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LETTER TO THE EDITOR
Using a Long-Axis Approach in Sonographically Guided Percutaneous Dilatational Tracheostomy: Feasible Disadvantages of the Technique To the Editor: A recent study by Dinh et al1 described the use of a long-axis approach on sonography during the initial puncture of the trachea and suggested this technique, especially for those with little or no experience in percutaneous dilatational tracheostomy (PDT) or the sonographic technique, after a brief training session with a phantom trachea model. The advantages of using realtime sonography for PDT and the training session to improve the technique were also elaborated. In this study, the initial seeking-needle puncture was performed at a 45° angle, in which longitudinal sonography parallel to the trachea was used for guidance, and the guide wire was inevitably introduced by a 45° angled track through the needle. A 1- to 1.5-cm vertical incision to the anterior tracheal surface, which is an unusual implementation to our knowledge, was made caudally to eradicate the insertion angle, so the guide wire was then perpendicular to the trachea. Additional blunt dilations were performed by 14F and Ciaglia Blue Rhino (Cook Medical, Inc, Bloomington, IN) horn dilators, respectively. After that stage, the authors referred to the traditional landmark technique for the remaining steps. By this description, it was posed that a 1- to 1.5-cm vertical incision to straighten the guide wire and additional wire-centered dilations with the 14F dilator and Blue Rhino horn to set the track for the tracheostomy tube were consecutively performed. This technique probably resulted in an extended skin wound that could have increased the recovery period when compared to traditional PDT procedures including a horizontal incision and a sole-puncture centered dilatational procedure. This newly described method also seems to be doable for noncomplicated patients with a rational skin-to-trachea distance. In a study by Yavuz et al,2 although the advantages of sonography for PDT were investigated, additional data, including a mean ± SD of 12.60 ± 3.77 mm (range, 6.5–29.6 mm) as the skin-to-trachea distance for the enrolled cohort, were provided. Although this mean value could be considered similar to the one provided by Dinh et al1 (11.2 ± 3.8 mm), no data for the range were provided in that study. In our opinion, it could not strictly be possible to procure and ensure the perpendicular aspect between the trachea and the needle by the long-axis method, particularly in patients with deeply sited tracheas, even by extended and deepened incisions. In this situation, lack of conformation of the tracheostomy tube to the form of the trachea might occur if
elimination of the initial puncture angle (45° as mentioned in the relevant study) could not be achieved (as most PDT tubes are designed to be sited with a 90° angle to the trachea). Thereby, undesirable conditions, including tracheal wall injuries due to a traumatization effect of the tip3 or catastrophic complications such as a trachea-innominate artery fistula due to a chronic irritation effect of the tube tip on the trachea and innominate artery in patients with a high-sited innominate artery,4 could possibly be encountered, albeit with rare incidence. Further observation of the enrolled patients in the recent study to determine subacute and longterm complications should be performed; thus, the entire consequences of angled penetration of the trachea by the long-axis approach could be revealed. In addition, in the study by Yavuz et al,2 needle puncture perpendicular to the trachea could be achieved by real-time sonographic guidance at the exact point at which the PDT tube was intended to be deployed. The needle echogenicity could be determined in most cases, and a new method based on needle vibration to ensure the needle location by sonography was also described.2 We thought that the perpendicular puncture could successfully be performed, especially by radiologists who have adequate experience with sonographically guided interventional procedures. Finally, the increasing number of studies highlighting the efficacy of sonography in PDT procedures should be considered as advancements that promise to ease these interventions and reduce their complication rates, so that every contribution to these objectives, including this relevant study, has unique importance. Alpaslan Yavuz, MD Assistant Professor Yuzuncu Yil University School of Medical Sciences Ercis, Turkey doi:10.7863/ultra.33.12.2217
References 1.
2.
3. 4.
Dinh VA, Farshidpanah S, Lu S, et al. Real-time sonographically guided percutaneous dilatational tracheostomy using a long-axis approach compared to the landmark technique. J Ultrasound Med 2014; 33:1407–1415. Yavuz A, Yilmaz M, Göya C, Alimoglu E, Kabaalioglu A. Advantages of US in percutaneous dilatational tracheostomy: randomized controlled trial and review of the literature [published online ahead of print August 4, 2014]. Radiology. doi:http://dx.doi.org/10.1148/radiol.14140088. Hess DR. Tracheostomy tubes and related appliances. Respir Care 2005; 50:497–510. Grant CA, Dempsey G, Harrison J, Jones T. Tracheo-innominate artery fistula after percutaneous tracheostomy: three case reports and a clinical review. Br J Anaesth 2006; 96:127–131.
