Rudas Máté, Seppelt Ian, Herkes Robert, Hislop Robert, Rajbhandari Dorrilyn, Weisbrodt Leonie
Crit Care. 2014 Sep 18;18(5):514. doi: 10.1186/s13054-014-0514-0.
Long-term ventilated intensive care patients frequently require tracheostomy. Although overall risks are low, serious immediate and late complications still arise. Real-time ultrasound guidance has been proposed to decrease complications and improve the accuracy of the tracheal puncture. We aimed to compare the procedural safety and efficacy of real-time ultrasound guidance with the traditional landmark approach during percutaneous dilatational tracheostomy (PDT).
A total of 50 patients undergoing PDT for clinical indications were randomly assigned, after obtaining informed consent, to have the tracheal puncture procedure carried out using either traditional anatomical landmarks or real-time ultrasound guidance. Puncture position was recorded via bronchoscopy. Blinded assessors determined in a standardised fashion the deviation of the puncture off midline and whether appropriate longitudinal position between the first and fourth tracheal rings was achieved. Procedural safety and efficacy data, including complications and number of puncture attempts required, were collected.
In total, 47 data sets were evaluable. Real-time ultrasound guidance resulted in significantly more accurate tracheal puncture. Mean deviation from midline was 15 ± 3° versus 35 ± 5° (P = 0.001). The proportion of appropriate punctures, defined a priori as 0 ± 30° from midline, was significantly higher: 20 (87%) of 23 versus 12 (50%) of 24 (RR = 1.74; 95% CI = 1.13 to 2.67; P = 0.006). First-pass success rate was 20 (87%) of 23 in the ultrasound group and 14 (58%) of 24 in the landmark group (RR = 1.49; 95% CI = 1.03 to 2.17; P = 0.028). The observed decrease in procedural complications was not statistically significant: 5 (22%) of 23 in the ultrasound group versus 9 (37%) of 24 in the landmark group (RR = 0.58; 95% CI = 0.23 to 1.47; P = 0.24).
Ultrasound guidance significantly improved the rate of first-pass puncture and puncture accuracy. Fewer procedural complications were observed; however, this did not reach statistical significance. These results support wider general use of real-time ultrasound guidance as an additional tool to improve PDT.
Australian New Zealand Clinical Trials Registry ID: ACTRN12611000237987 (registered 4 March 2011).
长期接受机械通气的重症监护患者常常需要进行气管切开术。尽管总体风险较低，但仍会出现严重的即刻和晚期并发症。有人提出实时超声引导可减少并发症并提高气管穿刺的准确性。我们旨在比较经皮扩张气管切开术（PDT）期间实时超声引导与传统体表标志法在操作安全性和有效性方面的差异。
共有50例因临床指征需行PDT的患者，在获得知情同意后，随机分为两组，分别采用传统解剖体表标志或实时超声引导进行气管穿刺操作。通过支气管镜记录穿刺位置。由不知情的评估者以标准化方式确定穿刺点偏离中线的程度以及是否在气管第一和第四软骨环之间获得了合适的纵向位置。收集操作安全性和有效性数据，包括并发症和所需穿刺尝试次数。
总共47组数据可进行评估。实时超声引导导致气管穿刺明显更准确。与中线的平均偏差为15±3°，而传统体表标志法为35±5°（P = 0.001）。预先定义为偏离中线0±30°的合适穿刺比例显著更高：超声引导组23例中有20例（87%），而传统体表标志法组24例中有12例（50%）（相对危险度=1.74；95%可信区间=1.13至2.67；P = 0.006）。超声引导组首次穿刺成功率为23例中的20例（87%），传统体表标志法组为24例中的14例（58%）（相对危险度=1.49；95%可信区间=1.03至2.17；P = 0.028）。观察到的操作并发症减少无统计学意义：超声引导组23例中有5例（22%），传统体表标志法组24例中有9例（37%）（相对危险度=0.58；95%可信区间=0.23至1.47；P = 0.24）。
超声引导显著提高了首次穿刺成功率和穿刺准确性。观察到的操作并发症较少；然而，这未达到统计学意义。这些结果支持更广泛地将实时超声引导作为一种辅助工具用于改善PDT。
澳大利亚新西兰临床试验注册中心标识符：ACTRN126110（2011年3月4日注册）。
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