The balloon dilation system (d) is a modified nylon-made angioplasty balloon 5.4 cm long, with an external diameter of 16 mm, when totally inflated (it is designed to reach a maximum pressure of 11 atm), mounted at the tip of a small dilator over which, before the beginning of the operation, a tracheal cannula (f) is loaded (it is important a good lubrification of the internal and external walls of the tracheal cannula). The pneumatic balloon has two channels, one, in the middle, for the guide wire, and the other to be connected with the balloon inflation device (e). Before the procedure, the balloon inflation device (e) has to be filled with about 20 ml of saline solution and connected to the pneumatic balloon trough the dedicated channel with a lower-lock connection.
To avoid injuries to superficial structures, neck ultrasound can be performed to identify aberrant blood vessels and the anatomy of thyroid gland and to estimate the distance from the skin to the trachea [10].
The procedure should follow the following steps:
1.
After disinfection of the skin and identification of tracheal rings below cricothyroid membrane, under bronchoscopic vision, the operator penetrates with the introducer needle (a) and reaches the trachea, through, preferably, the second tracheal space.
2.
A guide wire (b) is inserted through the introducer needle, and its position in trachea broncosopically controlled.
3.
A little transverse incision of the skin and a preliminary dilation with a 14 Fr dilator (c) are performed.
4.
The balloon dilation system with behind the loaded tracheal cannula (d + f) glides over the guide wire (b), across the different structures to be positioned in trachea. Approximately half balloon is inserted in trachea over the guide wire to reach the correct position to be inflated (a black marker line is visualised through bronchoscopy at the level of the internal anterior wall of trachea).
5.
When correctly positioned, the pneumatic balloon is inflated with the saline solution, loaded in the inflation device (e), by screwing the piston of the inflation device to reach and maintain a pressure not greater than 11 atm for 25–30 s. This manoeuvre will also make a compressive mechanical haemostasis of the small cutaneous and subcutaneous bleeding.
6.
After the dilation, the pneumatic balloon is quickly deflated and the preloaded tracheal cannula inserted in the trachea through the hole created by the dilation of the balloon (the tracheal stoma).
7.
After the insertion of tracheal cannula, balloon dilation system and guide wire are gently removed through the tracheal cannula.
8.
It is strongly recommended to check the correct position of the cannula through direct bronchoscopic vision.
During the procedure, one sign of a successful dilation is the loss of strength of the tissues that can be visible at the pressure gauge of the inflation device as a slight decrease in pressure. In this case, it must be compensated with an additional increase of pressure by screwing the piston of the inflation device. Usually, in old patients this loss of strength is well rendered. In young patients with stronger tissue, the dilation procedure may require few seconds more.
6.4 Balloon Dilation Tracheostomy in Literature
BDT is a relatively recent technique, and there is not a large body of study on it. Feasibility and efficacy have been shown, but, despite theoretical hypothesis, a real superiority compared to the most used and widespread SSDT is far to be demonstrated.
Preliminary report appeared in 2005, with the experimental study of Zogda and Berger on seven pigs [11]. In this work, the authors showed that percutaneous dilation by a balloon was feasible and safe; no tracheal damage on posterior wall was found on post-procedure dissection; no visible bleeding observed. Median time of execution was 5.5 min from tracheal puncture.
An initial documented clinical experience was published in 2009, with the work of Gromann in a cardiosurgical ICU [12]. Tracheostomy was made in 20 patients, always under bronchoscopic vision. Authors did not observe neither bleeding nor posterior tracheal perforation. There was one fracture of a single tracheal ring and, in one patient, subcutaneous emphysema during the dilation that did not require any treatment. Median time of procedure was around 3 min.
A randomised controlled trial compared BDT with SSDT in a medical and trauma ICU [13]. Thirty-five patients were randomly allocated to have BDT or SSDT. All procedures were made by the same three physicians and always under fiberoptic bronchoscopic vision. They found SSDT significantly faster than BDT (1.5 min vs. 4 min). Unexpectedly, bronchoscopic vision after 6 h from procedure revealed unapparent bleeding in 24 patients in BDT group (68.6 %) and in 12 patients of SSDT group (34.3 %) that did not require any treatment. Authors reported tracheal ring injury in 2 patients of SSDT group and in 3 patients of BDT group. Tracheal buckling affected 1 patient in SSDT group and 3 patients in BDT. No patient experienced major complication (pneumothorax, posterior tracheal wall perforation, tracheal tube misplacement). Difficulty in tracheal tube insertion was more frequent in BDT group (ten patients) than SSDT (three patients). However, BDT is more recent, and intensivists were less experienced with this technique. They argued also that the outward radial force of pneumatic dilation is not enough to facilitate tracheal tube insertion.
Related posts:
Complications of Percutaneous and Surgical Tracheostomy in Critically Ill Patients
Medical and Nursing Management of Tracheostomy
Tracheostomy: From Surgical to Percutaneous Techniques
Percutaneous Tracheostomy: The Ciaglia Techniques
Airway Management During Tracheostomy
Percutaneous Tracheostomy: The Guide Wire Dilating Forceps Technique
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