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Abstract Background Percutaneous dilatational tracheotomy (PDT) has become an established procedure in intensive care units (ICU). However, the safety of this method has been under debate given the growing number of critically ill patients with high bleeding risk receiving anticoagulation, dual antiplatelet therapy (DAPT) or even a combination of both, i.e. triple therapy. Therefore, the purpose of this study, including such a high proportion of patients on antithrombotic therapy, was to investigate whether PDT in high-risk ICU patients is associated with elevated procedural complications and to analyse the risk factors for bleeding occurring during and after PDT. Methods PDT interventions conducted in ICUs at 12 European sites between January 2016 and October 2019 were retrospectively analysed for procedural complications. For subgroup analyses, patient stratification into clinically relevant risk groups based on anticoagulation and antiplatelet treatment regimens was performed and the predictors of bleeding occurrence were analysed. Results In total, 671 patients receiving PDT were included and stratified into four clinically relevant antithrombotic treatment groups: (1) intravenous unfractionated heparin (iUFH, prophylactic dosage) (n = 101); (2) iUFH (therapeutic dosage) (n = 131); (3) antiplatelet therapy (aspirin and/or P2Y12 receptor inhibitor) with iUFH (prophylactic or therapeutic dosage) except for triple therapy (n = 290) and (4) triple therapy (DAPT with iUFH in therapeutic dosage) (n = 149). Within the whole cohort, 74 (11%) bleedings were reported to be procedure-related. Bleeding occurrence during and after PDT was independently associated with low platelet count (OR 0.73, 95% CI [0.56, 0.92], p = 0.009), chronic kidney disease (OR 1.75, 95% CI [1.01, 3.03], p = 0.047) and previous stroke (OR 2.13, 95% CI [1.1, 3.97], p = 0.02). Conclusion In this international, multicenter study bronchoscopy-guided PDT was a safe and low-complication airway management option, even in a cohort of high risk for bleeding on cardiovascular ICUs. Low platelet count, chronic kidney disease and previous stroke were identified as independent risk factors of bleeding during and after PDT but not triple therapy.

Abstract Background The rigid tracheotomy endoscope (TED) was recently introduced to improve the fiberoptic technique during percutaneous dilatational tracheotomy (PDT) in critically ill patients. The aim was to evaluate the long-term complications of PDT using TED equipment in a prospective multicenter investigation. Methods One hundred eighty adult patients underwent PDT using TED in four German hospitals. Patients who were alive or their guardians were contacted via telephone and interviewed using a structured questionnaire 6 months following the tracheostomy procedure. Patients with airway complaints were invited for outpatient clinical ENT examination. The incidence of adverse events related to PDT was registered. Results Of 180 patients who received tracheostomy, 137 (76.1%) were alive at the time of follow-up. None of the 43 lethal events was related to the PDT. Fifty-three (38.7%) patients were available for follow-up examination, whereas 14 (10.2%) were able to visit ENT physicians. Two (3.8%) out of 53 patients developed tracheocutaneous fistula with required surgical closure of tracheostoma. Dyspnea (7.5%), hoarseness (5.7%), stridor and swallowing difficulties (both with 3.8%) were the most common complaints. Tracheal stenosis was confirmed in 1 patient (1.88% [95% CI: 0.33; 9.93]). Conclusion The use of TED for PDT in the clinical setting is safe regarding adverse events at 6-month follow-up. The incidence of tracheal stenosis after PDT with TED is comparable with that of flexible bronchoscopy; however, its role for PDT at the intensive care unit should be clarified in further investigations.

Background: Percutaneous dilatational tracheotomy (PDT) has become an established procedure in intensive care units (ICU). However, the safety of this method has been under debate given the growing number of critically ill patients with high bleeding risk receiving anticoagulation, dual antiplatelet therapy (DAPT) or even a combination of both, i.e. triple therapy. Therefore, the purpose of this study, including such a high proportion of patients on antithrombotic therapy, was to investigate whether PDT in high-risk ICU patients is associated with elevated procedural complications and to analyse the risk factors for bleeding occurring during and after PDT. Methods: PDT interventions conducted in ICUs at 12 European sites between January 2016 and October 2019 were retrospectively analysed for procedural complications. For subgroup analyses, patient stratification into clinically relevant risk groups based on anticoagulation and antiplatelet treatment regimens was performed and the predictors of bleeding occurrence were analysed. Results: In total, 671 patients receiving PDT were included and stratified into four clinically relevant antithrombotic treatment groups: (1) intravenous unfractionated heparin (iUFH, prophylactic dosage) (n = 101); (2) iUFH (therapeutic dosage) (n = 131); (3) antiplatelet therapy (aspirin and/or P2Y12 receptor inhibitor) with iUFH (prophylactic or therapeutic dosage) except for triple therapy (n = 290) and (4) triple therapy (DAPT with iUFH in therapeutic dosage) (n = 149). Within the whole cohort, 74 (11%) bleedings were reported to be procedure-related. Bleeding occurrence during and after PDT was independently associated with low platelet count (OR 0.73, 95% CI [0.56, 0.92], p = 0.009), chronic kidney disease (OR 1.75, 95% CI [1.01, 3.03], p = 0.047) and previous stroke (OR 2.13, 95% CI [1.1, 3.97], p = 0.02). Conclusion: In this international, multicenter study bronchoscopy-guided PDT was a safe and low-complication airway management option, even in a cohort of high risk for bleeding on cardiovascular ICUs. Low platelet count, chronic kidney disease and previous stroke were identified as independent risk factors of bleeding during and after PDT but not triple therapy. [ABSTRACT FROM AUTHOR]

