Punktionstracheotomie in der Intensivmedizin – Update 2012

Zusammenfassung

Die Punktionstracheotomie ist ein fester Bestandteil der intensivmedizinischen Beatmungstherapie und bietet viele Vorteile gegenüber der prolongierten orotrachealen Intubation. Für den optimalen Zeitpunkt zur Tracheotomie gibt es gegenwärtig jedoch noch keine Evidenz. Der Eingriff wird in Allgemeinanästhesie unter fiberoptischer Kontrolle durchgeführt, wobei die Ciaglia Blue-Rhino-Technik am weitesten verbreitet ist. Ein neuartiges Verfahren stellt die CiagliaBlue-Dolphin-Technik dar, bei der eine radiäre Dilatation mithilfe eines flüssigkeitsgefüllten Hochdruckballons erfolgt. Unter Beachtung der Kontraindikationen (z.B. schwierige Intubation, keine sichere Identifikation laryngotrachealer Landmarken, hochgradige Gerinnungsstörungen) ist die Komplikationsrate aller Verfahren gering, wobei der Einsatz der Sonografie zu einer weiteren Erhöhung der Sicherheit beitragen kann. Schlussendlich muss beachtet werden, dass es sich bei der Punktionstracheotomie um einen Elektiveingriff handelt, für den eine rechtsgültige Einwilligung des Patienten oder seines Betreuers erforderlich ist.

Abstract

Percutaneous tracheostomy has become an established procedure in airway management of critically ill patients. It offers advantages over prolonged tracheal intubation. To date, there is no evidence of the optimal timing of the procedure. The Ciaglia Blue Rhino technique is the most common technique and, as any other techniques of percutaneous tracheostomy, is performed under general anaesthesia and with continuous bronchoscopic control. The recently introduced Ciaglia Blue Dolphin technique is based on radial dilatation with a fluid-filled high pressure balloon. Provided that specific contraindications are observed (e.g. difficult tracheal intubation, inability to identify anatomic landmarks, severe coagulopathy etc.), all techniques have low complication rates. The use of ultrasound may further enhance perioperative safety. Finally it must be noted that percutaneous tracheostomy is an elective procedure that requires informed consent from the patient or an attorney of law.

Kernaussagen

• Die Tracheotomie als eine der ältesten chirurgischen Prozeduren hat sich durch die modernen Punktionstechniken zu einem Standardeingriff in der Intensivmedizin entwickelt.

• Schäden infolge der endotrachealen Langzeitintubation (Verletzung der Aryknorpel, Mund- und Nasenschleimhaut, bis hin zur Trachealstenose), können durch Tracheotomie vermieden werden.

• Kontraindikationen sind vor dem Eingriff unbedingt zu beachten [Tab. 2].

• Für den idealen Zeitpunkt der Tracheotomie gibt es keine Evidenz.

• Der liegende Endotrachealtubus kann vor Beginn der Punktion durch eine Larynxmaske ersetzt werden.

• Bronchoskopie während der praktischen Durchführung ist obligat.

• Der einliegende Führungsdraht muss immer frei beweglich sein, um Trachealverletzungen zu vermeiden.

• Die Punktionstracheotomie ist eine elektive, aber hochinvasive Maßnahme.

Schlüsselwörter:

Tracheotomie - Dilatationstracheotomie - Beatmung - Intensivmedizin

Key words:

