Bronchoscopy assisted neonatal tracheostomy (BANT): A new technique

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International Journal of Pediatric Otorhinolaryngology (2007) 71, 211—215

www.elsevier.com/locate/ijporl

Bronchoscopy assisted neonatal tracheostomy (BANT): A new technique Kevin D. Pereira *, Yitzak E. Weinstock The Department of Otolaryngology, University of Texas Medical School at Houston, 6410 Fannin, Suite 1200, Houston, TX 77030, USA Received 25 August 2006; received in revised form 5 October 2006; accepted 5 October 2006

KEYWORDS Tracheostomy; Bronchoscopy; Neonatal

Summary Neonatal tracheostomy is a complex procedure associated with significant morbidity due to the small size and medical condition of the patient. Standard techniques have been well described and depend on palpation and visual identification of the trachea in the wound. This can at times be exceedingly difficult depending on the anatomical configuration of the neck. The potential for damage to adjacent neurovascular structures increases as dissection strays away from the midline. We describe a new technique that restricts dissection strictly to the midline and ensures accurate placement of the tracheostomy below the first tracheal ring. We feel that this technique will significantly shorten the operative time for the procedure and also reduce the morbidity associated with it. # 2006 Elsevier Ireland Ltd. All rights reserved.

1. Introduction Advances in medical technology have enabled the survival of increasing numbers of premature infants despite a decrease in the their gestational age at birth [1,2]. Many of these infants are born with very immature cardiopulmonary systems that require ventilatory support for prolonged durations [3,4]. The advent of polyvinyl chloride endotracheal tubes as well as our improved understanding of neonatal respiratory physiology and pathology has led to endotracheal rather than tracheostomy tubes being used * Corresponding author. Tel.: +1 713 500 5412; fax: +1 713 500 0661. E-mail address: [email protected] (K.D. Pereira).

as the conduits of choice for prolonged ventilation [3,5]. Tracheostomies are now performed in approximately 0.55—0.87% of all NICU admissions [3,6]. The most common indications for tracheostomy in the premature infant population remain prolonged ventilatory dependence and upper airway obstruction due to craniofacial or other structural abnormalities [3,7]. Tracheostomy in neonates continues to be a complex and technically demanding procedure mainly due to the small size of the patient, the small highly pliable trachea, and frequent multiple associated comorbidities. Frequent palpation to confirm tracheal position in the wound is required to avoid trauma to the adjacent neurovascular structures. This can prove difficult, as the incision is usually

0165-5876/$ — see front matter # 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2006.10.003

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K.D. Pereira, Y.E. Weinstock

smaller than the surgeon’s gloved finger. We describe a novel method of performing neonatal tracheostomies that allows for complete evaluation of the larynx and tracheobronchial tree while providing easy external anatomical identification for correct placement of the tracheostomy without the need for frequent and redundant operative movement. The bronchoscopic assisted neonatal tracheostomy (BANT) has proven a safe, rapid and efficient means of performing a neonatal tracheostomy in our practice.

2. Surgical technique All neonatal tracheostomies are performed in the operating room under general anesthesia on intubated patients transferred from the NICU. The infants are placed on the operating table with a shoulder roll and donut shaped headrest in place. The operating room is arranged as follows: Surgeon #1 is at the head of the bed along with the anesthesiologist. A mayo stand fixed to the operating table with a laryngoscope, rigid bronchoscopes of various sizes, endoscopic graspers and suction is at Surgeon #1’s side dependant on right or left handedness (Fig. 1). Surgeon #2 and surgical assistant are at the sides of the bed in usual location. The endoscopic video tower is arranged next to the surgical assistant in a manner that it is visible to both Surgeon #1 and #2 (Fig. 2). The endotracheal tube is removed by the Surgeon #1 and a standard laryngoscopy and bronchoscopy are performed using an appropriately sized rigid ventilating bronchoscope with a telescope. Upon completion of the bronchoscopy, the bronchoscope is withdrawn to the level of the

Fig. 1 Instruments required for bronchoscopy and bronchoscopic portion of tracheostomy procedure.

Fig. 2

OR setup and bronchoscopy.

second cartilaginous ring. The neck is injected with 1% lidocaine with 1:100,000 epinephrine at the point of maximal illumination from the bronchoscope, which externally depicts the correct location for the tracheostomy (Fig. 3). The infant’s neck is then prepared and draped in standard fashion. A small vertical incision is placed at the site of injection and subcutaneous fat excised

Fig. 3 The bronchoscope is withdrawn to the level of the second tracheal ring and injection is performed at the site of maximal skin illumination.

Bronchoscopy assisted neonatal tracheostomy

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Fig. 4 A vertical incision is made and the subcutaneous fat is debrided to expose the neck musculature. Note the illumination from the bronchoscope.