Background: The rigid tracheotomy endoscope (TED) was recently introduced to improve the fiberoptic technique during percutaneous dilatational tracheotomy (PDT) in critically ill patients. The aim was to evaluate the long-term complications of PDT using TED equipment in a prospective multicenter investigation. Methods: One hundred eighty adult patients underwent PDT using TED in four German hospitals. Patients who were alive or their guardians were contacted via telephone and interviewed using a structured questionnaire 6 months following the tracheostomy procedure. Patients with airway complaints were invited for outpatient clinical ENT examination. The incidence of adverse events related to PDT was registered. Results: Of 180 patients who received tracheostomy, 137 (76.1%) were alive at the time of follow-up. None of the 43 lethal events was related to the PDT. Fifty-three (38.7%) patients were available for follow-up examination, whereas 14 (10.2%) were able to visit ENT physicians. Two (3.8%) out of 53 patients developed tracheocutaneous fistula with required surgical closure of tracheostoma. Dyspnea (7.5%), hoarseness (5.7%), stridor and swallowing difficulties (both with 3.8%) were the most common complaints. Tracheal stenosis was confirmed in 1 patient (1.88% [95% CI: 0.33; 9.93]). Conclusion: The use of TED for PDT in the clinical setting is safe regarding adverse events at 6-month follow-up. The incidence of tracheal stenosis after PDT with TED is comparable with that of flexible bronchoscopy; however, its role for PDT at the intensive care unit should be clarified in further investigations. [ABSTRACT FROM AUTHOR]

Aim: Percutaneous dilatation tracheotomy in our clinic; It is opened using the advantages and methods of Griggs (GWDR) and Ciaglia Blue Rhino (CBR). We wanted to share our one-year experience with you. Method: In the study that we retrospectively examined tracheotomies performed in adult intensive care in 2019-2020; Demographic data of patients, SOFA scores, intensive care, tracheotomy, intubation days, complications, mortality and morbidity were recorded. Results: A total of 50 patients, 33 females, 17 males, were included in the study. The mean age is 65,54 ± 15,95. BMI was 26,94 ± 2,75. Ciaglia was used in 22 patients and Griggs method was used in 28 patients. Tracheotomy opening day is 10,45 ± 1,27. Griggs method; It was found to be significantly higher in terms of complications (6 minor bleeding, 1 emphysema, 1 lack of ventilation) (p = 0,001). Mortality (independent of tracheotomy method and complications) was significantly higher in the Griggs method (p = 0,005). Conclusion: Except for minor differences, no significant difference was found between both GDWR method and CBR method in the study. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Procalcitonin is a reliable biomarker of infection and sepsis. We aimed to determine whether tracheotomy influences the procalcitonin concentrations in patients without sepsis and assess whether operative duration and procedure affect the peak procalcitonin level. METHODS: A total of 38 non-septic patients who required a tracheotomy underwent either a percutaneous dilatational tracheotomy (n=19) or a surgical tracheotomy (n=19). Procalcitonin levels were measured at the beginning of the tracheotomy and at 2 h, 4 h, 8 h, 24 h, 48 h and 72 h after the procedure. RESULTS: The baseline procalcitonin concentration before the tracheotomy was 0.24±0.13 ng/mL. The postoperative levels increased rapidly, with a 4-fold elevation after 2 h, reaching a peak 4 h later with a 5-fold increase over baseline. Thereafter, the levels gradually returned to 2-fold greater than the baseline level within 72 h. The peak levels of procalcitonin showed a significant positive correlation with operative durations (r=0.710, p

