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© Borgis - Anaesthesiology Intensive Therapy 1/2001
Dariusz Maciejewski, Jerzy Paleczny
Translaryngeal Fantoni tracheostomy in intensive therapy unit: Preliminary experience
Department of Anaesthesiology and Intensive Therapy,
Head: D. Maciejewski M.D, Ph.D. Regional Hospital, Bielsko-Biała, Poland
Summary
We have performed percutaneous translaryngeal tracheostomy in eighteen mechanically ventilated ICU patients. The procedure lasted 23.6 (15-115) minutes on average and was usually associated with increase in the carbon dioxide tension (1.54 ± 1.12 kPa). The only serious complications were major bleeding [1], subcutaneous emphysema [1] and tracheal mucosal laceration [1]. Tracheostomy tubes were easy to exchange. Number of nosocomial infections was not increased. We recommend use of a flexible fiberscope during the procedure, especially in cases of difficult anatomy and/or immobile patient.
Tracheostomy, in intensive therapy units, is the alternative to long- lasting endotracheal intubation. The term "long - lasting" means tracheal intubation for a period of 14-21 days, without a chances of restoring the natural patency of the airways [1, 2, 3, 4].
The classic "surgical" technique of tracheostomy, presented as early as 1909, poses several difficult problems in intensive care. The condition of the patient is usually poor and requires permanent monitoring of vital functions, ventilation support and continuous drugs infusions, which makes the transfer to the operating theatre cumbersome. On the other hand, attempts to perform a tracheostomy "on the bed" increase the risk of complications [1, 5, 6, 7, 8].
The search for safer "bedside" methods of tracheostomy led to the introduction of the percutaneous tracheostomy in 1957 [9]. Almost 20 years later, Fantoni et al. proposed and clinically tested a new method called translaryngeal tracheostomy (TLT) [1, 3, 8, 10, 11, 12, 13].
This paper presents preliminary experience with TLT in an intensive therapy unit.
PATIENTS AND METHODS
From September 1997 to August 1998, TLTs using the Fantoni technique was performed in eighteen patients requiring prolonged intubation. These included multiple trauma (5), severe craniocerebral trauma (4), respiratory insufficiency in chronic obstructive pulmonary disease (3), anoxic encephalopathy (3), insufficiency of cerebral circulation (2) and respiratory failure complicating polyneuropathy (1). There were 16 men and 2 women aged from 21 to 67 years (mean 50.3 ± 11.2). The body weight ranged from 56 to 134 kg (mean 76.2 ± 9.8).
Tracheostomy was performed under general anaesthesia with skeletal muscle relaxation and mechanical ventilation. The site of tracheal puncture was infiltrated with 1.5% lidocaine with epinephrine. Five minutes before and during the procedure the patients were ventilated with 100% oxygen. Monitoring included ECG, pulsoximetry, capnography, temperature and invasive blood pressure. All patients were checked bacteriologically, according to the ward standards.
The procedure was performed by 2 intensive care doctors (familiar with other tracheostomy techniques), assisted by an anaesthetic nurse.
TLT set (Mallinckrodt Medical) and a bronchoscope were used: in the TLT technique a rigid instrument, and in the TLT-J technique - a fiberoptic flexible bronchoscope. Each set also contained sterile draping material, a sterile laryngoscope, surgical scissors and haemostatic and Magill forceps.
During the TLT procedure the head of the patient has to be deflected, which is not necessary in the TLT-J method.
After surgical scrubbing and draping of the operative field, anatomical landmarks were identified and the oropharyngeal cavity rinsed with sterile saline solution, which was suctioned out. Then the standard endotracheal tube was replaced with a tracheoscopy tube with a blackened tip. A rubber valve, enabling bronchoscopy without interrupting ventilation, was connected to the ventilator.
The bronchoscope was introduced to the tracheoscopy tube and its tip (indicated by reddish translumination of the neck) placed between the first and second tracheal rings.
During the TLT-J technique no tracheoscopy tube was used. Bronchoscope was introduced to the standard endotracheal tube via through a connector with a rubber valve. After placing the tip of the bronchofibroscope at the distal end of the endotracheal tube, the instrument (under direct vision control) was bent forward at the angle of about 30°. The light source was turned to its maximal intensity enabling sufficient translumination of the tissues of the neck. Moving the bronchoscope/endotracheal tube unit cranially or caudally, as in the TLT technique, helped to reach the desired position for tracheotomy.
Then the tracheal puncture (again under direct vision control) was performed, with the use of a special curved cannula, introduced perpendicular to the tracheal wall.
After the punction, a "J" teflon guide wire was introduced through the cannula in a cranial direction. It passed through the tracheoscopic tube lumen and out of the patient's mouth; in the TLT-J modification - along the external wall of endotracheal tube, after deflation of the cuff. The subsequent stages of the procedure were identical for both TLT and TLT-J techniques.
Following removal of the cannula and the bronchoscope/endotracheal tube unit the patient was intubated using a thin - wall, long tube No 5. Its tip was placed as close to the tracheal bifurcation as possible, which was confirmed by auscultation. At the same time the ventilator parameters were changed to meet the requirements of decreased respiratory system compliance.
