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* From the Division of Pulmonary and Critical Care Medicine, Department of Medicine (Drs. Mansharamani, Koziel, Ernst, and Mr. Garland) and Department of Surgery (Drs. LoCicero and Critchlow), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.
Correspondence to: Armin Ernst, MD, Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, One Deaconess Rd, Boston, MA 02115; e-mail: aernst{at}caregroup.harvard.edu
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Abstract |
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 TOP Abstract IntroductionMaterials and MethodsResultsDiscussionReferences |
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Design: Case series of consecutive obese patients (body
mass index 
27 kg/m2) with acute respiratory failure in
a medical, cardiac, or surgical ICU unit who required tracheostomy for
failure to wean and continued mechanical ventilatory support.
Results: Thirteen obese patients were identified and consented to the procedure. Bedside percutaneous dilatational tracheostomy was successfully performed in the ICU for all 13 patients. Procedural complications were limited to paratracheal tracheostomy tube placement in one patient, with immediate identification and appropriate correction. Postprocedural complications were limited to a cuff leak in one patient.
Conclusion: Bedside percutaneous tracheostomy can be safely performed in obese patients.
Key Words: morbid obesity • percutaneous dilatational tracheostomy • respiratory failure
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Introduction |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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Among the relative contraindications for PDT include patients with altered neck anatomy due to severe neck burns, and scarring from a previous tracheostomy.3 4 In addition, obese patients with large and thick necks are considered poor candidates for PDT, and are commonly referred for surgical tracheostomy placement. However, the feasibility and safety of bedside PDT in obese patients has not been extensively investigated. In this report, we describe our experience for bedside PDT in obese patients at a tertiary-care referral hospital.
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Materials and Methods |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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Patients
During the period of December 1996 to January 1999, consecutive
obese patients referred for PDT were identified for this report. All
patients were 18 years old, experienced acute respiratory failure
requiring endotracheal tube (ETT) intubation and mechanical
ventilation, and were referred for tracheostomy placement for
persistent respiratory failure and prolonged weaning from mechanical
ventilation. Only patients with a body mass index (BMI) 27
kg/m2 (considered "obese, > 50% of ideal
body weight") were included in the study. None of these patients had
absolute contraindications for PDT. Absolute contraindications included
the following: uncontrolled bleeding disorders; high ventilatory
demands (minute ventilation > 15 L/min), high oxygenation needs
(positive end-expiratory pressure > 15 cm H2O
or fraction of inspired oxygen of 0.7); and active cutaneous infection
over the proposed tracheostomy site.4
PDT
PDT is the procedure of choice at our institution for medical
and surgical patients with respiratory failure requiring tracheostomies
for prolonged mechanical ventilatory support. All PDT procedures were
performed by specially trained general surgeons, thoracic surgeons, and
pulmonologists. All PDT procedures are performed at the bedside in the
ICU in which the patient resided, with continuous monitoring of BP,
heart rate, respiratory rate, oxygen saturation, and cardiac rhythm
strip. Mechanical ventilatory support was maintained throughout the
procedure, the fraction of inspired oxygen was increased to 1.0, and
all patients were placed on mandatory mechanical ventilation mode. Most
procedures were attended by an anesthesiologist to assist in the
management of the airway in the event of complications.
Informed consent was obtained from each patient, or from a designated power of attorney or family member, if the patient was unable to provide informed consent. All patients received short-acting IV midazolam or propofol, and a short-acting paralytic agent such as vecuronium if necessary.
PDT was performed as previously described in detail,4 with few modifications dictated by the patients’ body habitus. Briefly, a 1.5- to 2.0-cm vertical or horizontal skin incision was performed, the pretracheal tissue was bluntly dissected with a hemostat, and the tracheal rings or cricoid cartilage were identified by palpation. Employing the Seldinger technique, a guidewire was then placed below the first tracheal ring, a stoma created by sequential dilatation, followed by placement of a # 8 Portex Perfit (Sims-Portex; Keene, NH) tracheostomy tube, a # 9 Portex Perfit (Sims-Portex) tracheostomy tube, or an extralong # 8 Portex (Sims-Portex) tracheostomy tube (sizes depict the inner diameter [ID] in millimeters). Extralong tubes were chosen for the additional horizontal tube length if the pretracheal tissue and fat plane was too thick for a regular-sized tracheal tube.
Flexible fiberoptic bronchoscopy was not routinely performed during the procedure, but was immediately available.
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Results |
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Procedural complications included the paratracheal placement of the tracheostomy tube in one case (patient 8). For this case, the tracheostomy tube initially dissected along a tissue plane adjacent to the trachea, but was immediately identified prior to ETT extubation. The tracheostomy tube was properly repositioned without clinical consequence to the patient, and proper tracheostomy position was verified by direct bronchoscopic visualization.
Postprocedural complications included a cuff leak in one patient (patient 5) on day 2 following the initial PDT. The tracheostomy tube was exchanged at the bedside with a changing kit.
