We performed a tracheotomy with suturing of the distal stump of Selleck ZD6474 the trachea diastase to the skin and suturing of the previous tracheotomy breach. During surgery, a careful dissection of the trachea was conducted in its distal portion and the anonymous artery was protected by a muscle flap. At the end of surgical treatment, mechanical ventilation through a tracheal cannula was hindered
by the reduced length of the residual trachea below the tracheotomy (about 2 cm from the tracheal carina). Any cannula or endotracheal tube could not be secured to the trachea using the cuff. The need to guarantee mechanical ventilation to the patient led to the implementation of a cuff securing system in the two main bronchi. Therefore, we selectively intubated the main bronchi under bronchoscopy guidance using two tubes (Portex Tracheal Tube, ID
5.5 mm; OD 7.4 mm), then inflating the cuffs at both main BAY 73-4506 price stem bronchi inlets (Fig. 2). A Y-shaped bridge was then added for ventilator connection to allow the same ventilation mode for both bronchial systems. Thus, we achieved an adequate minute volume to the patient, allowing us to correct the blood gas levels. During mechanical ventilation, no significant leaks were reported and ventilatory parameters remained stable. Four days later, a bronchoscopic examination showed no evidence of alterations on both main bronchi. The patient died forty days after surgery of sepsis. Currently, tracheotomy is largely performed on patients presenting with acute respiratory failure requiring prolonged mechanical ventilation so as to facilitate weaning, reduce the effort of breathing and curb complications
due to prolonged intubation.1 Although the optimum timing of tracheotomy in critically ill patients with acute respiratory failure still remains controversial, the current trend is to anticipate the procedure within the first week of mechanical FER ventilation. The results of a Cochrane meta-analysis performed on five clinical trials showed a significant reduction of days on mechanical ventilation and of hospitalization in ICU wards with early rather than late tracheotomy,2 while no significant difference was reported in mortality or risk of occurrence of hospital-acquired pneumonia. Complications of tracheotomy can be acute, related to or subsequent to the surgical procedure (haemorrhage, pneumothorax, infections, incidental decannulation), or late stage.3 The most frequent late complication is the formation of granulation tissue, with subsequent tracheal stenosis, which can remain asymptomatic for a long time, but which, in some cases, can lead to severe respiratory failure.4 Other types of late complication are rare but life-threatening events, such as tracheoesophageal fistula and tracheo-innominate artery fistula.5 Therefore, the presence of a cuff with a higher critical pressure may cause ischemia and tracheal mucosal necrosis.