Percutaneous dilatational tracheostomy versus conventional surgical tracheostomy

Background : As no clinical randomised studies have previously been performed comparing complications with the Ciaglia Percutaneous Dilatational Tracheostomy Introducer Set (PDT) and conventional surgical tracheostomy (TR), we designed a study with the aim of comparing the efficacy and safety of the two techniques.
Methods : Sixty patients selected for elective tracheostomy were randomised for either PDT (30 patients) or TR (30 patients). All patients had general anaesthesia and were ventilated with 100% oxygen. Furthermore, lidocaine with epinephrine 1% (3–5 ml) was used for local analgesia and to minimise bleeding during the procedure.
Results : The median time for insertion of the tracheostomy tube was 11.5 min (range 7–24 min) in the PDT group and 15 min (range 5–47 min) in the TR group ( P <0.01). Complications during the procedure were cuff puncture of the endotracheal tube in 5 cases in the PDT group. Minor bleeding was encountered in 6 cases in the PDT group as opposed to 24 cases in the TR group ( P <0.01), major bleeding in none versus 2 cases, respectively. In 8 cases in the PDT group, increased resistance to insertion of the tracheostomy tube was met by further dilatation. During the post-tracheostomy period, complications occurred with minor bleeding in 2 cases in the PDT group as opposed to 9 cases in the TR group ( P <0.05), and major bleeding was encountered in 1 case in each group. Minor infections were encountered in 3 cases in the PDT group as opposed to 11 cases in the TR group ( P <0.01). Major infection was encountered in none versus 8 cases, respectively ( P <0.01).
Conclusion : Our results indicate that the percutaneous dilatational tracheostomy technique performed with the Ciaglia Introducer Set is effective, safe and superior to conventional surgical tracheostomy as immediate complications as well as complications with the tracheostomy tube in situ are fewer and of less severity.     

Evaluation of a new percutaneous dilatational tracheostomy set apparatus

Percutaneous tracheostomy is a well established technique used primarily to assist weaning from mechanical ventilation on many intensive care units. We report our experiences of a total of 36 procedures performed with the new Blue Rhino Percutaneous Tracheostomy Introducer Set developed by Ciaglia. The technique was successful in all cases and was simpler and quicker to perform than with the earlier Ciaglia percutaneous tracheostomy set. Difficulties were encountered when using Shiley tracheostomy tubes. Significant complications included one posterior wall tear and one tracheal cartilage ring fracture.     

Percutaneous tracheostomy with the Blue Rhino trade mark technique: presentation of 100 consecutive patients

We assessed the peri-operative, early and late complications in 100 percutaneous tracheostomies performed with the Blue Rhino trade mark kit. The success rate was 98%. Peri-operative complications occurred in 30 patients. Six major complications occurred; these included bleeding which required surgical exploration (n = 3), and pneumothoraces (n = 2) and one false passage. Cannula insertion was made easier by blunt dissection of the cervical tissues anterior to the trachea. The median duration of the procedure was 8.5 min, which is significantly longer than other authors' results. Only one major complication occurred while the patient was cannulated (serious bleeding requiring exploration). Finally, in a single patient a tracheal stenosis occurred as a major late complication which eventually was treated by a successful tracheal resection. Percutaneous tracheostomy with the Blue Rhino trade mark kit is safe with a low incidence of major complications.     

Percutaneous tracheostomy by forceps dilation: report of 162 cases

A prospective, observational clinical study evaluated the safety of percutaneous single-step dilatational tracheostomy over a 43-month period. One hundred and sixty-two patients were deemed suitable for the procedure. The mean duration of tracheal intubation prior to tracheostomy was 6 days. The mean duration of the procedure was 9.3 min. Intra-operative complications occurred in 27 patients (16.6%), most of which were minor technical difficulties without morbidity. Postoperative complications, some of which were associated with morbidity, occurred in 16 patients. There were two deaths secondary to premature decannulation, one case of severe bleeding and five pneumothoraces. Long-term complications were assessed in 81 patients; there were four tracheal stenoses requiring surgery or laser therapy and seven patients with granulation tissue at the stoma site which did not require treatment. Forceps dilatational percutaneous tracheostomy appeared to be a convenient bedside procedure. However, complications do occur and further studies should address late sequellae, such as tracheal stenosis.     