tracheostomy - dilatational tracheostomy - ventilation - intensive care

• Literatur

• 1 Ciaglia P, Firsching R, Syniec C. Elective percutaneous dilatational tracheostomy. A new simple bedside procedure; preliminary report. Chest 1985; 87: 715-719
• 2 Byhahn C, Wilke HJ, Halbig S et al. Percutaneous tracheostomy: Ciaglia Blue Rhino versus the basic Ciaglia technique of percutaneous dilational tracheostomy. AnesthAnalg 2000; 91: 882-886
• 3 Bishop MJ, Hibbard AJ, Fink BR et al. Laryngeal injury in a dog model of prolonged endotracheal intubation. Anesthesiology 1985; 62: 770-773
• 4 Weymuller Jr EA, Bishop MJ, Fink BR et al. Quantification of intralaryngeal pressure exerted by endotracheal tubes. Ann OtolRhinolLaryngol 1983; 92: 444-447
• 5 Shapiro M, Wilson RK, Casar G et al. Work of breathing through different sized endotracheal tubes. Crit Care Med 1986; 14: 1028-1031
• 6 Marshak G, Doyle WJ, Bluestone CD. Canine model of subglottic stenosis secondary to prolonged endotracheal intubation. Laryngoscope 1982; 92: 805-809
• 7 Rumbak MJ, Newton M, Truncale T et al. A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients. Crit Care Med 2004; 32: 1689-1694
• 8 Holzapfel L, Chevret S, Madinier G et al. Influence of long-term oro- or nasotrachealintubation on nosocomial maxillary sinusitis and pneumonia: results of a prospective, randomized, clinical trial. Crit Care Med 1993; 21: 1132-1138
• 9 Deutschman CS, Wilton P, Sinow J et al. Paranasalsinusitis associated with nasotrachealintubation: a frequently unrecognized and treatable source of sepsis. Crit Care Med 1986; 14: 111-114
• 10 Santos PM, Afrassiabi A, Weymuller Jr. EA. Risk factors associated with prolongedintubation and laryngeal injury. Otolaryngol Head Neck Surg 1994; 111: 453-459
• 11 Hedden M, Ersoz CJ, Donnelly WH, Safar P. Laryngotracheal damage after prolonged use of orotracheal tubes in adults. JAMA 1969; 207: 703-708
• 12 Zilberberg MD, Luippold RS, Sulsky S, Shorr AF. Prolonged acute mechanical ventilation, hospital resource utilization, and mortality in the United States. Crit Care Med 2008; 36: 724-730
• 13 Zilberberg MD, de Wit M, Shorr AF. Accuracy of previous estimates for adult prolonged acute mechanical ventilation volume in 2020: update using 2000–2008 data. Crit Care Med 2012; 40: 18-20
• 14 Kluge S, Baumann HJ, Maier C et al. Tracheostomy in the intensive care unit: a nationwide survey. AnesthAnalg 2008; 107: 1639-1643
• 15 Plummer AL, Gracey DR. Consensus conference on artificialairways in patients receiving mechanical ventilation. Chest 1989; 96: 178-180
• 16 Blot F, Similowski T, Trouillet JL et al. Early tracheotomy versus prolonged endotracheal intubation in unselected severely ill ICU patients. Intensive Care Med 2008; 34: 1779-1787
• 17 Durbin Jr C, Perkins MP, Moores LK. Should tracheostomy be performed as early as 72 hours in patients requiring prolonged mechanical ventilation?. Respir Care 2010; 55: 76-87
• 18 Barquist ES, Amortegui J, Hallal A et al. Tracheostomy in ventilator dependent trauma patients: a prospective, randomized intention-to-treat study. J Trauma 2006; 60: 91-97
• 19 Terragni PP, Antonelli M, Fumagalli R et al. Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: a randomized controlled trial. JAMA 2010; 303: 1483-1489
• 20 Rizk EB, Patel AS, Stetter CM et al. Impact of tracheostomy timing on outcome after severe head injury. Neurocrit Care 2011; 15: 481-489
• 21 Devarajan J, Vydyanathan A, Xu M et al. Early tracheostomy is associated with improved outcomes in patients who require prolonged mechanical ventilation after cardiac surgery. J Am CollSurg 2012; 214: 1008-1016
• 22 Gomes Silva BN, Andriolo RB, Saconato H et al. Early versus late tracheostomy for critically ill patients. Cochrane Database Syst Rev CD 007271 2012; 3