While passing the guide wire through the anterior neck wall, radial incision (about 1 cm long) of the skin and subcutaneous tissue was made. The cranial end of the wire cut off in the place indicated by a marker. Then, this end of the wire was passed through the conical end of the armed Fantoni tube. The quadruple surgical knot of the guide, tightened with forceps, was wedged in the conical end of the tube, and the part of the guide wire above the knot was cut off.
Then the distal end of the wire was pulled caudally with a use of a special handle. At the same time the operator pressed gently the tracheal wall around the tracheostomy point. The manoeuvre of extraction of the tube through the tracheal wall and tissues of the neck was facilitated by applying force to the handle with a circular (radius: 5-7 cm) motion. Passing of the tube through the vocal chords and larynx was performed under direct vision, laryngoscopic or bronchoscopic, control. The tube was exteriorised to the level of 5 cm mark, with subsequent extrusion of the cuff connector. During the last stage of the procedure a plastic obturator, covered with a lubricating water-soluble agent, was introduced to the tube at the angle of 30° to the sternum. Then with a swinging movement, the tube was placed at 120° (its tip facing caudally) and at the same time rotated 90°. Observation of the marking on the tube wall and direct visual bronchoscopic control facilitated this manoeuvre.
The procedure ended with careful suctioning of secretions from the trachea and oropharynx. The thin-walled endotracheal tube No 5 was discarded and the tracheostomy cuff inflated. A sterile dressing was applied around the tracheostomy orifice and the tube secured in place with a neckband. Ventilator parameters were set up according to the patients' needs.
RESULTS
In total, 18 translaryngeal tracheostomies using the Fantoni technique were performed. In 8 cases the TLT-J modification was used and in the remaining 10 - the classical TLT technique. The duration of the procedure averaged 23.6 ± 8.2 minutes and ranged from 15 to 115 minutes (Fig.1).
Fig. 1. Duration (minutes) of the TLT procedure. Procedures no. 15 and 17 were performed by doctors starting their training in this technique
Sixteen out of 18 patients reported in this paper died after an ICU stay averaging 20.5 ± 8.9 days. The unfavourable outcome depended on the severity of the basic disease and its complications. No cause of death was attributed to the technique of tracheostomy, or its complications. One patient, admitted for cerebral thromboembolism, demonstrated the complete healing of the tracheostomy canal after 67 days of treatment. Now, on the 180th day, he does not demonstrate any symptoms of post - tracheostomy tracheal narrowing. The cosmetic effect of the procedure is good. Tomography of the trachea, performed on day 90, demonstrated only the presence of a small granular tissue patch at the site of TLT (Figs 2, 3).
Fig. 2. Tracheal tomogram in a patient after TLT. The arrow points to granular tissue at the tracheostomy site
Fig. 3. The same patient, 90 days after TLT - a 3-dimensional reconstruction of the upper airways in coaxial tomography. The arrow indicates the tracheostomy site
Another patient is now 18 days after TLT and stays in the ICU.
A TLT-J tracheostomy was successfully performed in a woman with morbid obesity (height: 156 cm, weight: 134 kg) and in a patient admitted for treatment of a cervical spinal cord lesion. The procedure was done without changing the patients position.
In our material, the exchange of a Fantoni tube for a standard tracheostomy tube was always performed 72 hours after TLT, with a tube of the same size or 5mm smaller. No difficulties in exchanging the tubes were encountered. This was also the case in a patient in whom a the TLT tube was accidentally removed, 5 hours after insertion. The anaesthesiologist on duty inserted a standard tracheostomy tube without neither technical problems nor negative consequences to the patient.
Bacteriological examination of the oropharynx and bronchial tree in the perioperative period did not demonstrate the presence of descending infection in any patient (Table I). In bronchial secretion the same Gram negative micro-organisms dominated pre- and postoperatively. In one case growth of Candida species, not diagnosed before, was observed 3 days post TLT.
Table I. Quantitative comparison of bacterial profile before and 3 days following TLT
MicroorganismBefore TLT3 days post-TLT
Oropharynx 
n
Main bronchi 
n
Oropharynx
n
Main bronchi 
n
Streptococcus viridans110160
Candida1791610
Pseudomonas aeurginosa0909
Klebsiella pneumoniae011010
Acinetobacter0303
Staphylococcus aureus0202
Serratia0708
The most commonly observed intraoperative finding was carbon dioxide retention with normal values of arterial oxygen saturation. The comparison of mean values of end-tidal CO2 and SaO2 are presented in fig. 4.
Fig. 4. Mean values of end tidal CO2 (%) and SaO2 (% = scale x 100)
The values observed from the fifth procedure onward have been taken into account, to eliminate the influence of the low technical skill of the operating team on PECO2 readings.
Other complications included a tracheal mucosal tear, 1cm long, caudal from the point of insertion of the guide wire. This complication, irrelevant for the success of TLT, was diagnosed only at autopsy and could be caused by too early extraction of curved cannula during pulling the guide wire up to the patient's mouth. In one case bleeding from atypically localised subcutaneous vessels was also observed. Bleeding stopped spontaneously after exteriorising the tube. Complications and technical difficulties encountered during TLT are summarised in table II.
Table II. Complications and technical difficulties during 18 TLT procedures

