الفهرس 
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Abstract
T
he oldest recorded surgical procedure on the airway is in the Edwin Smith Papyrus, an ancient Egyptian medical text thought to date around 1600 BCE. It illustrates what is thought to be a tracheotomy to provide an emergency airway. With the evolution of mechanical ventilation, the indications for elective tracheostomy increased to include reduction of anatomical dead space, avoidance of laryngeal injury caused by prolonged intubation, aid in management of tracheobronchial and pulmonary secretions and to facilitate weaning off mechanical ventilation.
Recently, it was found that the length of stay in the ICU and duration of mechanical ventilation was significantly lower with early tracheostomy. However, timing of tracheostomy had no effect on mortality or the development of pneumonia.
Percutaneous tracheostomy has become a safe alternative to conventional surgical tracheostomy being an easier safe bedside procedure with a very low rate of complications. Many assisting tools have been suggested to guide the procedure of percutaneous tracheostomy and decrease the incidence of complications such as bleeding due to vascular injury, hypercapnia and false passage. Fiberoptic flexible bronchoscopy provides the vision required to confirm tracheostomy tube placement and prevent posterior tracheal wall lesions.
Ultrasonography guidance have been recently suggested being a less invasive technique that requires less experience than bronchoscopy with the ability to avoid associated hypercapnia and preventing bleeding via Doppler examination of the neck prior to the procedure.
Percutaneous tracheostomy has become a safe alternative to conventional surgical tracheostomy being an easier safe bedside procedure with a very low rate of complications. Many assisting tools have been suggested to guide the procedure of percutaneous tracheostomy and decrease the incidence of complications such as bleeding due to vascular injury, hypercapnia and false passage. Fiberoptic flexible bronchoscopy provides the vision required to confirm tracheostomy tube placement and prevent posterior tracheal wall lesions.
Ultrasonography guidance have been recently suggested being a less invasive technique that requires less experience than bronchoscopy with the ability to avoid associated hypercapnia and preventing bleeding via Doppler examination of the neck prior to the procedure.
Despite its marvelous advantages, PDT has some limitations. It is absolutely contraindicated in cellulites or anatomic distortion of the neck and in cases of cervical vertebral injury and it is relatively contraindicated if the neck is extremely obese or extremely long and if the age is blew 18 years.
Unfortunately, the PDT has also its own complications as subcutaneous emphysema, penumo-thorax, pneumo-mediastinum, aspiration, posterior tracheal wall lesion and false passage. In order to reduce these complications, numerous adjunct tools were being suggested over the previous years like the ultrasound
Our study is a randomized controlled clinical trial conducted on 40 critically ill patients admitted to the Intensive Care Unit at Ain Shams University Hospitals, from the period from September 2020 until March 2021 they were intubated and mechanically ventilated and required elective percutaneous dilatational tracheotomy.
Our objective was to evaluate ultrasound guided percutaneous tracheostomy and conventional tracheostomy in critically ill patients regarding effect on outcome (weaning from mechanical ventilation and ICU stay), duration of the technique, success rate and to evaluate incidence of perioperative, early and late complications.
In our study, 44 patients were recruited for percutaneous dilatational tracheotomy insertion. They were randomly divided into two groups: 20 patients Undergoes conventional PDT and 20 in guided US group with a mean age of 59.6±13.6 y, and 50.6±17.5y. Male to Female ratio was 1:2 compared to 1:3 respectively (P=0.490).
The procedure was easy and successfully decreased time of insertion (P<0.05) and reduced number of punctures. Insertion time was less in US-guided group 3.9±0.6 min as compared to conventional group 4.8±1.4 min (P<0.012). The puncture site was changed in 5% of US-guided Group, while 40% of conventional required a change of puncture site.
US-guided group showed fewer procedural complications compared to conventional group. We had faced procedural complications in conventional group in form of 2(10%) of patients suffer from hypoxemia, Pneumothorax, decannulation and post. Tracheal wall injury. 3(15%) of patients had transient hypotension and false passage. And 5 (25%) cases of perforation of ETT cuff during insertion, one case (5%) of subcutaneous emphysema and 7 (35%) cases of minor bleeding compered to three cases of minor bleeding in US-guided group, one case of decannulation and three case of transient hypotension.
No early complications were detected in both study groups; except one case of tube obstruction or displacement in conventional group.
According to late complications our analysis illustrates decrease in late complication in US-guided group 2(10%) versus 4(20%) in conventional group.
In US-guided group only two cases of Stoma site infection resolved by antibiotic and local care. In conventional group there were two case of Tracheoesophageal fistula, one case of Stoma site infection and one case of Tracheoinnominate fistula.