Chapter 105: Percutaneous Tracheostomy

INTRODUCTION

Tracheostomy is defined as creating an artificial airway passage through the neck directly into the trachea. Percutaneous tracheostomy or percutaneous dilatational tracheostomy (PDT) refers to the method of performing tracheostomy using the modified Seldinger (over wire) and dilatational technique. The development of the PDT technique was a natural progression in the era of the rise of minimally invasive approaches. There are, however, notable differences between PDT versus a surgical tracheostomy (ST), in terms of risks and benefits, which will be further discussed in detail. PDT has received wide acceptance by many clinicians, and is now being routinely performed by intensivists, interventional pulmonologists, and surgeons in many countries. It is crucial for those managing patients with tracheostomies to be familiar with PDT in order to provide the best care possible.

HISTORY

Tracheostomy is considered one of the oldest procedures dating back to 3600 BC. The earliest written descriptions are found in Rigveda, a sacred Hindu book, and Babylonian Talmud circa 2000 BC. Percutaneous tracheostomy dates back to 1955, when Sheldon et al used a cutting trocar to place a tracheostomy tube.¹ However, due to the sharp trocar, many deaths occurred. This technique was modified in 1969 when Toye and Weinstein introduced a single tapered dilator with a recessed cutting blade over wire.² It was not until 1985, however, when wide acceptance of the percutaneous approach resulted from Ciaglia’s new technique of serial dilations over wire in 24 patients.³ Following this, other techniques came on the horizon including Rapitrach (1989), Griggs (1990), Fantoni, and PercuTwist, which will be discussed further below. Ciaglia’s original multidilator method also underwent further refinement leading the Ciaglia Blue Rhino one step dilation technique in 1999, which is undoubtedly considered the most popular approach at this time.⁴

INDICATIONS AND CONTRAINDICATIONS

Indications for PDT are the same as the indications for tracheostomy; however, patient selection is especially important for PDT to minimize potential complications. Unlike ST, the trachea is not directly visualized prior to insertion of the tube during PDT. Only minimal blunt dissection is performed during PDT with rare use of cautery, and therefore, unexpected bleeding can occur during or immediately following the dilatation step.

According to the American Academy of Otolaryngology and Head and Neck Surgery, suggested indications for tracheostomy include the following⁵:

1. Upper airway obstruction

2. Prolonged or expected prolonged intubation

3. Inability of patient to manage secretions (aspiration or excessive bronchopulmonary secretions)

4. Facilitation of ventilation support

5. Inability to intubate

6. Adjunct to manage head and neck surgery

7. Adjunct to manage significant head and neck trauma

In addition, tracheostomy appears to improve the work of breathing and respiratory mechanics.^6,7,8 In comparison to ST, PDT is an elective procedure typically performed in the intensive care unit (ICU) setting in patients who are already ...