Direct Percutaneous Tracheostomy from NIV in ICU Patients with Respiratory Failure - A Case Series

Nationally thousands of patients every year require endotracheal intubation after failure of non-invasive ventilation for a multitude of pathologies. These pathologies include but are not limited to chest infections, exacerbations of known lung disease, pancreatitis, neuromuscular diseases and acute respiratory distress syndrome (ARDS). Some of these patients may also be severely haemodynamically unstable and therefore intubation may be associated with a high risk of cardiovascular collapse despite the clinician’s best intentions. Patients that will require mechanical ventilation for a prolonged period or be slow to wean off mechanical ventilation can often be accurately predictable. We identified three patients and performed a percutaneous tracheostomy directly from NIV whilst bypassing endotracheal intubation. All 3 of these patients were severely haemodynamically unstable to the extent it was felt that all 3 may completely cardiovascular collapse in the induction or sedative period. However all 3 required invasive ventilation. The procedure was performed under ultrasound guidance, with local anaesthetic infiltration and under light sedation. We describe all three of these patients. The procedure was well tolerated in all 3 cases. Airway care and tracheal suctioning could start immediately after the procedure. As these patients never had to be sedated and ventilated for a prolonged period, no deconditioning occurred. A change to their pre-tracheostomy ventilator settings was not always necessary and weaning could begin promptly. By avoiding the typical 7-10 day period of intubation and deconditioning, it is approximated ITU stay could be cut by up to 7 days. This can have a significant economic impact in both ITU bed days as well as physical capacity. We devised a safety checklist to maintain safety during the procedure, advocating the use of ultrasound whilst remaining aware at all times of the potential urgent need for airway protection.