Complications of percutaneous dilatational tracheostomy in children

Experience with percutaneous dilatational tracheostomy in children is limited. This report discusses two significant complications which occurred following the use of this technique     

纤支镜导引下经皮扩张气管造口术的临床研究

目的 探讨纤支镜导引下经皮扩张气管造口术相对于常规经皮扩张气管造口术（PDT）的优点。方法 60例患者随机分为两组，即纤支镜导引组（A组，n=28），常规组（B组，n=32）。记录两组的手术时间，近期远期并发症例数，作统计分析。结果 A组有更大的成功率，更少的近期和远期并发症，手术时间并没有延长。结论 纤支镜导引下经皮扩张气管造口术相对于常规经皮扩张气管造口术有更高的安全性与实用性。     

Percutaneous dilatational tracheostomy for ICU patients with severe brain injury

Objective： To sum up our experience in percutaneous dilatational tracheostomy （PDT） in ICU patient with severe brain injury. Methods： Between November 2011 and April 2014, PDTs were performed on 32 severe brain injury patients in ICU by a team of physicians and intensivists. The success rate, efficacy, safety, and complications including stomal infection and bleeding, paratracheal insertion, pneumothorax, pneumomediastinum, tracheal laceration, as well as clinically significant tracheal stenosis were carefully monitored and recorded respectively. Results： The operations took 4-15 minutes （mean 9.1 minutes±4.2 minutes）. Totally 4 cases suffered from complications in the operations： 3 cases of stomal bleeding, and 1 case of intratracheal bloody secretion, but none required intervention. Paratracheal insertion,pneumothorax, pneumomediastinum, tracheal laceration, or clinically significant tracheal stenosis were not found in PDT patients. There was no procedure-related death occurring during or after PDT. Conclusion： Our study demonstrats that PDT is a safe, highly effective, and minimally invasive procedure. The appropriate sedation and airway management perioperatively help to reduce complication rates. PDT should be performed or supervised by a team of physicians with extensive experience in this procedure, and also an intensivist with experience in difficult airway management.     

Repeat percutaneous dilatational tracheostomy in an awake and unintubated patient

Bedside percutaneous dilatational tracheostomy (PDT) has become an accepted method for securing airways in patients requiring prolonged ventilatory support. Repeat PDT in patients who have had a tracheostomy earlier is considered a relative contraindication as a result of distorted anatomy. Three case series have been reported supporting the safety of repeat bedside PDT in experienced hands, but there is no previously published data regarding repeat PDT in awake and unintubated patients. We report a case in which a repeat PDT was done on an awake 20-year-old female patient with cerebral palsy and kyphoscoliosis admitted owing to pneumonia and respiratory failure. This facilitated tracheal toilet in this patient without resorting to general anaesthesia and mechanical ventilation. In conclusion, both repeat PDT and awake PDT, both separately or together, can be very useful in the management of critical care and pre-critical care patients and merit wider use.     

Use of the Combitube for airway maintenance during percutaneous dilatational tracheostomy

The Combitube airway allows short-term ventilation during cardiopulmonary resuscitation and can be useful in the management of the difficult airway. In a prospective observational study we assessed its use during percutaneous dilatational tracheostomy (PDT). Twenty-one intensive care patients scheduled for elective PDT had their tracheal tube replaced by a Combitube airway retaining the same ventilator settings. Arterial blood gases, airway pressures, SpO₂ and end-tidal CO₂ were measured as were the transmural pressures exerted by the Combitube cuffs. Combitube placement was successful in 20 of 21 patients although adequate ventilation was possible in only 17 (85%). There was no significant change in P a O ₂, S p O ₂, end-tidal CO₂, P a CO ₂ or mean airway pressure during Combitube ventilation. A high mean (SD) transmural pressure of 14.7 (5) kPa was exerted by the distal cuff. The Combitube provided a satisfactory alternative airway to the tracheal tube during performance of PDT in 85% of our patients. Potential problems associated with its use in intensive care patients are outlined.     

Percutaneous dilatational tracheostomy in a patient with thyroid cancer and severe airway obstruction

A patient with extensive metastatic thyroid cancer scheduled for palliative tracheostomy is presented. He had laryngeal dislocation with severe airway obstruction and few anatomical landmarks due to tumour infiltration and radiation. Successful percutaneous dilatational tracheostomy was performed under local anaesthesia.     

Percutaneous dilatational tracheostomy

BACKGROUND: The aim of this study was to investigate the rate, timing, the incidence of complications of percutaneous dilatational tracheostomy (PDT) and its effects by on nosocomial pneumonia. METHODS: The study is a retrospective analysis of 104 patients (56 males, 48 females) > or = 18 years (54 +/- 19) who had undergone a PDT for respiratory failure during the five years 1998-2003. RESULTS: Among 238 patients requiring mechanical ventilation > or = 48 hours, 104 (43.7%) required PDT. PDT was performed after 4.3 +/- 2.3 days of ventilation and the disconnection from mechanical ventilation was 13.6 +/- 8.5 days. Lower airway tract infection was detected in 88 patients: 55 patients (62.5%) before PDT and in 33 patients (37.5%) after PDT. The nosocomial pneumonia was observed after 5.9 +/- 1.67 days of ventilation. CONCLUSIONS: Our results suggest that PDT was performed relatively early, with an acceptable complication rate and that our post-PDT nosocomial pneumonia incidence is low.     