Background: Fiberoptic tracheo-bronchoscopy is the most commonly used procedure for percutaneous dilational tracheotomy (PDT). However, PDT can be associated with major complications, including death. Furthermore it is unclear, whether the tracheal ring fractures may contribute to the development of tracheal stenosis after PDT nor whether tracheal ring fractures can be prevented by using a rigid endoscope for this procedure. The purpose of this study was to evaluate the feasibility of and the incidence of complications for PDT using the rigid tracheotomy endoscope (TED). Methods: In a prospective multicenter observational study from 2006 to 2010, 180 adult patients in intensive care and those scheduled for ear, nose and throat surgery underwent PDT using TED. Data collection was performed using a structured protocol. The patients were observed according to PDT phase (phase 1: puncture, phase 2: dilatation and phase 3: cannula insertion). The descriptive data are given as the number (percent) of cases and the mean ± standard deviation (SD) where appropriate. The relationships between dichotomous and categorical parameters were analyzed using the chi-square test. P values ≤ 0.05 were considered significant. Results: PDT was performed in 179 patients. The procedure time was 14.8 ± 6.2 (mean ± SD) minutes. Pneumothorax or procedure-related lethal complications did not occur. Other adverse events included tracheal ring fractures (17.1%), desaturations (6.8%), special incidents (6.2%), bleeding (5.5%), anesthesia complications (4.5%) and posterior tracheal wall injuries (1.1%). Conclusion: The use of TED in PDT is feasible, and the incidence of complications and adverse events was comparable with that of PDT using the flexible endoscope. Tracheal ring fractures in PDT cannot be avoided by the use of a rigid endoscope. With TED, the airway always remains open thus the use of jet ventilation via the TED during PDT is possible. [ABSTRACT FROM AUTHOR]

Purpose: Percutaneous dilatational tracheostomy (PDT) is a standard procedure routinely performed on intensive care units. While complication rates and long-term outcomes have been studied in different patient populations, there are few studies known to these authors involving PDT in trauma patients and the complications which may result. Methods: Between March 2007 and August 2013, all instances and peri-procedural complications during PDT occurring on the trauma intensive care unit, a unit specialized in the care of injured patients and especially polytrauma patients, were documented. PDTs were performed by a surgeon with the assistance and supervision of another, using bronchoscopic guidance performed by the respiratory medicine department. Results: 289 patients were included in the study, 225 men and 64 women with a mean age of 49 ± 21 years. Complications occurred in 37.4 % of cases. The most common complication, bleeding, occurred in 26.3 % of patients ranging from little to severe bleeding. Fracture of tracheal cartilage occurred in 6 % of PDT cases. Additional complications such as dislocation of the guidewire, hypotension, and oxygen desaturation were observed. Most complications did not require treatment. The second tracheal intercartilaginous space was successfully intubated in 82 % of cases. Conclusions: PDT is a safe procedure in trauma patients. When considering the severity of complications such as major blood loss, pneumothorax, or death, this evidence suggests that PDT is safer in trauma patients compared to other patient cohorts. [ABSTRACT FROM AUTHOR]

BACKGROUND: The prevalence of obesity in developed countries is rising. Currently, Europe has a prevalence of 9-30% with significant impact on public health systems. Obese patients in ICUs require special management and treatment. Altered anatomy in obese patients complicates procedures such as mechanical ventilation. Obesity affects cardiopulmonary physiology and requires elevated ventilation pressures. In our retrospective study, we determined the effect of early percutaneous dilatational tracheotomy (PDT) and cessation of sedation on respiratory parameters in severely obese subjects. METHODS: From June 2010 to July 2014, we included all subjects with a body weight of > 130 kg (body mass index >35 kg/m²) and respiratory failure who were admitted to the medical ICU of the University Hospital of Miinster. All subjects were treated with early PDT and immediate cessation of sedative drugs. We compared ventilator parameters and blood gas analysis before and after PDT. Parameters were recorded on days 0, 1, 3, and 5. Day 0 represents values during ventilation via an endotracheal tube, and days 1, 3, 5 represent values during ventilation via a tracheotomy tube. PDT was performed on day 0 after recording values during ventilation via an endotracheal tube. RESULTS: We included 23 subjects with a mean body mass index of 53.1 kg/m² and respiratory failure. After PDT and cessation of sedation, the required ventilation pressures and ... could be rapidly reduced (P < .001), whereas blood gas parameters significantly improved. We observed no severe PDT-associated complications in our cohort. CONCLUSIONS: In severe obesity, respiratory failure might be increased by problems in mechanical ventilation due to required high pressures and obesity-induced pulmonary restriction. Rapid tracheotomy with reduction of dead-space ventilation and airway resistance as well as cessation of sedation to enable spontaneous breathing might be a key factor in the therapy of respiratory failure. [ABSTRACT FROM AUTHOR]

