Percutaneous dilatational tracheostomy: collaborative team approach for safe airway management

Abstract

Since Jackson first standardized the technique in 1909 [1], surgical tracheostomy (ST) has been the golden standard surgical procedure by which to manage the airway in critically ill patients. An alternative procedure, cricothyrotomy (cricothyroidotomy) [2], has also been utilized as a surgical option to secure the failed airway in selected emergency situations. To simplify the tracheostomy procedure, Shelden (1950) described the technique of percutaneous dilatational tracheostomy (PDT). However, due to the increased potential to induce extra injury to arteries and the esophagus, the PDT as proposed by Sheldon did not gain popularity among intensive care physicians and airway surgeons. In 1985, Ciaglia et al. [3] introduced a novel PDT method to create a stoma by a series of graduated dilators following needle puncture into the trachea. This method involved the relatively easy Seldinger technique to introduce the serial dilators and a tracheostomy tube. The Griggs guidewire dilating forceps (GWDF) technique introduced in 1990 was aimed at enlargening a small tracheal aperture with a guidewiredilating forceps especially manufactured for this purpose [4]. In 1998, a modification of the Ciaglia technique was introduced (Ciaglia Blue Rhino Percutaneous Tracheostomy Introducer kit; Cook Critical Care, Bloomington, IN). The Ciaglia Blue Rhino (CBR) technique incorporated a single, sharply tapered dilator with a hydrophilic coating, allowing complete dilation of the stoma in one step [5]. Although all of these methods have the potential to be improved and refined, the CBR is—mainly due to its simplified concept—currently the most popular PDT technique worldwide. In Japan, as in other countries, PDT is becoming a wellknown procedure. It is being performed as one of the technical options to secure the airway in multiple situations by physicians of various specialties. However, although this procedure is gaining in popularity in Japan, critical information on its indications, contraindications, and safety issues, including potential risks, have not yet been precisely defined and discussed. Thus, while the handiness of this technique is attractive to anesthesiologists and critical care physicians the best approach to perform PDT for successful airway management still needs to be considered and decided upon. K. Saito (&) Department of Otolaryngology–Head and Neck Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan e-mail: koichiro@ja2.so-net.ne.jp