There were no serious bleeding complications during the procedures and no cardiopulmonary complications. None of the patients for whom PDT was performed required conversion to emergent surgical tracheostomy placement. There were no deaths associated with bedside PDT.
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Discussion |
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The care of the obese patient in the ICU poses many challenges, and establishing an artificial airway in this patient population can be technically difficult. In most institutions, obese patients in need of a tracheostomy are referred for surgical tracheostomy placement. However, even the surgical approach can be challenging, and may require tracheostomy with cervical lipectomy to overcome the technical barriers.5 PDT, first described in its current form in 1985,3 has increasingly evolved as a viable alternative to surgical tracheostomy placement.6 However, prior reported experience of PDT in obese patients has been limited. The current report suggests that obesity may not be a relative contraindication to PDT, and that in the absence of other anatomic abnormalities, PDT can be safely performed in these patients requiring prolonged maintenance of an artificial airway.
In general, PDT is considered very safe, with a complication rate of 4 to 17% in experienced hands.2 The most common complications include bleeding, subcutaneous emphysema, aspiration, and stomal infection.2 7 8 These complication rates are similar to those reported for surgical tracheostomies, and the postprocedural complication rate for PDT may be lower than surgically placed tracheostomy.2 6 9 The observed complication rate for obese patients in the current study is consistent with rates reported for other patients undergoing PDT. In this report, the complications were limited and included paratracheal placement of the tracheostomy tube in one patient (7.7%) and a postprocedure cuff-leak in one patient (7.7%). Of note, the paratracheal insertion was performed by a resident in training under close supervision by the attending surgeon. Due to this close supervision, the misplacement was immediately identified and corrected. In both cases, the tracheostomy tube was replaced with a new tracheostomy tube without further complications and without clinical consequences to the patients.
Several important features may have contributed to the success of bedside PDT placement in the obese patient population included in this report. Due to the high case load at the BIDMC ICUs, all operators have a large cumulative experience with bedside PDT. The cumulative number of PDT procedures performed by the operators in this report is > 400. Furthermore, all procedures were performed in an ICU setting, with the appropriate monitoring and with the appropriate facilities to appropriately manage adverse events. Anesthesiologists were present for most procedures in this patient population, although no complications in airway management were experienced. Additionally, it is necessary to adapt the inserted tracheostomy tube to the anatomic requirements. Thus, in patients with very large necks, we had extralong tubes available for insertion if necessary.
Finally, the availability of fiberoptic bronchoscopy facilitated the proper positioning of a tracheostomy tube in one case. These safeguards should be considered for complex PDT procedures.
The findings in this report are limited by the relatively small number of patients included. However, this report represents the largest reported experience for PDT in obese patients. The experience of successful PDT in obese patients at the BIDMC may not represent patients at other institutions in various medical centers in this country and the world. However, the underlying medical conditions were quite diverse, and likely represent various medical and surgical patients encountered in other practices. Clearly, as successful PDT placement in obese patients requires specialized skill, this procedure may not be appropriate in centers with less experience.
Our experience suggests that PDT is a feasible, well-tolerated, and safe procedure for the obese patient requiring prolonged mechanical ventilatory support for persistent respiratory failure. When performed by experienced surgeons and interventional pulmonologists at the bedside of the patient in the ICU of a tertiary-care medical center, PDT may be associated with a high success rate and low complication rate in the obese patient, and may offer a significant cost advantage.
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Footnotes |
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Received for publication June 3, 1999. Accepted for publication November 23, 1999.
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References |
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This article has been cited by other articles:
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  A. Ben Nun, M. Orlovsky, and L. Anson Best Percutaneous tracheostomy in patients with cervical spine fractures - feasible and safe Interactive CardioVascular and Thoracic Surgery, August 1, 2006; 5(4): 427 - 429. [Abstract] [Full Text] [PDF]
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 A. B. Nun, E. Altman, and L. A. Best Extended Indications for Percutaneous Tracheostomy Ann. Thorac. Surg., October 1, 2005; 80(4): 1276 - 1279. [Abstract] [Full Text] [PDF]
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 J E Heffner Management of the chronically ventilated patient with a tracheostomy Chronic Respiratory Disease, July 1, 2005; 2(3): 151 - 161. [Abstract] [PDF]
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 D. Charlebois and D. Wilmoth Critical Care of Patients With Obesity Crit. Care Nurse, August 1, 2004; 24(4): 19 - 27. [Full Text] [PDF]
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A. Ben-Nun, E. Altman, and L.-A. E. Best Emergency percutaneous tracheostomy in trauma patients: an early experience Ann. Thorac. Surg., March 1, 2004; 77(3): 1045 - 1047. [Abstract] [Full Text] [PDF]
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 A. A. El-Solh Clinical Approach to the Critically Ill, Morbidly Obese Patient Am. J. Respir. Crit. Care Med., March 1, 2004; 169(5): 557 - 561. [Full Text] [PDF]
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