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LETTER TO THE EDITOR
Using a Long-Axis Approach in Sonographically Guided Percutaneous Dilatational Tracheostomy: Feasible Disadvantages of the Technique To the Editor: A recent study by Dinh et al1 described the use of a long-axis approach on sonography during the initial puncture of the trachea and suggested this technique, especially for those with little or no experience in percutaneous dilatational tracheostomy (PDT) or the sonographic technique, after a brief training session with a phantom trachea model. The advantages of using realtime sonography for PDT and the training session to improve the technique were also elaborated. In this study, the initial seeking-needle puncture was performed at a 45° angle, in which longitudinal sonography parallel to the trachea was used for guidance, and the guide wire was inevitably introduced by a 45° angled track through the needle. A 1- to 1.5-cm vertical incision to the anterior tracheal surface, which is an unusual implementation to our knowledge, was made caudally to eradicate the insertion angle, so the guide wire was then perpendicular to the trachea. Additional blunt dilations were performed by 14F and Ciaglia Blue Rhino (Cook Medical, Inc, Bloomington, IN) horn dilators, respectively. After that stage, the authors referred to the traditional landmark technique for the remaining steps. By this description, it was posed that a 1- to 1.5-cm vertical incision to straighten the guide wire and additional wire-centered dilations with the 14F dilator and Blue Rhino horn to set the track for the tracheostomy tube were consecutively performed. This technique probably resulted in an extended skin wound that could have increased the recovery period when compared to traditional PDT procedures including a horizontal incision and a sole-puncture centered dilatational procedure. This newly described method also seems to be doable for noncomplicated patients with a rational skin-to-trachea distance. In a study by Yavuz et al,2 although the advantages of sonography for PDT were investigated, additional data, including a mean ± SD of 12.60 ± 3.77 mm (range, 6.5–29.6 mm) as the skin-to-trachea distance for the enrolled cohort, were provided. Although this mean value could be considered similar to the one provided by Dinh et al1 (11.2 ± 3.8 mm), no data for the range were provided in that study. In our opinion, it could not strictly be possible to procure and ensure the perpendicular aspect between the trachea and the needle by the long-axis method, particularly in patients with deeply sited tracheas, even by extended and deepened incisions. In this situation, lack of conformation of the tracheostomy tube to the form of the trachea might occur if
elimination of the initial puncture angle (45° as mentioned in the relevant study) could not be achieved (as most PDT tubes are designed to be sited with a 90° angle to the trachea). Thereby, undesirable conditions, including tracheal wall injuries due to a traumatization effect of the tip3 or catastrophic complications such as a trachea-innominate artery fistula due to a chronic irritation effect of the tube tip on the trachea and innominate artery in patients with a high-sited innominate artery,4 could possibly be encountered, albeit with rare incidence. Further observation of the enrolled patients in the recent study to determine subacute and longterm complications should be performed; thus, the entire consequences of angled penetration of the trachea by the long-axis approach could be revealed. In addition, in the study by Yavuz et al,2 needle puncture perpendicular to the trachea could be achieved by real-time sonographic guidance at the exact point at which the PDT tube was intended to be deployed. The needle echogenicity could be determined in most cases, and a new method based on needle vibration to ensure the needle location by sonography was also described.2 We thought that the perpendicular puncture could successfully be performed, especially by radiologists who have adequate experience with sonographically guided interventional procedures. Finally, the increasing number of studies highlighting the efficacy of sonography in PDT procedures should be considered as advancements that promise to ease these interventions and reduce their complication rates, so that every contribution to these objectives, including this relevant study, has unique importance. Alpaslan Yavuz, MD Assistant Professor Yuzuncu Yil University School of Medical Sciences Ercis, Turkey doi:10.7863/ultra.33.12.2217
References 1.
2.
3. 4.
Dinh VA, Farshidpanah S, Lu S, et al. Real-time sonographically guided percutaneous dilatational tracheostomy using a long-axis approach compared to the landmark technique. J Ultrasound Med 2014; 33:1407–1415. Yavuz A, Yilmaz M, Göya C, Alimoglu E, Kabaalioglu A. Advantages of US in percutaneous dilatational tracheostomy: randomized controlled trial and review of the literature [published online ahead of print August 4, 2014]. Radiology. doi:http://dx.doi.org/10.1148/radiol.14140088. Hess DR. Tracheostomy tubes and related appliances. Respir Care 2005; 50:497–510. Grant CA, Dempsey G, Harrison J, Jones T. Tracheo-innominate artery fistula after percutaneous tracheostomy: three case reports and a clinical review. Br J Anaesth 2006; 96:127–131.
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