Fig. 6 A 2-0 FiberWire suture (Arthrex, Naples, FL) is passed through the catheter and is grasped within the tracheal lumen by a forceps passes through the bronchoscope. The catheter is then removed.

with a Colorado tip monopolar cautery to expose the strap muscles and midline (Fig. 4). A 20-gauge angiocath is then inserted into the trachea in the midline at the level of the second cartilaginous ring with bronchoscopic guidance (Fig. 5). The

needle is then withdrawn from the plastic catheter and a 2-0 FiberWire (Arthrex, Naples, FL) is passed through the catheter into the tracheal lumen. The FiberWire is grasped intraluminally and drawn into the bronchoscope by Surgeon #1 using a forceps and secured outside the bronchoscope (Fig. 6). The catheter is removed. With the FiberWire secured in place, the trachea is gently elevated in the wound and dissection is carried down to the anterior tracheal wall with electrocautery using the wire as a guide (Fig. 7). Once the anterior tracheal wall is reached a #11 blade is used to make a vertical incision in the second tracheal ring. Bilateral stay sutures are placed and an appropriate size tracheostomy tube is inserted under direct and

Fig. 5 A 20-gauge angiocath is placed into the midline trachea under bronchoscopic visualization to ensure correct placement.

Fig. 7 The suture can now be used to elevate the trachea and provides a guide for dissection directly to the second tracheal ring. Once the trachea is reached a standard vertical tracheotomy is performed.

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Fig. 8 Stay sutures are placed and a tracheostomy tube is inserted under bronchoscopic and direct visualization. Tracheal positioning is assured in this fashion.

bronchoscopic visualization (Fig. 8). The bronchoscope is withdrawn completely and the tracheostomy tube is sutured into place.

3. Discussion The senior author (KDP) has recently published large series of neonatal tracheostomies using a well accepted technique [1,3]. The departmental transition to the BANT procedure has heralded several advantages over traditional methods. First, the BANT offers economy of procedure and accurate identification of the anterior tracheal wall in the midline without the need for frequent palpation. Second, the laryngoscopy and bronchoscopy are incorporated into the procedure rather than disassociated and separated into a pre-tracheostomy step. The ventilating bronchoscope stabilizes the trachea in the midline, provides rigidity to the structure and counterpressure for angiocath placement and dissection. Placement of the suture into the trachea under direct visualization ensures appropriate location and therefore allows for rapid dissection along its length. A FiberWire suture (Arthrex, Naples, FL) was selected because of its rigidity as well as durability in that it does not break if contacted by the electrocautery. The smallest bronchoscope that can be effectively utilized for this procedure is a 3.0 as it is difficult to pass both the telescope and forceps through one with a smaller diameter. This size constraint also limited our use of the BANT procedure to patients who require a tracheostomy for the indication of prolonged ventilatory support since there would be a mechanical

K.D. Pereira, Y.E. Weinstock barrier to passing a rigid bronchoscope in patients with narrowing of the tracheal lumen such as in subglottic stenosis. The patient characteristics and surgical morbidity of our population has already been published and a slightly lower complication rate was noted at our institution [1,3]. Our early experience with the BANT procedure shows no change in the type or incidence of postoperative complications. Strict midline dissection should reduce the risk of subcutaneous emphysema and theoretically the risk of infection. In addition, anesthesiologists and OR personnel are able to view the entire procedure and do not need to confirm correct placement of the tracheostomy tube. There was a sharp learning curve for this procedure with the initial time frame for the entire procedure being in the range of 50 min for our first case. However, that rapidly decreased to about 15 min of total operative time, including bronchoscopy, by the 10th one. This is likely due to the OR team’s increasing familiarity with the instrumentation and set up for the procedure. The only recognized disadvantage of this procedure is that it requires two surgeons. At teaching institutions like ours this is unlikely to be an issue with resident physicians actively participating in the operation. Alternatively, having the anesthesiologist assist with the bronchoscope during the tracheostomy step can free the primary surgeon to perform the surgery with an assistant obviating the need for a second surgeon.

4. Conclusion The bronchoscopic assisted neonatal tracheostomy (BANT) procedure is a novel way of performing neonatal tracheostomy efficiently and safely. This procedure incorporates a full evaluation of the larynx and tracheobronchial tree while providing a rapid means of intraoperative tracheal exposure as well as ensures correct placement of the tracheostomy tube.

References [1] K.D. Pereira, A.R. MacGregor, R.B. Mitchell, Complications of neonatal tracheostomy: a 5-year review, Otolaryngol. Head Neck Surg. 131 (2004) 810—813. [2] S.K. Dankle, D.E. Schuller, R.E. McClead, Prolonged intubation in neonates, Arch. Otolaryngol. Head Neck Surg. 113 (1987) 841—843. [3] K.D. Pereira, A.R. MacGregor, C.M. McDuffie, R.B. Mitchell, Tracheostomy in preterm infants: current trends, Arch. Otolaryngol. Head Neck Surg. 129 (2003) 1268—1271.

Bronchoscopy assisted neonatal tracheostomy [4] M.A. Kenna, J.S. Reilly, S.E. Stool, Tracheotomy in the preterm infant, Ann. Otol. Rhinol. Laryngol. 96 (1987) 68—71. [5] I. Ratner, J. Whitfield, Acquired subglottic stenosis inthe very-low-birth-weight infant, AJDC 137 (1983) 40— 43.

215 [6] D.L. Walner, M.S. Loewen, R.E. Kimura, Neonatal subglottic stenosis: incidence and trends, Laryngoscope 111 (2001) 48—51. [7] J.D. Carron, C.S. Derkay, G.L. Strope, J.E. Nosonchuk, D.H. Darrow, Pediatric tracheostomies: changing indications and outcomes, Laryngoscope 110 (2000) 1099—1104.

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