Technique, Complications, and Improvements in Percutaneous Dilatational Tracheostomy

Abstract

In the excellent article in this issue of CHESTby Trottier and colleagues (see page 1383), the cause of posterior tracheal wall perforation during percutaneous dilatational tracheostomy (PDT) was studied clinically and in swine and cadaver experiments. In the clinical part of the study, the authors were justifiably concerned about the high incidence of posterior tracheal wall trauma. Twenty-four medical-surgical ICU patients underwent PDT using the Per-fit Percutaneous Tracheostomy Kit (Smiths Industries Medical Systems Portex Inc; Keene, NH), and three patients suffered posterior tracheal wall perforations. After the PDT in each of the patients with a posterior perforation, the investigator noted that the guidewire had been kinked during the procedure. It was believed that the dilators were advancing over the guiding catheter intratracheally onto the guidewire during the procedure (see Trottier and colleagues, Fig 1, bottom). The guidewire alone, according to the investigators, would not provide enough support to keep the dilator within the trachea, and therefore predispose to perforation of the posterior tracheal wall. I agree. The authors, to test this theory, developed a protocol to evaluate the PDT in animal and cadaver models. This was excellent reasoning, and good animal and cadaver models were developed. Especially interesting were these swine and cadaver experiments, which showed that if the guiding catheter was intentionally retracted into the dilator during PDT, the dilator would perforate the posterior tracheal wall, as demonstrated in their Figure 2. The authors then clearly and honestly state, “the ridge on the guiding catheter from the Ciaglia Percutaneous Tracheostomy Introducer Set prevented the dilators from advancing over the catheter.” Finally, in the last section of their discussion, the authors frankly state, “Owing to the findings documented in this study, the Per-fit Percutaneous Tracheostomy Kit is currently undergoing modification to include a guiding catheter with a ridge (Fig 3).” The authors are to be commended for their honesty and the excellence in the presentation of their experimental work. In the use of the rigid dilators of the present PDT set, the Per-fit set uses straight, rigid dilators instead of the curved, rigid dilators of the Ciaglia Percutaneous Tracheostomy Introducer Set (Cook Inc; Bloomington, IN). The straight dilators necessitate an oblique insertion as soon as the dilator enters the tracheal lumen in order to avoid trauma to the posterior tracheal wall. The present Ciaglia curved dilators make it easier to avoid injury to the posterior wall. The day of the rigid dilator in PDT, curved or straight, Ciaglia or Per-fit, is over. The rigid dilator is being replaced by the long, flexible cone, as in the Savary Esophageal Dilators (Wilson-Cook Medical Inc; Winston-Salem, NC). The flexibility and the long cone provide a marked safety feature with easy, safe following of the guidewire and guiding catheter with the safety ridge. In the meantime, those using the Ciaglia PDT set or the Per-fit PDT set should constantly remember the obliquity of the dilators on penetration, with verification by video-assisted tracheoscopy. The Per-fit set would do well now that a ridge is being added to the guiding catheter but also, a curve should be added to the dilators. The users should remember, no matter what rigid dilator they are using, that the rigid, straight, or curved dilator, inserted at right angles, can still cause trauma to the posterior tracheal wall if too much force is exerted. A final correction to the report on PDT: the authors state in their introduction that PDT was described in 1957 by Sheldon and colleagues and modified in 1985 by Ciaglia and colleagues. If the authors would look at the instrument described by Sheldon and colleagues, or at pictures of it in their 1957 report,1Sheldon CH Pudenz RH Tichy FY Percutaneous tracheotomy.JAMA. 1957; 165: 2068-2070Crossref PubMed Scopus (101) Google Scholar they would see sharp, cutting blades which produced a percutaneous tracheostomy but not a PDT. I originated and reported that procedure in 1985.2Ciaglia P Firsching R Syniec C Elective percutaneous dilatational tracheostomy: a new simple bedside procedure; preliminary report.Chest. 1985; 87: 715-719Crossref PubMed Scopus (911) Google Scholar