Type of complication

n
Intraoperative increase of PECO218
Bleeding1
Subcutaneous emphysema1
Tear in tracheal mucosa1
Difficult insertion of guide wire to the tube (TLT)4
Difficult rotation of the tube3
Damage to the bronchoscope by puncture needle (TLT-J)1
Inadvertent TLT-J2


DISCUSSION
From the middle nineties, TLT has been investigated widely in many clinical trials as one of the three methods for a bedside transcutaneous tracheostomy (according to Cook et al., Griggs et al. and Fantoni et al.) [1, 8, 11, 15, 16, 17, 18]. The world-wide experience in this technique, documented in several thousands of patients, becomes more and more popular in Polish intensive care units [19].
The character and small number of patients included in the presented analysis do not yet give us a possibility to comment on the long-term results of TLT (except for 1 patient). Complications were observed during the initial period and were mainly of technical character. There did not influence the subsequent treatment scheme, nor forced us to change the chosen technique. Similar to other authors' reports, an increase of end-tidal CO2 concentration was observed in each patient undergoing TLT [14, 18, 20, 21]. This was the consequence of the need for reintubation (2-3 intubations per procedure), as well as a decrease in ventilation. Some authors state that the period of apnoea of about 80 s does not negatively influence arterial oxygen saturation, provided ventilation with 100% O2 is assured. At the same time the partial pressure of CO2 rises significantly by 11.6 ± 8.4 mmHg (1.54 ± 1.12 kPa)[18]. This could implicate that TLT should not be used in patients with acute brain oedema. It is possible that the technique of jet-ventilation, proposed by Reilly et al., will reduce this limitation of TLT [20].
The TLT technique seems to be complicated. This complexity, however, is the main asset of TLT and does not create problems, if correct synchronisation of the intraoperative manoeuvres is observed. At the same time it allows shortening the time of the procedure. The time curve shown in Fig.1 also represents the learning and complications-risk graph [22]. TLT, as a relatively time-consuming method, can be regarded only as an elective procedure. A bronchoscope is an invaluable technical aid, allowing reduction the operating team to two persons and shortening the procedure time.
Another problem, suggested by some centres, is the possibility of development of descending lower respiratory tract infection from the oropharynx [23]. Bacteriological investigations confirmed that preoperative prophylactic measures (lavage and suctioning of the oropharyngeal secretions) helped to avoid infectious complications. We must emphasise the importance of proper surgical technique and sterility of equipment (laryngoscope). One may anticipate that the risk of descending infection will increase proportionally to the time of intubation preceding TLT (paranasal sinusitis, bacterial translocation). These problems are not frequently reported in the literature, but will surely constitute an important issue in future reports, as the method will be more popular.
In spite of some inconvenience, the Fantoni method seems to have an important place among the techniques of tracheostomy. This is because of the possibility of the most accurate placing of the tube tip on the planned level under direct visual control. The performance of TLT is possible even in most difficult technical conditions, such as in morbid obesity, in children and neonates. As the level of tracheostomy is chosen under direct vision, the most frequent long-term complications of this procedure are incidental and usually remain asymptomatic. Minimal trauma to the tracheal wall is due to the unique pattern of formation of the tracheostomy canal from the lumen of the trachea during TLT.
Additionally, a tight canal seals the operative field. So, bleeding is observed in only 2% of patients [7, 11, 12, 13, 14, 17, 18].
Disposable set for TLT is expensive, but it gives independence from the complicated logistics of the operating theatre (transportation, larger operating team, equipment, sterilisation etc.). This allows economical profit, when TLT and other methods of transcutaneous tracheostomy are used. [24].
The statement that the TLT method opens a new era may be somewhat premature, in view of the 90-year of experience with a standard technique [12, 14]. Our preliminary results, as well as data collected from other publications, confirm the usefulness of the Fantoni method in critically ill patients [14, 17, 19, 21].
CONCLUSIONS
1. TLT seems to be an effective and safe method of tracheostomy at the bedside
2. TLT can be an alternative to other methods of tracheostomy in intensive care patients

Originally published in Anestezjologia Intensywna Terapia 31; (2), 93-97, 1999.
Piśmiennictwo
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Adres do korespondencji:
Wyspiańskiego Str. 21; 43-300 BIELSKO-BIAŁA, Poland

Anaesthesiology Intensive Therapy 1/2001