Percutaneous Tracheostomy : Prospective Evaluation of a Modification of the Current Technique in 100 Patients

Percutaneous dilatational tracheostomy (PDT) is being increasingly used. Concerns have been raised as to its safety, especially when it is done at the bedside. A prospective evaluation was conducted of 100 consecutive, unselected critically ill patients with PDT. The mean intensive care unit (ICU) stay before PDT was 12 days. One surgeon performed PDT alone (5 cases) or assisted residents (95 cases) in all operations; 84 were performed at the ICU bedside. Only the first six patients were taken to the operating room solely for tracheostomy. A modified technique was used: (1) the endotracheal tube was left in place during sequential dilations; (2) dilators were inserted in a 60-degree cephalad orientation to the skin and directed caudally after penetration of the anterior tracheal wall; (3) a digit was inserted through the tracheal opening to guide withdrawal of the endotracheal tube to the level of the vocal cords; and (4) size 8 tracheostomy cannulas were inserted over 28F dilators. The average time from skin incision to insertion of the tracheostomy tube was 12 minutes (< 10 minutes, 41 patients; 10 to 15 minutes, 37 patients; > 15 minutes, 22 patients). Sixty-five percent had unfavorable anatomic conditions due to spinal precautions or diffuse neck edema. Postoperative complications occurred in four patients; surgical emphysema after tracheal lacerations in three, cannula dislodgment in one. All complications were successfully managed without an operation by tube exchange (n 5 3) or observation (n 5 1); there was no procedure-related mortality. Forty patients were available for long-term follow-up (6–18 months after tracheostomy) by telephone; one had persistent hoarseness without respiratory difficulty. We concluded that bedside PDT is safe and easy to teach when performed with a technique that ensures correct instrumentation. Percutaneous dilational tracheostomy (PDT) has evolved into a well recognized technique for managing the airway of critically ill patients. Since its first description by Ciaglia et al. in 1985 [1], the technique has been repeatedly modified to improve its safety [2–5]. Its use at the intensive care unit (ICU) bedside is appealing [6–8]. Performing tracheostomies on critically ill patients in the operating room (OR) usually requires extensive mobilization of multiple health care professionals, and complications related to poor monitoring during transportation, dislodging of wires and tubes, and movement of patients from bed to bed are not uncommon [9, 10]. Cost and OR occupation are of concern [10, 11]. The procedure is frequently postponed because of its low priority on busy surgical lists. OR unavailability leads to unnecessary delays associated with prolonged orotracheal intubation and its possible complications [12]. Bedside ICU tracheostomy has been shown to be safe [9–11]. Although hazards associated with transportation are avoided, it requires extensive preparation and the involvement of multiple persons, including at least two surgical operators. The commitment to an open procedure in an environment other than the OR is always hazardous owing to inadequate illumination, instrument supply, or ICU personnel unfamiliar with surgical techniques. Converting an ICU room to a mini-OR by using multiple instruments, specialized personnel, and relevant apparatus obviates the reason for performing the procedure in the ICU. The PDT technique offers an ideal alternative for ICU-performed tracheostomy. The technique is simple and does not require sophisticated equipment or multiple operators [13–17]. One surgeon can perform it using one of the commercially available PDT kits. Although backup support is desirable, most cases can be done without the hazards of transportation or extensive personnel mobilization. However, before the procedure can be adopted as a reasonable bedside approach to the airway of critically ill patients, safety must be proven beyond any doubt. The procedure must also be easy to teach to gain wide acceptance. At this point, PDT is still under evaluation. The surgical community has not reached consensus as to the need for adopting or further exploring this technique. The increasing number of publications from authors in other specialties [18–23] indicates that the opportunity for surgeons to take the lead in an evolving field may be lost if action is not taken. This study analyzes the experience of one surgeon who taught and supervised all PDTs done by surgical residents in an academic medical center. Important modifications of the technique were made to improve safety. These modifications and their importance are described in detail. Patients and Methods