From sedative: hypotension, bradycardia (propofol).
Procedure
Laryngospasm or bronchospasm.
Hypoxemia.
Fever.
Hemoptysis.
Management of complications
| Complication | Treatment |
| Hypotension | Fluids, vasopressors |
| Laryngospasm | Lidocaine (topical) |
| Bronchospasm | Bronchodilators |
| Hypoxemia | If patient is not on 100% O2 increase O2 If on 100% O2, remove bronchoscope until saturation increases |
| Hemoptysis | Usually minimal but for moderate hemoptysis use local epinephrine, tamponade, intubation of the non‐bleeding lung |
| Fever | May occur for 24 hours post‐procedure; treatment is rarely needed but antipyretics can be given |
Follow‐up
A CXR is generally not required after airway clearance, visualization, and lavage, but is often done to assess the efficacy of treatment for atelectasis.
Reading list
1 Foster WM, Hurewitz AN. Aerosolized lidocaine reduces dose of topical anesthetic for bronchoscopy. Am Rev Respir Dis 1992; 146(2):520–2.
2 Gonlugur U, et al. Major anatomical variations of the tracheobronchial tree: bronchoscopic observation. Anat Sci Int 2005; 80:111–15.
3 Jin F, MU D, Chu D, et al. Severe complications of bronchoscopy. Respiration 2008; 76:429.
4 Jose R, Shaefi S, Navani N. Sedation for flexible bronchoscopy: current and emerging evidence. Eur Respir Rev 2013; 22(128):106–16.
5 Langmack EL, Martin RJ, Pak J, Kraft M. Serum lidocaine concentrations in asthmatics undergoing research bronchoscopy. Chest 2000; 117(4):1055–60.
Images
Figure 5.1 Simplified diagram of the bronchial tree (not drawn to scale), which is easily visualized by the bronchoscopist standing at the head of the bed, behind the patient. T, trachea; MC, main carina. Right bronchus: RMB, right mainstem bronchus; RBI, right bronchus intermedius; RSC, right secondary carina; RUL, right upper lobe: AN, anterior; AP, apical; P, posterior; RML, right middle lobe: L, lateral; M, medial; RLL, right lower lobe: AB, anterior basal; LB, lateral basal; MB, medial basal; PB, posterior basal. Left bronchus: LMB, left mainstem bronchus; LSC, left secondary carina; LUL, left upper lobe: AN, anterior; AP, apico‐posterior; IL, inferior lingula; SL, superior lingual; LLL, left lower lobe: AB, anterior basal; LB, lateral basal; MB, medial basal.
Figure 5.2 Right upper lobe.
Additional material for this chapter can be found online at:
www.wiley.com/go/mayer/mountsinai/criticalcare
This includes multiple choice questions and Videos 5.1, 5.2 and 5.3. The following image is available in color: Figure 5.2.
CHAPTER 6 Bedside Percutaneous Dilational Tracheostomy
George Coritsidis1 and Viren Kaul2
1 Icahn School of Medicine at Mount Sinai, New York, NY, USA
2 Crouse Health, Syracuse, NY, USA
OVERALL BOTTOM LINE
The bedside percutaneous dilational tracheostomy (PDT) with a minimal tracheostomy incision utilizes the Seldinger technique and gradual dilation to insert the tracheostomy.
PDT is a safe procedure in the critical care setting and should be first choice when available. Its use is more cost‐effective and trends towards fewer complications compared with open surgical tracheostomy.
Proper selection of the bedside candidate requires a hemodynamically stable patient with no bleeding diatheses and normal neck anatomy.
PDT is associated with less bleeding than open tracheostomy. Patients on anticoagulation or with severe derangements of INR or platelet count may either be supplemented with the appropriate blood products or deferred until stable for the procedure.
Bronchoscopic guidance is often used during bedside tracheostomy procedures, but is not routinely required since it has not demonstrated better outcomes. Those not routinely using a bronchoscope may reserve its use for difficult cases.
Background
Surgical tracheostomy has been performed since 1909.
Percutaneous tracheostomy using the Seldinger technique allows tracheostomy placement at the bedside in the ICU.
Tracheostomy benefits (Table 6.1)
Tracheostomy is considered for the patient who is expected to require a prolonged course of mechanical ventilation or requires an artificial airway for obstruction or secretion clearance.
For patients requiring mechanical ventilation for more than 2 weeks, it is believed that tracheostomy may be beneficial in avoiding continued injury
