages of US-guided PDT when compared with the conventional technique or alternative methods such as bronchoscopic-guided PDT have evidently been elaborated. A study by Gobatto et al [2], in which a cohort of 49 patients were initially planned to have US-guided PDT (1 patient then referred to bronchoscopy-guided PDT), had the purpose to evaluate the efficacy of US-guided PDT by comparing with bronchoscopy-guided PDT. The US-guided PDT was concluded to be effective and safe and was associated with similar complication rates and clinical outcomes compared with bronchoscopy-guided PDT. In this promising search, many features such as sonographically quantified skin to second tracheal ring distances and transverse tracheal diameters were provided. The ratios for the changes in the planned puncture sites after US check, the procedure times, and the presence of precautions such as vasculatures between the skin and the second tracheal rings were stated. The complications were classified and compared with the bronchoscopy-guided technique. Fortunately, a similar study within the recent date was also published by Yavuz et al [3], in which US-guided PDT was compared with the conventional landmark-based PDT in terms of procedure times and complication rates. A larger cohort within an extended date of study was enrolled, and the advantages of peroperative and preoperative US guidance associated with the elaboration of the technique were stated. A comparison of the results between the studies by Yavuz et al and Gobatto et al was summarized in Table; because of the difference in study designs, only the US-guided PDT populations could obviously be compared. In the study by Gobatto et al, 1 patient was managed with bronchoscopy guidance but was initially planned to be completed with US guidance; however, it is not clarified that the patient was accounted as 1 of the 49 patients who were managed with US guidance and the reason for this technical alteration was not noticed. In addition, the US guidance technique was not elaborated; even the usage of linear probes could be understood by only checking the figures up. It is not clear that the puncture of the trachea was performed under US guidance, and if it was, the
0883-9441/© 2014 Elsevier Inc. All rights reserved.
preferred imaging plan (axial or longitudinal) used for this purpose was not stated. Of course, this lack of information could be the result of the retrospective manner of the study, which should be mentioned in the limitation section in my opinion. In the study by Yavuz et al, both axial and longitudinal sonographic planes were used while imaging guidance during initial tracheal puncturing to ensure the exact tracheal midline and intended craniocudal level puncturing, respectively. A linear US probe was similarly used. The peroperative sonographic guidance was also used to avoid endotracheal cuff puncturing, posterior tracheal wall injury, and misintroduction of the guide wire; all the techniques were described within the article. We wonder if the authors would share any of their experience by these aspects, as they stated that the US-guided PDT was introduced as an alternative to bronchoscopy-guided PDT because the availability of US equipment is greater than that of bronchoscopy equipment in their ICUs. The comparative analysis of complication rates between the studies by Yavuz et al and Gobatto et al revealed that although no major complications with 20 minor complications including 6 cases with transient hypotension, 2 cases with minor bleeding, 2 cases with transient acute hypoxemia, 5 cases with orotracheal cannula puncture, and 3 cases with other minor complications in a total of 49 patients were reported by Gobatto et al, 2 major bleedings, 6 minor bleedings, and 4 transient oxygen desaturations in a total of 154 patients were recorded by Yavuz et al. In our opinion, the atelectasis (if it was secondary to the puncture of highly sited pulmonary apex) and the punctures of the orotracheal cannula, cuff, and the posterior tracheal wall could be avoided by using US guidance peroperatively. Although the puncture of the vasculature was avoided by