Ultrasound use in percutaneous dilatational tracheostomy

Dear Sir/Madam,

I read with interest the article ‘Venous air embolism during percutaneous dilatational tracheostomy: a case report’ (Nov 2018). This article highlights an important potential complication of percutaneous dilatational tracheostomy (PDT), particularly in patients undergoing renal replacement therapy during the procedure. However, I was concerned with their concluding statement asserting that this case has not led to a change in local practice. The authors do not currently use periprocedural ultrasound and they state they ‘do not believe [ultrasound] would have altered the outcome in this case as no major vessel was injured and there was evidence of no … bleeding’.

It is clear from the case that a pre-tracheal vein was damaged enough to allow aspiration of air into the venous system. Pre-tracheal vessels are very common in the general population, with 41% having a vessel overlying potential PDT insertion sites. ¹ The use of real-time ultrasound guidance can help to identify these vessels to avoid insertion sites where they are present. This can then reduce procedural bleeding risk, need for surgical intervention for haemostasis and the risk of venous air embolism. It can also help to identify patients with high-risk vascular anatomy in whom it may be more appropriate that a surgical tracheostomy be sited instead. A randomised controlled trial has demonstrated reduced bleeding with the use of ultrasound guidance. ²

I believe there is a role for real-time ultrasound in guiding PDT and would encourage others to employ this technique with a view to reducing procedural complications such as bleeding and air embolism.