经皮气管切开术（图文演示）

英文版：经皮气管切开术（中文图文演示）

PERCUTANEOUS   TRACHEOSTOMY
Authors
A Stefani, D Gossot
Abstract
The description of the percutaneous tracheostomy covers all aspects of the surgical procedure used for the management of upper airway obstruction.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way. Consequently, this operating technique is well standardized for the management of this condition.

1. Introduction
In 1969, Toye and Weinstein were the first to cannulate the trachea percutaneously using a Seldinger guidewire (Toye and Weinstein, 1986). However, it was only after Ciagla’s description of the technique of serial dilatation (Ciaglia et al., 1985) that percutaneous tracheostomy was widely accepted and percutaneous tracheostomy kits with specific cannulas became commercially available.

2. Indications
Percutaneous tracheostomy is:
- an alternative to the standard technique in emergencies or in critically ill patients in the Intensive Care Unit, or it can be used electively at the patient’s bedside (Petros and Engelmannn, 1997; Moe et al., 1999);
- quicker, easier, and less invasive than the standard technique;
- within the abilities of inexperienced personnel in the emergency room or in less favourable situations (eg, the patient’s home, in a bed, an ambulance, a helicopter, an elevator).

Relative contraindications
- young patients (<16 years);
- goiter or large isthmus;
- large tumors of the neck;
- edema of the neck;
- impossible to palpate the thyroid and cricoid cartilages;
- calcified tracheal rings.

Absolute contraindications
According to Anderson and Bartlett (1991), emergency tracheostomy is an absolute contraindication for percutaneous tracheostomy.

3. Major principles
Two principles should be observed:
- retracting the endotracheal tube (if one is in place) to a position just below the vocal cords prior to puncturing the trachea,
- ensuring that air is aspirated with the syringe before introducing the guidewire.

4. Operating room

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The procedure is performed under local anesthesia using a prefabricated set with all the necessary equipment, including the tracheostomy cannula. The following conditions are required:
- supine position;
- arms by the sides;
- neck stabilized and fixed in midposition;
- sandbag under the shoulders to place the neck in hyperextension. This can be accentuated by dropping the head of the table; however, excessive extension can cause the tracheostomy to be placed too low.

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1. The surgeon stands to the right of the patient.
2. The assistant stands to the left of the patient.
3. The scrub nurse stands to the right of the surgeon.
4. The anesthesiologist stands at the head of the patient.

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1. Operating table
2. Anesthetic unit
3. Electrocautery

5. Instruments
&#8226; Operating instruments

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1. Standard dissecting forceps
2. Metzenbaum dissecting scissors with curved tip

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1. 10 mL syringe for inflation of the tracheostomy cuff
2. Band for fastening
3. Trocar
4. Connector tubing for the ventilator

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1. Mosquito forceps
2. Standard needle holder
3. Kelly forceps

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1. Beckmann-Adson self retaining retractor
2. Farabeuf retractor
3. Laborde dilator
4. Trousseau dilator

6. Technique

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The intervention can be performed under local anesthesia, but if it is not an emergency, it may be more convenient to use sedation or a general anesthetic.
Preparation of the patient and the sterile field is the same as for conventional tracheostomy.
All the necessary equipment is supplied in the prefabricated kit.

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The incision in the trachea can be vertical or horizontal, but should be short (1 to 1.5 cm).
It is advisable to stabilize the trachea with 2 fingers of the left hand and lift up.

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A large bore needle is introduced into the trachea by puncturing the anterior wall between 2 tracheal rings until air is aspirated. The guidewire is introduced through this needle, which is then removed.

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Many techniques can be used to dilate the opening in the trachea.
The technique of serial dilatation described by Ciagla et al. (1985) uses rigid dilators of increasing diameter over the guidewire until the opening is large enough to introduce the cannula.
Ciagla introduced the cannula into the space between the cricoid and the first tracheal ring, but nowadays it is introduced between the second and third or between the third and fourth tracheal rings.

&#8226; One-step dilatation

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The techniques of one-step dilatation use instruments specifically designed for rapid dilatation in a single step.
These include the ''Rapitrach technique'' described by Schachner et al. (1989) and the ''Guide Wire Dilating Forceps technique'' described by Griggs et al. (1990).

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In a recent review of the literature, Van Heerbeek et al. found fewer complications with the methods of Ciagla and Griggs, while there was an increased complication rate when the Rapitrach technique was used (Van Heerbeek et al., 1999).

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7. End of the procedure
Once the cannula has been introduced, the rest of the procedure and postoperative care are identical to those for conventional tracheostomy.

8. Complications
During the 1990s, a number of serious complications were reported when the technique was used for emergency airway access:
- formation of a false tract;
- perforation of the tracheal wall with surgical emphysema and pneumothorax;
- rupture of the endotracheal cuff and hemorrhage.

Percutaneous tracheostomy does not cause more complications than conventional tracheostomy. On the contrary, many authors report a decreased complication rate using the percutaneous technique (Moe et al., 1999; Holdgaard et al., 1998), particularly regarding bleeding and infection (the cannula fits tightly in the tracheal opening).

9. Discussion
Many authors suggest endoscopic guidance during the intervention to avoid damage to the trachea, the peritracheal structures or the endotracheal tube (Moe et al., 1999; Berrouschot et al., 1997).
Others recommend ultrasound guidance to visualize the peritracheal structures while avoiding the hypercapnia associated with endoscopy (Reilly et al., 1997; Hatfield and Bodenham, 1999).

Fantoni has described the technique of translaryngeal tracheostomy (Fantoni et al., 1996). A guidewire is introduced into the trachea and pulled out through the mouth. The cannula is then threaded over the guidewire in the reverse direction, from the mouth to the larynx. Once the cannula is in the trachea, it is pulled out through the anterior wall of the trachea and the soft tissue of the neck by traction on the guidewire. Fantoni performs the procedure with the aid of rigid bronchoscopy.

For patients who cannot be intubated easily (with lesions of the cervical spine or with severe hypoxia), fiberoptic bronchoscopy can be utilized (Sarpellon et al., 1998). There are few comparative studies, but this technique could become an alternative to conventional percutaneous tracheostomy (Walz and Peitgen, 1998). Nevertheless, the equipment for classic tracheostomy and endotracheal intubation (if not already intubated) should always be available in case the percutaneous technique fails.