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Percutaneous tracheostomy in three morbidly obese patients using the ‘Blue Rhino TM ’ technique

2000; Wiley; Volume: 55; Issue: 9 Linguagem: Inglês

10.1046/j.1365-2044.2000.01664-13.x

1365-2044

M. J. P. Scott, J. M. LEIGH,

Esophageal and GI Pathology

We read with interest the case report of percutaneous dilatational tracheostomy in a patient with morbid obesity (Unwin et al. Anaesthesia 2000; 55: 393–4). We report three cases where we recently performed a percutaneous tracheostomy in patients who were very obese using the new Blue Rhino™ single dilator technique developed by Ciaglia and made by Cook ( 8-10). We believe this technique of percutaneous tracheostomy is safer and easier than the original Ciaglia [1] sequential dilation technique and has particular advantages when performing percutaneous tracheostomy in the very obese. Photograph showing the Cook Blue Rhino™ percutaneous tracheostomy dilator loaded onto the guiding catheter. The Blue Rhino is appropriately named because of the similarity of its shape with a rhino's horn. The Blue Rhino™ dilator being inserted over the wire and introducer into the trachea. The dilator is passed over the guiding catheter beyond the 38F mark depending on the size of tracheostomy required but not beyond the upper black mark. The tip end of the Blue Rhino™ dilator is flexible and can almost bend round on itself. The narrow distal end of the dilator can follow the passage of the wire down the trachea easily despite the proximal portion of the dilator remaining perpendicular to the skin. A 56-year-old woman was admitted under the care of the general surgeons complaining of left-sided flank pain. She had severe rheumatoid arthritis for the last 30 years of her life and required maintenance steroid therapy of prednisolone 20 mg.day−1 and nonsteroidal anti-inflammatory drugs. Her weight was 120 kg and her height was 1.58 m. Her body mass index was 48.1 kg.m−2. On day 5 of her admission, she became septic. At laparotomy, she was found to have a perforated diverticulum and necrotising fasciitis of her abdominal wall, which was debrided and her wound was left open but requiring further repeated surgical cleansing and debridement. Following surgery, she was admitted to the ICU for ventilation. On day 5, we decided to perform a percutaneous tracheostomy to aid further management on the ICU with the prospect of prolonged ventilation. During the percutaneous tracheostomy the patient was ventilated using 50% oxygen, air and isoflurane and received 150 µg of fentanyl and 20 mg of cis-atracurium. The patient was positioned on the operating table with the neck extended with a sandbag under the shoulders. The neck was prepared with chlorhexidine and the area around the point of insertion of the tracheostomy was infiltrated with 6 ml of lidocaine 1% with epinephrine 1 : 200 000. The tracheal tube was pulled back and a horizontal incision in the skin was made using a scalpel. Using blunt dissection the pretracheal fascia was exposed and the needle introduced into the trachea between the first and second tracheal rings. Bronchoscopy was used to confirm the correct position of the needle. The guidewire was then passed into the trachea and the needle withdrawn. The white guiding catheter was then introduced over the wire and its position checked using the bronchoscope. The Blue Rhino™ dilator was then passed over the guiding catheter until the tip lay in the trachea. Then using a gentle seesaw action the space was dilated with very little resistance. A size-8 tracheostomy tube was then loaded onto the appropriate introducer and passed over the guiding catheter and wire into the trachea. The wire and guiding catheter were then removed and we suctioned down the trachea. Ventilation was then re-established via the tracheostomy. Bronchoscopy and a chest X-ray were performed to exclude any immediate complications. A 54-year-old man was admitted to our ITU with respiratory failure due to a chest infection. He also suffered from extrinsic allergic alveolitis. He weighed 146 kg and his height was 1.75 m. His body mass index was 47.7 kg.m−2. We performed a percutaneous tracheostomy using the above technique, which was uneventful and inserted a size-9 tracheostomy tube. A 64-year-old woman was admitted under the physicians with respiratory failure due to a chest infection. She had rheumatoid arthritis and had long-term chronic obstructive pulmonary disease. She weighed 102 kg and her height was 1.54 m. Her body mass index was 43.0 kg.m−2. She was admitted to the ICU for ventilation. After two unsuccessful attempts to wean her from mechanical ventilation, we decided to perform a percutaneous tracheostomy to aid weaning from mechanical ventilation. The percutaneous tracheostomy was performed on the ICU and a size-8 tracheostomy tube inserted. The technique was the same as that above and was uncomplicated. The Blue Rhino™ single dilator method of percutaneous tracheostomy has now been adopted as standard in our ICU because we feel it offers several advantages over the traditional Ciaglia sequential dilator technique. These are: 1 A smaller skin incision is required to dilate, which enables a snugger fit of the skin around the tracheostomy tube. This may reduce the likelihood of infection around the tracheostomy tube and produces a better cosmetic result after healing. 2 The process of dilating up the space between the tracheal rings requires less force and is quicker than other dilating techniques. If the operator keeps the tip of the Blue Rhino™ in the trachea at all times and dilates the tissues using a ‘seesaw’ technique, the dilation is very smooth and atraumatic. This reduces the likelihood of bleeding and tissue damage as compared to the Ciaglia sequential dilator technique where the ‘shoulders’ of the dilator often catch on tissues or the tracheal cartilage. 3 The increased speed of technique reduces the time during which the tracheal tube is pulled back and dilators are obstructing the airway. The technique could be adapted for use in the creation of an emergency airway where cricothyrotomy is not appropriate. 4 The dilator is hydrophilic and when immersed in water or saline becomes very smooth and effectively lubricated. This enables easy passage of the dilator through tissues without the need for lubricating jelly, which can make everything very slippery. 5 It makes performing a percutaneous tracheostomy in the obese easier and safer. Traditional dilators are quite stiff and directing them caudally when the trachea is deeply situated is difficult and there is a risk of damaging the posterior wall of the trachea if they cannot bend at the appropriate angle. The Rhino dilator is flexible so that it can follow the direction of the wire down the trachea even when the proximal portion of the dilator is still perpendicular to the skin.