preoperative US check of the puncture site, we considered that the 4 of minor bleedings in our study (by Yavuz et al) were inevitable because of the inevitable thyroidal isthmus puncturing, and one of the documented major bleedings was hypothesized to be related to mild coagulopathy from chronic renal failure. However, no informatics and suggestions including cases of thyroidal pathologies such as goiter or thick thyroidal isthmus were declared in the study by Gobatto et al. The US guidance preoperatively was also advantageous in patients with tracheal deviations while performing PDT. As the PDT procedure candidates are mostly ICU patients, evident tracheal deviations can be encountered among them due to varied aspects including unilateral lung atelectasis, prior neck surgery, massive goiter, and others. In our study, peroperative and preoperative US imaging of the neck region was considered to be reliable to manage this kind of cases. However, no additional information by this specific topic was provided by the study of Gobatto et al;
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Letter / Journal of Critical Care 30 (2015) 425–426
Table The comparative analysis of mutual parameters between 2 recent studies by Yavuz et al and Nunes et al was summarized Compared parameters
Study by Yavuz et al
Study by Gobatto et al
Patient number (initially enrolled) Mean age Sex distribution Mean skin to trachea distance Mean tracheal transverse diameter The ratio of patients refereed to alternative technique, n (%) The ratio of patients with precautions, n (%) The ratio for the changes of puncture sites after US check, n (%) No. of tracheal punctures Procedure times
166 59.57 ± 14.85 y 96 males, 70 females 12.61 ± 3.77 mm (between 6.5 and 29.6 mm) 19.29 ± 3.28 mm (between 11.3 and 27.1 mm) 12/166 (7.2%, referred to surgical tracheostomy) 38/164 (23.2%) 29/166 (17.5%) N1 puncture in 6/154 (3.9%) 24.09 ± 8.05 min (between 14 and 68 min)
49 52 y 31 males, 18 females 9.5 mm (between 8.2 and 13.0 mm) 20.8 (between 17.2 and 23.3 mm) 1/49 (2.0%, referred to bronchoscopy-guided PDT) 3/49 (6.1%) 9/49 (18.4%) 1 (between 1 and 2) 12 min (between 8 and 15 min)
besides, this can be the result of the lack of cases with tracheal deviation in the enrolled patients. We still would like to be informed of the opinions of the authors regarding these specific conditions as they stated that the US-guided PDT is already part of intensive care medicine residency training program. Therefore, the application of US-guided PDT procedure in cases with tracheal abnormalities might be experienced by the crew. In conclusion, although the increasing number of promising studies encourage the usage of US peroperatively and preoperatively during PDT procedures, more precise studies with “randomized control trial” designs are needed to elaborate the details of the technique, to stabilize the exact areas of usage, and even to figure out the guidelines, which might soon lead the standardization of US guidance by PDT application. Acknowledgment No technical, secretarial, or financial contribution by any fund or grand was used for this study.
Alpaslan Yavuz, MD Department of Radiology, School of Medical Science Yüzüncü Yıl University, Van, Turkey Department of Radiology, School of Medical Science Yüzüncü Yıl University, 65100, Van, Turkey. Tel.: +90 532 3424959 fax: +90 432 2168352 E-mail address: [email protected] http://dx.doi.org/10.1016/j.jcrc.2014.11.011 References [1] Ciaglia P, Firsching R, Syniec C. Elective percutaneous dilatational tracheostomy. A new simple bedside procedure; preliminary report. Chest 1985;87 (6):715–9. [2] Gobatto AL, Besen BA, Tierno PF, Mendes PV, Cadamuro F, Joelsons D, et al. Comparison between ultrasound- and bronchoscopy-guided percutaneous dilational tracheostomy in critically ill patients: a retrospective cohort study. Journal of Critical Care 2015;30:220.e13–7. http://dx.doi.org/10.1016/j.jcrc.2014.09.011. [3] Yavuz A, Yilmaz M, Goya C, Alimoglu E, Kabaalioglu A. Advantages of US in percutaneous dilatational tracheostomy: randomized controlled trial and review of the literature. Radiology 2014;273:927–36.
