Ultrasound-guided, videolaryngoscopy-assisted percutaneous tracheostomy in a high-altitude patient. Case report

Vollständiger Abstract

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Introduction: Percutaneous dilation tracheostomy has largely replaced surgical tracheostomy in most intensive care units. Bronchoscopy remains the standard guidance method, although it partially obstructs the tube lumen, increases carbon dioxide levels, and requires equipment that is not always available. At high altitudes, where arterial oxygen levels are already reduced, these disadvantages are even more significant. Case report: An 82-year-old male patient, a permanent resident at 3650 meters above sea level, was admitted to the intensive care unit for a right hemisphere ischemic stroke, hemodynamic and ventilatory instability, atrial flutter, bilateral pleural effusion, and hospital-acquired pneumonia. After 16 days of invasive ventilation, a bedside tracheostomy was planned. A 5-10 MHz linear transducer identified the thyroid and cricoid cartilages, the tracheal rings, the pretracheal tissue, and the absence of vessels along the planned tracheostomy path. The videolaryngoscope allowed for the withdrawal of the endotracheal tube under direct vision until the cuff was positioned immediately below the vocal cords. The cannula was inserted using a modified Seldinger technique, with oxygenation goals appropriate for high altitude. Discussion: Ultrasound and videolaryngoscopy address different problems: the former defines the extraluminal anatomy of the anterior neck, while the latter monitors the endolaryngeal position of the tube and its cuff. Their combination reproduces much of the information provided by bronchoscopy without inserting an instrument into the tube lumen, a significant advantage in a patient whose baseline arterial oxygen pressure is approximately 56 mmHg. Conclusions: Ultrasound-guided, videolaryngoscopy-assisted percutaneous tracheostomy by dilation proved feasible at the bedside of a neurocritically ill patient residing at 3650 meters above sea level, without immediate complications and respecting the oxygenation goals specific to high altitude.