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Posterior tracheal wall perforation with the Blue Rhino™ tracheostomy set

2002; Wiley; Volume: 57; Issue: 1 Linguagem: Inglês

10.1046/j.1365-2044.2002.2412_13.x

1365-2044

K. Westphal, V. Lischke, Christian Byhahn, J. W. Goethe,

Airway Management and Intubation Techniques

We read with interest the article describing the experience of the Ciaglia Blue Rhino™ Percutaneous Tracheostomy Introducer Set in 36 consecutive patients (Bewsher et al. Anaesthesia␣2001; 56: 859–64). We started to use the Blue Rhino™ set in October 1999 and have gained experience in more than 150 adults to date. Besides frequently occurring tracheal cartilage fractures [1, 2], we also experienced one case of posterior tracheal wall perforation, the mechanism of which we would like to discuss. A 72-year-old woman who required respiratory support for septic shock underwent elective Blue Rhino™ tracheostomy on day 5 of intubation. The procedure was performed with flexible fibreoptic bronchoscopy, and tracheal puncture and introduction of the Blue Rhino™ dilator was uneventful. When the tracheal cannula (TracheoSoft Perc™, Mallinckrodt Medical, Athlone, Ireland) with 9.3 mm internal diameter was introduced over the corresponding loading dilator of the Blue Rhino™ set, much force had to be applied, resulting in tracheal collapse in the anteroposterior plane and inability to bronchoscope during the cannula insertion. Thereafter, the cannula's correct position was confirmed with bronchoscopy via the cannula. Within the next few hours, the cannula's cuff had to be re-inflated, and cuff leakage was considered. During the subsequent␣bronchoscopic examination through the glottis with the cannula's cuff deflated, a 4-cm longitudinal posterior tracheal wall tear was identified, along with a tear of the anterior oesophageal wall. The tracheal cannula was removed, and the patient was re-intubated orally with the tracheal tube's cuff distal to the posterior tracheal wall injury. After surgical repair of tracheal and oesophageal tears two days later, an 8.0-mm internal diameter tracheal cannula was carefully introduced over a loading dilator through the initial stoma and placed with its cuff distal to the site of injury. The patient was weaned from the respirator and uneventfully decannulated on day 12 after tracheostomy. Unfortunately, the patient gave no consent for a follow-up examination 6 months after discharge from our hospital. In contrast to Bewsher and colleagues who suspected severe problems immediately after withdrawal of a kinked guide wire, stoma dilation was uneventful in our patient. However, because of our patient's morbid obesity (body mass index 50.8 kg.m-2), introduction of the tracheostomy cannula was difficult and required much force. We therefore attribute the accidental injuries most likely to the loading dilator that, in contrast to the soft tip Blue Rhino™ dilator, has a hard tip. The hard tip, in combination with much force applied to the anterior tracheal wall and subsequent collapse of the tracheal lumen, seems to be the mechanism of this potentially devastating complication. In summary, the danger of posterior tracheal wall injury remains a disadvantage of percutaneous tracheostomy techniques with antegrade dilation. Fantoni's translaryngeal technique (TLT), in which stoma dilation is achieved in retrograde fashion from inside the trachea to the outside with the tracheostomy cannula itself, is said to be safe with regard to the posterior tracheal wall [3]. Indeed, except for a posterior tracheal tear that occurred during intratracheal straightening and rotation of the cannula [4], no other adverse events have been reported in association with the TLT. Also, the new␣PercuTwist™-Set (Rüsch GmbH, Kemen, Germany) with its screw-like dilating device, is said to enhance safety. The anterior tracheal wall can be lifted during dilation, thus keeping the tracheal lumen open and enabling an unrestricted bronchoscopic view of the dilation site at any given time [5]. However, no clinical studies have yet been published of this new technique.