Pulmonary
Tracheostomy and Bronchostomy
PREOPERATIVE DIAGNOSIS: Respiratory failure and failure to wean.
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE:
1. Insertion percutaneous tracheostomy.
2. Therapeutic bronchostomy.
SURGEONS: V., MD; S., PGY4.
ANESTHESIA: Local with IV sedation.
COMPLICATIONS: None.
BLOOD LOSS: 25-50 cc.
INDICATIONS: The patient is a 52-year-old gentleman who is 15 days status post orthotopic liver transplant, who has been unsuccessful in weaning from ventilator. Surgery was consulted for tracheostomy placement. Bedside percutaneous procedure was selected. The procedure and risks of the procedure to the family. Questions were answered to their satisfaction and the consent was given to proceed.
PROCEDURE IN DETAIL: After informed consent, the patient was seen in his hospital room in the SICU. His neck was prepped and draped in a sterile fashion. His ET tube was managed by the respiratory therapist and was retracted under bronchoscopic vision. Blotting through the anterior tracheal wall demonstrated good position of the tube and a Cook needle advanced in the midline under the direct vision by the bronchoscope into the trachea. The guidewire was inserted and was seen to flow downstream. A stab incision was made over the skin approximately 1 cm. The serial dilators were passed over the wire into the trachea under bronchoscopic vision without difficulty. The tracheostomy was then placed over the guide wire and stiffening wire into the trachea. Several attempts were required due to resistance by the bevel of the tube. However, this was able to be placed uneventfully. Position was confirmed by the bronchoscope in the trachea, and the new tracheostomy was connected to the airway circuit and the patient was ventilated. The patient’s oxygen saturations remained at 98 to 100 percent throughout the entire procedure and his vital signs were stable.
Following placement of the tracheostomy, the bronchoscope was placed through the tracheostomy tube into the branchial tree and segment of bronchi. Aspiration of sputum on these areas was obtained for culture. All secretions and blood was aspirated until clear up to the segment of bronchi. No extra lumina of pathology was noted.
The procedure was concluded. The patient tolerated the procedure well and without complications. It is to be noted, I present and participated actively throughout the entire procedure from beginning to end.