Objective To assess the impact of timing of percutaneous dilatational tracheotomy (PDT) on incidence of deep sternal wound infections (DSWI) after cardiac surgery with median sternotomy. Design Retrospective study between 2003 and 2013. Setting Single-center university hospital. Participants Eight hundred seventy-nine patients after cardiac surgery with extracorporeal circulation and median sternotomy. Interventions PDT using the Ciaglia-technique with direct bronchoscopic guidance. Measurement and Main Results Mean time from surgery and (re)intubation to PDT was 6.7±9.9 and 3.8±3.3 days, respectively. Incidence of DSWI was 3.9% (34/879). The incidence of DSWI was comparable between patients with PDT performed before postoperative day (POD) 10 and those with PDT after POD 10 (29/755 [3.8%] v 5/124 [4.0%], p = n.s.). However, the authors observed an association of timing of PDT and DSWI: The incidence of DSWI was significantly higher in patients with PDT performed≤POD 1 compared to those with PDT after POD 2 (12/184 [6.52%] v 22/695 [3.16%], p = 0.046). In multivariate analysis, obesity, use of bilateral internal mammary arteries, ICU stay>30 days and PDT<48 hours after surgery (OR 3.519, 95% CI 1.242-9.976, p = 0.0018) were independent predictors of DSWI. In 15/34 patients (44.1%), similarity of microorganisms between sternotomy site and tracheal cultures was observed, indicating a possible cross-contamination. Conclusions PDT within the first 10 postoperative days after cardiac surgery with median sternotomy can be performed safely without an increased risk of DSWI. In contrast, very early PDT within 48 hours after surgery is associated with an increased risk of mediastinitis and should, therefore, be avoided. [ABSTRACT FROM AUTHOR]

Aim: As it can easily be performed at the bedside with minimal morbidity, percutaneous dilatational tracheotomy (PDT) is preferred over surgical tracheotomy. The aim of this study is to compare the effects of different PDT techniques on posterior tracheal wall injury. Materials and methods: The study was conducted at the Gazi University Laparoscopy Training Center after approval was granted by the ethics committee. After sedation with xylazine/ketamine, electrocardiography, peripheral oxygen saturation, and blood pressure were monitored. Propofol was used to achieve the desired level of sedation during the procedure. There were 16 pigs, randomly allocated into 4 groups. Multiple, single, forceps, and twist dilator techniques were performed in groups I, II, III, and IV, respectively. At the end of the course all pigs were sacrificed and tracheas were harvested for macroscopic and histopathological evaluation. Results: Macroscopic evaluation revealed erythematous/hemorrhagic and ulcerative lesions on the posterior wall of all samples. Histopathological injury was observed in all samples and was similar in all groups. Procedural time was significantly longer in group I than in all other groups (P < 0.05). Conclusion: Although the results are conflicting, bronchoscopy-aided PDT is believed to reduce complications. In our study, PDTs were performed without bronchoscopy, and posterior wall injury was observed in all samples. Therefore, we suggest using bronchoscopy to reduce procedure-related complications and improve patient safety during PDT. [ABSTRACT FROM AUTHOR]

