PERCUTANEOUS TRACHEOSTOMY

Important summary of my presentation:

Since Ciaglia et al. described the percutaneous dilatational tracheostomy (PDT) in 1985, PDT has gained popularity over surgical  tracheostomy in the intensive care setting. Percutaneous tracheostomy (PCT) requires less time to perform, it is less expensive and it is typically performed sooner (because an operating room does not have to be scheduled).  In a meta-analysis of 17 randomized control trials, PDT offers several advantages such as decreased wound infections, decreased bleeding and mortality compared to surgical technique. Indications for PCT are the same as those for standard open tracheostomy. Established contraindications against PCT are unstable fractures of cervical spine, severe local infection of anterior neck and uncontrolled coagulopathy. Relative contraindications are high PEEP or oxygen requirements, difficult anatomy, proximity to extensive burns or surgical wounds, elevated intracranial pressure, haemodynamic instability and previous radiotherapy to the neck.  In experienced hands, PDT seems to be a safe procedure. The number of relative contraindications to PDT declines with increasing operator experience. Overweight patients have a five times higher risk of perioperative complications with PDT than normal weight patients.

Percutaneous tracheostomy using the dilator (or Ciaglia) technique is superior to other percutaneous approaches including the single-forceps (Griggs) technique. Several commercial kits are available for PDT. Eventhough procedure differs slightly with choice of kit, the basic steps remain common. No strong evidence supports one specific kit or technique. To minimize complications, it is recommended that each institution chooses one kit and gain familiarity to appreciate its advantages and drawbacks. With bronchoscope guidance, the operator can ascertain correct tracheostomy site, intratracheal guidewire placement, intratracheal dilator placement without tracheal damage, proper partial withdrawal of the endotracheal tube and placement of tracheostomy tube. If ultrasound machine is available, a skilled operator can evaluate the anatomy of major vessels and the thyroid gland in relation to tracheostomy site. It helps in localize the level of tracheal rings and indentify midline puncture, depth etc. Following PDT, a routine chest radiograph is probably unnecessary, provided the procedure had been uncomplicated. In a retrospective review of 60 patients undergoing tracheostomy with bronchoscopic guidance, a post-procedure chest radiograph was only useful in detecting complications following procedures deemed difficult by and experienced operator.