Bronchoscopy Guided V.S Ultrasound Guided Percutaneous Tracheostomy

Abstract Introduction Percutaneous dilatational tracheostomy (PDT) is a widely utilized technique in the intensive care unit as it is a safe and cost effective technique. Bronchoscopy guided percutaneous dilatational tracheostomy has traditionally been used as a safety adjunctive tool in order to define the appropriate site for the tracheal puncture, to guide the real-time entrance of the needle into the trachea, avoiding tracheal posterior wall injuries, and confirming the endotracheal tube placement. By contrast, bronchoscopy might not precisely identify the cervical anatomical structures. Ultrasound has emerged as potentially useful tool in assisting percutaneous dilatational tracheostomy when factors that increase the technical difficulty of the procedure (morbid obesity, difficult anatomy & cervical spine precautions) are present. Several studies have demonstrated the value of pre-procedure cervical ultrasound in order to improve the safety of percutaneous dilatational tracheostomy. Objectives This review aimed at comparing bronchoscopy guided versus ultrasound guided percutaneous tracheostomy in terms of the detected complications resulting from each procedure. Design A randomized prospective comparative trial. Setting Critical care department, Ain Shams university hospital. Patients Forty adult patients, requiring elective PDT, and need to maintain a secure airway. Methods They were randomly assigned to 2 groups; fiber optic bronchoscopy PDT group I and Ultrasound guided PDT group II. Both groups used Blue Rhino technique for PDT. Post-operative complications were recorded. Results In group I, males were 11(55%) and females were 9(45%) while in group II, males and females were 14(70%) and 6(30%) respectively. Age in group I ranged from 37-67 with mean value of 52.4±10.89 and in group II ranged from 40-71 with mean value of 54.6±9.81. There was one puncture in 19 cases (95%) in group I, while one puncture in 17 cases (85%) in group II. Total time in group I was ranged from 3-9 with mean value 5.3±1.69 and in group II was ranged from 3-9 with mean value 6.2±1.79. Transient hypoxemia occurs in about 3 cases (15%) in the bronchoscopy guided PDT group in comparison to none in the ultrasound guided PCT group. Bleeding occurred in 2 patients (10%) in bronchoscopy guided PDT group versus one patient (5%) in Ultrasound guided PCT group. Misplacement of the tracheostomy tube was encountered in only two cases (10%) in US guided PDT group and non in the other bronchoscopy guided PDT group, which lead subsequently to pneumothorax in one case (5%). Conclusion Percutaneous dilatational tracheostomy is a bedside safe procedure with low rate of complications. US guided PDT and bronchoscopy guided PDT are effective, safe and associated with similar complication rate and clinical outcome. Bronchoscopy guidance during PDT offers the best vision decreasing the need for multiple punctures and the risk of misdirection or false passage of the tube. Ultrasound is a promising less invasive method to guide the percutaneous tracheostomy procedure.