• 23 Linstedt U, Zenz M, Krull K et al. Laryngeal mask airway or endotracheal tube for percutaneous dilatational tracheostomy: a comparison of visibility of intratracheal structures. AnesthAnalg 2010; 110: 1076-1082
• 24 Westphal K, Lohrengel A, Wilke HJ et al. Die perkutane Dilatationstracheotomie bei Intensivpatienten in der Herzchirurgie. Z Herz Thorax Gefäßchir 1998; 12: 177-181
• 25 Westphal K, Lischke V, Byhahn C. Posterior tracheal wall perforation with the Blue Rhino tracheostomy set. Anaesthesia 2002; 57: 89-90
• 26 Dexter TJ. The laryngeal mask airway: a method to improve visualisation of the trachea and larynx during fiberoptic assisted percutaneous tracheostomy. Anaesth Intensive Care 1994; 22: 35-39
• 27 Lyons BJ, Flynn CG. The laryngeal mask simplifies airway management during percutaneous dilatational tracheostomy. ActaAnaesthesiolScand 1995; 39: 414-415
• 28 Gründling M, Kuhn SO, Riedel T et al. Application of the laryngeal mask for elective percutaneous dilatation tracheotomy. AnaesthesiolReanim 1998; 23: 32-36
• 29 Di Pietro A, Coletta RP, Barbati G, Blasetti AG. Laryngeal mask vs. endotracheal tube in airway managment during percutaneous tracheotomy using Blue Rhino technique. ActaAnaesthItalica 2006; 57: 51-63
• 30 Dosemeci L, Yilmaz M, Gürpinar F, Ramazanoglu A. The use of the laryngeal mask airway as an alternative to the endotracheal tube during percutaneous dilatational tracheostomy. Intensive Care Med 2002; 28: 63-67
• 31 Ambesh SP, Sinha PK, Tripathi M, Matreja P. Laryngeal mask airway vs. endotracheal tube to facilitate bedside percutaneous tracheostomy in critically ill patients: a prospective comparative study. J Postgrad Med 2002; 48: 11-15
• 32 Strametz R, Pachler C, Byhahn C et al. Laryngeal mask airway versus endotracheal tube for percutaneous dilatational tracheostomy in critically ill patients. Cochrane Database Syst Rev CD 009901 2012; 6
• 33 Rajajee V, Fletcher JJ, Rochlen LR, Jacobs TL. Real-time ultrasound-guided percutaneous dilatational tracheostomy: a feasibility study. Crit Care 2011; 15
• 34 Kristensen MS. Ultrasonography in the management of the airway. ActaAnaesthesiolScand 2011; 55: 1155-1173
• 35 Kollig E, Heydenreich U, Roetman B et al. Ultrasound and bronchoscopic controlled percutaneous tracheostomy on trauma ICU. Injury 2000; 31: 663-668
• 36 Kleine-Brueggeney M, Greif R, Ross S et al. Ultrasound-guided percutaneous tracheal puncture: a computer-tomographic controlled study in cadavers. Br J Anaesth 2011; 106: 738-742
• 37 Byhahn C, Lischke V, Meininger D et al. Peri-operative complications during percutaneous tracheostomy in obese patients. Anaesthesia 2005; 60: 12-15
• 38 Guinot PG, Zogheib E, Petiot S et al. Ultrasound-guided percutaneous tracheostomy in critically ill obese patients. Crit Care 2012; 16
• 39 Datta D, Onyirimba F, McNamee MJ. The utility of chest radiographs following percutaneous dilatational tracheostomy. Chest 2003; 123: 1603-1606
• 40 Haddad SH, Aldawood AS, Arabi YM. The diagnostic yield and clinical impact of a chest X-ray after percutaneous dilatational tracheostomy: a prospective cohort study. Anaesth Intensive Care 2007; 35: 393-397
• 41 Kumar VM, Grant CA, Hughes MW et al. Role of routine chest radiography after percutaneous dilatational tracheostomy. Br J Anaesth 2008; 100: 663-666
• 42 Griggs WM, Worthley LI, Gilligan JE et al. A simple percutaneous tracheostomy technique. SurgGynecolObstet 1990; 170: 543-545
• 43 Frova G, Quintel M. A new simple method for percutaneous tracheostomy: controlled rotating dilation. A preliminary report. Intensive Care Med 2002; 28: 299-303
• 44 Fantoni A, Ripamonti D. A non-derivative, non-surgical tracheostomy: the translaryngeal method. Intensive Care Med 1997; 23: 386-392
• 45 Zgoda MA, Berger R. Balloon-facilitated percutaneous dilational tracheostomy tube placement: preliminary report of a novel technique. Chest 2005; 128: 3688-3690