Evaluation of the Effect of Morphological Structure on Dilatational Tracheostomy Interference Location and Complications with Ultrasonography and Fiberoptic Bronchoscopy

Abstract

Background: Percutaneous dilatational tracheostomy (PDT) is the most commonly performed minimally invasive intensive care unit procedure worldwide. Methods: This study evaluated the percentage of consistency between the entry site observed with fiberoptic bronchoscopy (FOB) and the prediction for the PDT level based on pre-procedural ultrasonography (USG) in PDT procedures performed using the forceps dilatation method. The effect of morphological features on intervention sites was also investigated. Complications that occurred during and after the procedure, as well as the duration, site, and quantity of the procedures, were recorded. Results: Data obtained from a total of 91 patients were analyzed. In 57 patients (62.6%), the USG-estimated tracheal puncture level was consistent with the intercartilaginous space observed by FOB, while in 34 patients (37.4%), there was a discrepancy between these two methods. According to Bland Altman, the agreement between the tracheal spaces determined by USG and FOB was close. Regression formulas for PDT procedures defining the intercartilaginous puncture level based on morphologic measurements of the patients were created. The most common complication related to PDT was cartilage fracture (17.6%), which was proven to be predicted with maximum relevance by punctured tracheal level, neck extension limitation, and procedure duration. Conclusions: In PDT procedures using the forceps dilatation method, the prediction of the PDT intervention level based on pre-procedural USG was considerably in accordance with the entry site observed by FOB. The intercartilaginous puncture level could be estimated based on morphological measurements.

Keywords: complications; fiberoptic bronchoscopy; morphology; percutaneous dilatational tracheostomy; ultrasonography.

Figure 1

Anatomical landmark for site of intervention (A). Determination of the skin-to-trachea distance by fiberoptic bronchoscopy (B). Depth mark created with a scalpel in the dilator at skin level (C). Trachea puncture angle 1. Puncture angle > 30° --> repeat puncture. 2. Midline puncture. 3. Puncture angle < 30° (D). Cartilage fracture (E).

Figure 2

Flow diagram of the study.

Figure 3

Bland–Altman analysis of the differences between ultasound-determined intercartilaginous puncture level and FOB-determined intercartilaginous puncture level.

Figure 4

Comparison of ROC curves for puncture levels detected by FOB and ultrasound.

Figure 5

Linear regression analyses performed between PDT intercartilaginous puncture levels confirmed by FOB and anatomical measurements.

Figure 6

Predictor importance scores in terms of cartilage fracture during PDT. The relationship of 22 different variables was examined with the mRMR method to determine their relationship with cartilage fracture. This algorithm determines the relationship between inputs and responses based on mutual information. According to their mutual information scores, the algorithm ranks the input variables. The details of the algorithm are explained in the Methods section.