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INDICATIONS

Indications for percutaneous dilational tracheotomy are similar to those for open tracheotomy. They include providing a means for prolonged ventilatory support and a portal for pulmonary toilet in patients who are unable to clear their own secretions, such as in debilitated or neuromuscular disease patients. Similar to open tracheotomy, percutaneous dilational tracheotomy should be considered in patients requiring mechanical ventilation 7–10 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 percutaneous dilational tracheotomy over a prolonged translaryngeal intubation include a reduced risk of direct endolaryngeal injury, 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. In suitable patients, the major advantage of percutaneous dilational tracheotomy over open tracheotomy 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 percutaneous dilational tracheotomy, a thorough history and physical examination will identify relative contraindications, including previous difficult tracheal intubation, morbid obesity, obscure cervical anatomy, goiter, short and thick neck, previous neck surgery (especially tracheotomy), cervical infection, cervical trauma/fractures, halo traction, or known presence of subglottic stenosis. Physiologic contraindications to percutaneous dilational tracheotomy include hemodynamic instability, requirement of a fraction of inspired oxygen greater than 0.60, a positive end-expiratory pressure greater than 10 cm of water, or uncontrolled coagulopathy. Cervical deformity, previous radiation therapy, edema, or tumor also can make tracheal cannulation difficult and increase the risk of morbidity. The need for emergency control of the airway is a contraindication to percutaneous dilational tracheotomy.

Complications of percutaneous dilational tracheotomy include injury to the posterior tracheal wall resulting in a tracheoesophageal fistula, injury to the cupula of the lung with pneumothorax, tracheal ring rupture, paratracheal insertion, tube dislodgement with loss of airway, stomal hemorrhage, peristomal cellulitis, subglottic or tracheal stenosis, and a tracheoinnominate fistula. A guidewire placed too deep in the trachea during the procedure can potentially cause pneumothorax, although the current use of J-wires makes this complication much less likely.

PREOPERATIVE PREPARATION

Several components are required for percutaneous dilational tracheotomy placement. We strongly recommend performing the procedure under direct vision with a bronchoscope. The other necessary elements include medications, a tracheotomy insertion kit, and a tracheotomy tube. Kits are available for either a single or serial dilator technique, and either a standard or a percutaneous tracheotomy tube may be used. The tube cuff should be checked for leaks and then be well lubricated prior to placement. Most adults can accommodate an 8 French tracheotomy tube, and that size should be used if secretion clearance is one of the indications for tracheotomy. We recommend that the operator develop a ...

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