气管插管状态下纤维支气管镜导引经皮扩张气管造口术的临床研究

目的探讨气管插管病人用纤支镜导引下经皮扩张气管造口术相对于常规经皮扩张气管造口术（PDT）的优点。方法ICU60例气管插管患者随机分为两组,即纤支镜导引组（A组,n=32）,常规组（B组,n=28）。记录两组的手术时间,并发症例数,作统计分析。结果A组有更大的成功率,更少的并发症,手术时间并没有延长。结论气管插管病人以纤支镜导引行经皮扩张气管造口术相对于常规经皮扩张气管造口术有更高的安全性与实用性。     

Percutaneous dilational and surgical tracheostomy in burn patients: Incidence of complications and dysphagia

The aim of this study is to evaluate the incidence of complications and dysphagia in relation to the timing of tracheostomy and tracheostomy technique in 49 consecutive adult burn patients. We analysed prospectively collected data. Bronchoscopy was used to diagnose tracheal stenosis and a modified Evans blue dye test was used to diagnose dysphagia. Eighteen patients received a percutaneous dilatational tracheostomy (PDT) and thirty-one patients received an open surgical tracheostomy (OST). Eight patients developed significant complications (16%) following tracheostomy, there is no difference in the incidence of complications; post op infection, stoma infection or tracheal stenosis between PDT and OST groups. Patients with full thickness neck burn who developed complications had a tracheostomy significantly earlier following autografting (p = 0.05). Failed extubation is associated with dysphagia (p = 0.02) whereas prolonged intubation and ventilation prior to tracheostomy independently predicts dysphagia (p = 0.03).     

Ultrasonographically guided percutaneous dilatational tracheostomy after anterior cervical spine fixation

Patients with anterior cervical spine fixation (ACSF) after acute spinal cord injury often require tracheostomy for prolonged ventilatory support and upper respiratory tract clearance. The authors report two patients with ACSF who underwent a successful ultrasonographically guided percutaneous tracheostomy with dilatation forceps technique. Possible advantages of the ultrasonographically guided method with dilatation forceps in patients with ACSF are discussed.     

Percutaneous dilatational tracheostomy is as safe as open tracheostomy

Although percutaneous dilatational tracheostomy (PDT) has been advocated as an alternative to open tracheostomy (OT) its relative safety has been questioned repeatedly. This study prospectively compared the safety and complications of PDT and OT. Ninety-four patients underwent PDT and 252 patients underwent OT at this institution from December 1998 through April 2000 with the choice of procedure left to the operator. OT was performed in the operating room whereas PDT was performed in intensive care units (ICUs). PDT was performed by surgeons and medical intensivists under a strict institutional policy and procedure governing patient selection and conduct of the procedure. Complications were defined as bleeding, loss of airway, hypotension, hypoxia, tracheostomy tube malposition, subcutaneous emphysema, infection, and conversion of PDT to OT. All patients survived the operation. PDT and OT had similar complication rates: 2.1 per cent for PDT versus 2.8 per cent for OT (P = not significant). Postoperative bleeding, which was the most frequent complication, occurred in one PDT patient and four OT patients. One PDT patient required conversion to OT as a result of extensive tracheal fibrosis. Subcutaneous emphysema, soft-tissue infection, and a malpositioned tracheostomy tube were the remaining complications in the OT patients. We conclude that the complication rates of PDT and OT are comparable. The choice of PDT or OT should be dictated by the surgeon's training and experience, the patient's condition, neck anatomy, and stability for transfer to the operating room.     

Acute fatal haemorrhage during percutaneous dilatational tracheostomy

Percutaneous dilatational tracheostomy (PDT) is associated witha number of life-threatening complications. We present a caseof massive and fatal arterial haemorrhage that occurred in theintensive care unit during an elective PDT on an 86-year-oldwoman following earlier evacuation of a traumatic subdural haematoma.An avulsed right subclavian artery was found at post mortem.Previous thyroid surgery and aberrant arterial anatomy contributedto the fatal outcome. Br J Anaesth 2003; 90: 517–20     

Percutaneous tracheostomy: a guide wire complication

We report an unusual complication of percutaneous dilatationaltracheostomy, in which the guide wire became lodged in the bronchialtree. The assistance of an expert bronchoscopist resulted insuccessful removal of a fractured J wire with no adverse sequelaefor the patient. A subsequent incident has given insight intothe mechanism of damage to the guide wire. Br J Anaesth 2004; 92: 891–3