Contents lists available at ScienceDirect
Journal of Critical Care journal homepage: www.jccjournal.org
Ultrasound-guided percutaneous dilatational tracheostomy: Stated advantages are just the tip of the iceberg Since its first description by Ciaglia et al [1], percutaneous dilatational tracheostomy (PDT) has been used as an effective method to maintain the airway patency especially for many intensive care unit (ICU) patients in whom the necessity of prolonged ventilation support is considered. Increasing number of studies demonstrating the advantages of peroperative and/or preoperative ultrasound (US) guidance in PDT protocol have been reported; however, the available data from most of these studies were limited to case series instead of randomized control trials. Only a few recently published works were constructed as including control groups; thus, the advantages of US-guided PDT when compared with the conventional technique or alternative methods such as bronchoscopic-guided PDT have evidently been elaborated. A study by Gobatto et al [2], in which a cohort of 49 patients were initially planned to have US-guided PDT (1 patient then referred to bronchoscopy-guided PDT), had the purpose to evaluate the efficacy of US-guided PDT by comparing with bronchoscopy-guided PDT. The US-guided PDT was concluded to be effective and safe and was associated with similar complication rates and clinical outcomes compared with bronchoscopy-guided PDT. In this promising search, many features such as sonographically quantified skin to second tracheal ring distances and transverse tracheal diameters were provided. The ratios for the changes in the planned puncture sites after US check, the procedure times, and the presence of precautions such as vasculatures between the skin and the second tracheal rings were stated. The complications were classified and compared with the bronchoscopy-guided technique. Fortunately, a similar study within the recent date was also published by Yavuz et al [3], in which US-guided PDT was compared with the conventional landmark-based PDT in terms of procedure times and complication rates. A larger cohort within an extended date of study was enrolled, and the advantages of peroperative and preoperative US guidance associated with the elaboration of the technique were stated. A comparison of the results between the studies by Yavuz et al and Gobatto et al was summarized in Table; because of the difference in study designs, only the US-guided PDT populations could obviously be compared. In the study by Gobatto et al, 1 patient was managed with bronchoscopy guidance but was initially planned to be completed with US guidance; however, it is not clarified that the patient was accounted as 1 of the 49 patients who were managed with US guidance and the reason for this technical alteration was not noticed. In addition, the US guidance technique was not elaborated; even the usage of linear probes could be understood by only checking the figures up. It is not clear that the puncture of the trachea was performed under US guidance, and if it was, the
0883-9441/© 2014 Elsevier Inc. All rights reserved.
preferred imaging plan (axial or longitudinal) used for this purpose was not stated. Of course, this lack of information could be the result of the retrospective manner of the study, which should be mentioned in the limitation section in my opinion. In the study by Yavuz et al, both axial and longitudinal sonographic planes were used while imaging guidance during initial tracheal puncturing to ensure the exact tracheal midline and intended craniocudal level puncturing, respectively. A linear US probe was similarly used. The peroperative sonographic guidance was also used to avoid endotracheal cuff puncturing, posterior tracheal wall injury, and misintroduction of the guide wire; all the techniques were described within the article. We wonder if the authors would share any of their experience by these aspects, as they stated that the US-guided PDT was introduced as an alternative to bronchoscopy-guided PDT because the availability of US equipment is greater than that of bronchoscopy equipment in their ICUs. The comparative analysis of complication rates between the studies by Yavuz et al and Gobatto et al revealed that although no major complications with 20 minor complications including 6 cases with transient hypotension, 2 cases with minor bleeding, 2 cases with transient acute hypoxemia, 5 cases with orotracheal cannula puncture, and 3 cases with other minor complications in a total of 49 patients