Modified Percutaneous Dilatational Tracheostomy without Bronchoscopic Guidance Experience of 165 Consecutive Cases

Abstract

Objectives: The use of percutaneous dilatational tracheostomy (PDT) has become more prevalent over the past decade. While recent studies have advocated intraoperative bronchoscopic guidance during the procedure, the routine use of intraoperative bronchoscopy is still controversial. Herein, we present our experience of percutaneous dilatational tracheostomy without bronchoscopic guidance. Methods: From July 2004 through December 2008, 165 patients who underwent PDT without bronchoscopic guidance were enrolled. The PDT technique was as follows: (1) subcutaneous tissue was dissected down to the pretracheal fascia until direct visualization of the anterior tracheal wall; (2) a mosquito clamp was used to identify the correct puncture level of the trachea; (3) a fingertip was used to guide the endotracheal (ET) tube, which was withdrawn to the level above the puncture site; (4) the ET tube was pushed forward to prevent posterior tracheal wall injury while introducing a Seldinger wire. All patients' preoperative condition and postoperative outcome were recorded for analysis. Results: The mean operating time was 6.2±1.6 minutes. One patient (0.6%) died of posterior tracheal wall injury with subsequent tracheal bleeding and tears. Complication occurred in 31 cases (18.8%), including stoma infection in 22 cases (13.3%), stoma oozing in 7 cases (4.2%) and tracheal tear in one case (0.6%). Conclusions: We have demonstrated that with minimal dissection of the pretracheal fascia, it is possible to perform precise counting of the tracheal rings and advancement of the ET tube. Then, the routine use of bronchoscopic guidance for a safe PDT may not be necessary.