Indications for percutaneous dilational tracheotomy (PDT) are similar to those for open tracheotomy (OT) and include providing a portal for pulmonary toilet in debilitated patients or patients with neuromuscular disease, and providing a means for prolonged ventilatory support. Similar to OT, PDT should be considered in patients requiring mechanical ventilation 7 to 10 days following initial intubation. If prolonged intubation is expected based on patient circumstances (high spinal cord or traumatic brain injury), earlier tracheotomy may be considered.
Advantages of PDT over a prolonged translaryngeal intubation include a reduced risk of direct endolaryngeal injury, decreased risk of ventilator-associated pneumonia (VAP), more effective pulmonary toilet, increased airway security and ease in weaning from mechanical ventilation, improved patient comfort with decreased requirements for sedation, and earlier discharge from the intensive care unit (ICU). In suitable patients, the major advantage of PDT to OT is that it is performed as a bedside procedure, obviating the need for operating room time and patient transport, as well as being significantly more cost effective.
When evaluating a patient for PDT, a thorough history and physical examination will identify anatomic contraindications, including previous difficult tracheal intubation, morbid obesity, obscure cervical anatomy, goiter, short thick neck, previous neck surgery (especially tracheotomy), cervical infection, facial or cervical trauma/fractures, halo traction, or known presence of subglottic stenosis. Physiologic contraindications to PDT include hemodynamic instability, requirement of FiO2 >0.60, a positive end-expiratory pressure (PEEP) >10 cm H2O, or uncontrolled coagulopathy. Cervical deformity, previous radiation therapy, edema, or tumor can also make tracheal cannulation difficult and increase the risk of morbidity. The need for emergency control of the airway is an absolute contraindication to PDT.
Complications of PDT include injury to posterior tracheal wall resulting in a tracheoesophageal fistula, injury to cupula of lung with pneumothorax, tracheal ring rupture, recurrent laryngeal nerve injury, paratracheal insertion, tube dislodgement with loss of airway, stomal hemorrhage, peristomal cellulitis, subglottic or tracheal stenosis, or a tracheoinnominate fistula. A guidewire placed too deep in the trachea during the procedure can potentially cause bronchoconstriction or lung injury.
Several components are required for PDT placement, and these include bronchoscope, medications, tracheotomy insertion kit, and tracheotomy tube. Kits are available for either the single or the serial dilator technique, and either a standard or a percutaneous tracheotomy tube may be used. The tube cuff must be checked for leaks and then be well lubricated prior to placement. We recommend that the operator develop a materials checklist to facilitate gathering of the critical components prior to the procedure.
A three-drug regimen including sedative, analgesic, and nondepolarizing muscle relaxant agents facilitates placement. It is important to maintain immobility during insertion of the introducer needle, guidewire, dilators, and tracheotomy tube to prevent inadvertent puncture of the posterior tracheal wall. Direct manipulation of the trachea (particularly during ...