were reported by Gobatto et al, 2 major bleedings, 6 minor bleedings, and 4 transient oxygen desaturations in a total of 154 patients were recorded by Yavuz et al. In our opinion, the atelectasis (if it was secondary to the puncture of highly sited pulmonary apex) and the punctures of the orotracheal cannula, cuff, and the posterior tracheal wall could be avoided by using US guidance peroperatively. Although the puncture of the vasculature was avoided by preoperative US check of the puncture site, we considered that the 4 of minor bleedings in our study (by Yavuz et al) were inevitable because of the inevitable thyroidal isthmus puncturing, and one of the documented major bleedings was hypothesized to be related to mild coagulopathy from chronic renal failure. However, no informatics and suggestions including cases of thyroidal pathologies such as goiter or thick thyroidal isthmus were declared in the study by Gobatto et al. The US guidance preoperatively was also advantageous in patients with tracheal deviations while performing PDT. As the PDT procedure candidates are mostly ICU patients, evident tracheal deviations can be encountered among them due to varied aspects including unilateral lung atelectasis, prior neck surgery, massive goiter, and others. In our study, peroperative and preoperative US imaging of the neck region was considered to be reliable to manage this kind of cases. However, no additional information by this specific topic was provided by the study of Gobatto et al;
426
Letter / Journal of Critical Care 30 (2015) 425–426
Table The comparative analysis of mutual parameters between 2 recent studies by Yavuz et al and Nunes et al was summarized Compared parameters
Study by Yavuz et al
Study by Gobatto et al
Patient number (initially enrolled) Mean age Sex distribution Mean skin to trachea distance Mean tracheal transverse diameter The ratio of patients refereed to alternative technique, n (%) The ratio of patients with precautions, n (%) The ratio for the changes of puncture sites after US check, n (%) No. of tracheal punctures Procedure times
166 59.57 ± 14.85 y 96 males, 70 females 12.61 ± 3.77 mm (between 6.5 and 29.6 mm) 19.29 ± 3.28 mm (between 11.3 and 27.1 mm) 12/166 (7.2%, referred to surgical tracheostomy) 38/164 (23.2%) 29/166 (17.5%) N1 puncture in 6/154 (3.9%) 24.09 ± 8.05 min (between 14 and 68 min)
49 52 y 31 males, 18 females 9.5 mm (between 8.2 and 13.0 mm) 20.8 (between 17.2 and 23.3 mm) 1/49 (2.0%, referred to bronchoscopy-guided PDT) 3/49 (6.1%) 9/49 (18.4%) 1 (between 1 and 2) 12 min (between 8 and 15 min)
besides, this can be the result of the lack of cases with tracheal deviation in the enrolled patients. We still would like to be informed of the opinions of the authors regarding these specific conditions as they stated that the US-guided PDT is already part of intensive care medicine residency training program. Therefore, the application of US-guided PDT procedure in cases with tracheal abnormalities might be experienced by the crew. In conclusion, although the increasing number of promising studies encourage the usage of US peroperatively and preoperatively during PDT procedures, more precise studies with “randomized control trial” designs are needed to elaborate the details of the technique, to stabilize the exact areas of usage, and even to figure out the guidelines, which might soon lead the standardization of US guidance by PDT application. Acknowledgment No technical, secretarial, or financial contribution by any fund or grand was used for this study.
Alpaslan Yavuz, MD Department of Radiology, School of Medical Science Yüzüncü Yıl University, Van, Turkey Department of Radiology, School of Medical Science Yüzüncü Yıl University, 65100, Van, Turkey. Tel.: +90 532 3424959 fax: +90 432 2168352 E-mail address: [email protected] http://dx.doi.org/10.1016/j.jcrc.2014.11.011 References [1] Ciaglia P, Firsching R, Syniec C. Elective percutaneous dilatational tracheostomy. A new simple bedside procedure; preliminary report. Chest 1985;87 (6):715–9. [2] Gobatto AL, Besen BA, Tierno PF, Mendes PV, Cadamuro F, Joelsons D, et al. Comparison between ultrasound- and bronchoscopy-guided percutaneous dilational tracheostomy in critically ill patients: a retrospective cohort study. Journal of Critical Care 2015;30:220.e13–7. http://dx.doi.org/10.1016/j.jcrc.2014.09.011. [3] Yavuz A, Yilmaz M, Goya C, Alimoglu E, Kabaalioglu A. Advantages of US in percutaneous dilatational tracheostomy: randomized controlled trial and review of the literature. Radiology 2014;273:927–36.
