Percutaneous dilatational tracheostomy techniques

As the number of critically ill patients requiring tracheotomy for prolonged ventilation has increased, the demand for a procedural alternative to the surgical tracheostomy (ST) has also emerged. Since its introduction, percutaneous dilatational tracheostomies (PDT) have gained increasing popularity. The most commonly cited advantages are the ease of the familiar technique and the ability to perform the procedure at the bedside. It is now considered a viable alternative to (ST) in the intensive care unit. Evaluation of PDT procedural modifications will require evaluation in randomized clinical trials. Regardless of the PDT technique, meticulous preoperative and postoperative management are necessary to maintain the excellent safety record of PDT. Introduction Tracheostomy is one of the oldest surgical procedures, described in ancient books of medicine [1]. The standard operative tracheostomy technique presented by Jackson [2] remains little changed more than 100 years on. Several tracheostomy techniques have been described as percutaneous [3,4]. A technique of performing percutaneous dilatational tracheostomy (PDT) over a guidewire was first described by Ciaglia in 1985. It is increasingly being performed in intensive care units (ICUs) at the bedside. The Ciaglia technique, including its modifications, has become the most widely used procedure for the performance of PDT. In the first part of this review we consider general issues related to PDT. In the second section we focus on evidencebased recommendations, using the best available evidence, regarding issues such as modifications to PDT procedures designed to enhance patient safety and timing of performance in the ICU [5]. We conducted searches of Medline, the National Electronic Library for Health, the Cochrane Database of Systematic Reviews and the TRIP Database for reports published between 1985 and 2005, using the following key words: ‘percutaneous’, ‘tracheostomy’ and ‘intensive care units’. Evidence is weighted according to the following rating scheme: A = scientific evidence provided by randomized and nonrandomized trials with statistically significant results; B = scientific evidence provided by observational studies or by controlled trials; and C = expert opinion with lack of scientific evidence. Percutaneous dilatational tracheostomy techniques Various types of PDT techniques are available. They all require puncture of the trachea and insertion of a guidewire into the trachea. The puncture should be performed between the first and second or between the third and fourth tracheal rings. There is some evidence that a puncture between the third and fourth tracheal rings is associated with the lowest rate of accidental injury to aberrant vessels and other structures if there are anatomical abnormalities [6]. In most techniques the guidewire is then advanced toward the carina; however, in the Fantoni translaryngeal tracheostomy (TLT) method the guidewire is fed upward through the vocal cords. The Ciaglia method uses increasing sizes of hydrophilic coated dilators, ultimately allowing the tracheal cannula to be inserted into the trachea. Since Ciaglia’s first report [5], the technique has undergone three major modifications: the tracheal interspace for cannulation has been moved one or two tracheal interspaces caudal from the cricoid cartilage; routine use of video fibreoptic bronchoscopy has been advocated; and a single, bevelled and curved dilator (Blue Rhino) has been substituted for multiple dilators. In a prospective, randomized trial of trauma patients [7] use of a single dilator was compared with multiple dilators in PDT. There were no major complications with either technique. The single-step dilator has the advantage of not requiring a change in dilator, thereby reducing tidal volume loss until the tracheostomy tube is ready to be inserted. Review Clinical review: Percutaneous dilatational tracheostomy Mariam A Al-Ansari1 and Mohammed H Hijazi2 1Consultant Intensivist, Salmaniya Medical Complex, Ministry of Health, Manama, Kingdom of Bahrain 2Assistant Professor of Medicine, Consultant Intensivist, Section of Critical Care Medicine, Department of Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Kingdon of Saudi Arabia Corresponding author: Mariam A Al-Ansari, [email protected] Published: 26 October 2005 Critical Care 2006, 10:202 (doi:10.1186/cc3900X) This article is online at http://ccforum.com/content/10/1/202 © 2005 BioMed Central Ltd