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Percutaneous dilatational tracheotomy has become a routine procedure in ICUs. However, given the high and steadily growing number of patients receiving anticoagulation, dual antiplatelet therapy, or even a combination of both (also known as "triple therapy"), there are concerns about the safety of the procedure, in particular for critically ill patients with a high risk of bleeding. In this retrospective study, we investigated whether percutaneous dilatational tracheotomy in this high-risk population was associated with elevated procedural complications., Design: Retrospective single-center study with analysis of all percutaneous dilatational tracheotomies performed in our cardiac ICU from January 2018 to May 2019., Setting: Munich university hospital's cardiac ICU., Patients and Interventions: A total of 34 patients who underwent percutaneous dilatational tracheotomy according to Ciaglia technique with accompanying bronchoscopy in our cardiac ICU from January 2018 to May 2019 were included. Patients were stratified into clinically relevant risk groups based on anticoagulation and antiplatelet therapy considering standard laboratory coagulation parameters, that is, activated partial thromboplastin time, international normalized ratio, and platelet count with differentiated analysis of procedure-related complications in each risk group until hospital discharge., Measurements and Main Results: A total of 34 patients who underwent percutaneous dilatational tracheotomy were included and assigned to five clinically relevant treatment groups: IV unfractionated heparin (prophylactic dosage) ( n = 4), IV unfractionated heparin (therapeutic dosage) ( n = 4), aspirin and IV unfractionated heparin (therapeutic dosage) ( n = 7), dual antiplatelet therapy with IV unfractionated heparin (prophylactic dosage) ( n = 5), and dual antiplatelet therapy with IV unfractionated heparin (therapeutic dosage) ( n = 14). Three bleedings without surgical intervention or blood transfusion were documented in the whole cohort, but no single bleeding did occur in the triple therapy group. These were exclusively caused by skin bleedings at the immediate puncture site-each of which could be easily treated with one or two single stitches. There were no severe bleeding complications or potentially life-threatening procedure-related complications. Additionally, the rate of complications in patients with elevated body mass index was not increased., Conclusions: Bronchoscopy-guided percutaneous dilatational tracheotomy according to Ciaglia technique with careful consideration of all potential indications and contraindications may be a safe and low-complication procedure for airway management, even in patients receiving dual antiplatelet therapy and therapeutic anticoagulation simultaneously in our cohort with a high risk of bleeding., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Objective: A recent study reported decreasing trends in tracheotomy procedures by its otolaryngology service. We set out to determine whether the previously reported decrease in otolaryngology performed tracheotomies by one institution is a local or generalizable phenomenon., Design: Retrospective cohort study from 2010 to 2015., Setting: Tertiary care hospital and affiliated regional hospitals., Subject and Methods: All patients who received tracheotomy during the period of analysis were included. Performing specialty, surgical technique, and procedure location were recorded. Procedures were stratified by year and specialty to generate incidence rate ratios for otolaryngologists and non-otolaryngologists. Incidence rate ratios were estimated with negative binomial regression across services., Results: The otolaryngology service demonstrated a yearly decrease of 3.4% in the total number of tracheotomies (95% CI -7.9% to +1.4, P=0.17). While the thoracic service remained constant (+0.3%, 95% CI -2.6% to +3.3%, p=0.83), general surgery demonstrated the greatest increase in procedures (+4.4%, 95% CI -6.0% to +15.8%, P=0.42). Thoracic and general surgery both dramatically increased the number of percutaneous tracheotomies performed, with general surgery also performing a greater number of bedside procedures., Conclusions and Relevance: We observed a similar decline in the number of tracheotomies otolaryngology over six years. Our trend is likely due to changes in consultations patterns, increasing use of the percutaneous method, and an increase in adjunctive gastrostomy tube placements. Investigations on the impact of a greater number of non-otolaryngology performed tracheotomies on follow up care is warranted., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: By comparing flexible lightwand-assisted and conventional endotracheal tube (ETT) withdrawal in percutaneous dilatational tracheotomy (PDT), this paper aims to provide guidance for precise ETT withdrawal by anesthesiologists and accurate determination of the incision site by surgeons., Methods: Sixty patients who underwent PDT in our hospital were randomly divided into the lightwand group (Group L, n=30) and the withdrawal group (Group W, n=30) using the envelope method. For Group L patients, a flexible lightwand was inserted into an ETT (based on the patient's size), the light source was positioned at the root of the cuff, and the depth from the root of the cuff to the end of the ETT was marked. The flexible lightwand was inserted into the patient's ETT to the marked depth. The ETT along with the flexible lightwand was withdrawn until the highlighted spot was located at the level of the thyroid cartilage. The incision site was approximately 3 finger widths (approximately 4.8cm) below the highlighted spot. For Group W patients, the ETT was withdrawn to a tube depth of 17cm at the upper incisors in males and 15cm in females, and surgeons determined incision sites without assistance. The following metrics were recorded for the two groups: occurrences of inadvertent extubation, ETT puncture and cuff rupture; success rate of first puncture; hypoxia rate; SpO 2 at the time of tracheostomy cannula intubation (T 1 ); and postoperative hemorrhage rate., Results: Inadvertent extubation, ETT puncture and cuff rupture occurred significantly less frequently in Group L than in Group W, and the success rate of first puncture and SpO 2 at T 1 were markedly higher in Group L than in Group W. Moreover, significant between-group differences in hypoxia rate and postoperative hemorrhage rate were observed., Conclusions: The use of a flexible lightwand in PDT is a safe and effective approach. This approach can effectively and directly guide precise ETT repositioning and provide incision site confirmation with few intra- and postoperative anesthesia-related or operative complications compared with the traditional technique of ETT withdrawal to a pre-determined depth., (Copyright © 2017 Elsevier Inc. All rights reserved.)