Dilatational Tracheostomy Research Articles

Design and application of alaryngeal mask and monitoring device facilitating withdrawal of endotracheal tube

Percutaneous dilatational tracheostomy (PDT) is a surgical method for quickly establishing an artificial airway, which has been favored by clinicians because of its simple operation, small trauma and bedside operation. However, for patients with tracheal intubation in intensive care unit (ICU), the tip and balloon of the existing endotracheal tube will not only hinder percutaneous puncture, but also hinder insertion of guidewire and tracheotomy tube, and consequently affect the process of PDT. On the contrary, blind withdrawal of the existing endotracheal tube may cause the tracheal tube tipleave the glottis, leading to an emergency airway situation that endangers the patient's life. Therefore, the medical staff from intensive care medicine department of the First People's Hospital of Chenzhou designed a laryngeal mask and its monitoring device, which is convenient for withdrawal of endotracheal tube, and obtained the national utility model patent of China (patent number: ZL 2020 2 2795887.1). The device is composed of a laryngeal mask and a monitoring device. The laryngeal mask mainly includes a laryngeal mask body, a vent tube, a guidance tube and other components. The laryngeal mask body is mainly used to seal the throat and provide the air supply channel for the patient together with the ventilation tube. The main function of the guidance tube is to accommodate the tracheal tube and facilitate the withdrawal of the inserted tracheal tube. During percutaneous dilatation tracheotomy, this device can monitor the withdrawal of tracheal catheter in real time, and immediately ensure the airway patency of patients without re-intubation when the cuff of tracheal catheter exits the glottis. The utility model has the advantages of real-time monitoring, simple operation, safety and convenience, and is worthy of transformation and promotion.

Is bedside percutaneous dilational tracheotomy superior to surgery in critically ill patients?

Is bedside percutaneous dilational tracheotomy superior to surgery in critically ill patients?

Association Between Timing of Percutaneous Dilatational Tracheotomyand Clinical Outcomes of Critically-ill Elderly Patients.

To determine the effect of timing of tracheotomy on the outcome of critically-ill elderly patients. Descriptive study. Place and Duration of the Study: Intensive Care Unit, Jingxian Hospital, Anhui, China, from January 2017 to December 2021. Two hundred and thirty-five critically-ill elderly patients who had undergone percutaneous dilatational tracheotomy (PDT) were enrolled. The PDT-related complications and clinical outcomes were analysed. Overall, the PDT-related complications, including the amount of bleeding (6.1 ± 1.0 vs. 5.8 ± 0.9 vs. 5.8 ± 0.9,p<0.46) and wound infection [8(5.0%) vs. 2 (4.9%) vs. 3 (9.1%),p=0.62], showed no significant difference among the three groups. The length of ICU stay (13.3 ± 8.4 vs. 18.4 ± 17.8 vs. 24.1 ± 16.1 days,p<0.0001) in the very early PDT group was significantly shorter than that in the early and late PDT groups. The lowest hospital mortality rate [(59 (36.6%) vs. 28 (68.3%) vs. 15 (45.5%),p=0.0012)] was noted in the very early PDT group among the three groups, and a longer postoperative survival was recorded. A shortened length of ICU stay and a decreased hospital mortality were found in the very early PDT group, while a better postoperative survival rate was achieved. Percutaneous dilatational tracheotomy, Mortality, Outcome, Timing, Intensive care unit.

Surgical Versus Dilational Tracheostomy in Patients with Severe Stroke: A SETPOINT2 Post hoc Analysis

BackgroundTracheostomy in mechanically ventilated patients with severe stroke can be performed surgically or dilationally. Prospective data comparing both methods in patients with stroke are scarce. The randomized Stroke-Related Early Tracheostomy vs Prolonged Orotracheal Intubation in Neurocritical Care Trial2 (SETPOINT2) assigned 382 mechanically ventilated patients with stroke to early tracheostomy versus extubation or standard tracheostomy. Surgical tracheostomy (ST) was performed in 41 of 307 SETPOINT2 patients, and the majority received dilational tracheostomy (DT). We aimed to compare ST and DT in these patients with patients.MethodsAll SETPOINT2 patients with ST were compared with a control group of patients with stroke undergoing DT (1:2), selected by propensity score matching that included the factors stroke type, SETPOINT2 randomization group, Stroke Early Tracheostomy score, patient age, and premorbid functional status. Successful decannulation was the primary outcome, and secondary outcome parameters included functional outcome at 6 months and adverse events attributable to tracheostomy. Potential predictors of decannulation were evaluated by regression analysis.ResultsBaseline characteristics were comparable in the two groups of patients with stroke undergoing ST (n = 41) and matched patients with stroke undergoing DT (n = 82). Tracheostomy was performed significantly later in the ST group than in the DT group (median 9 [interquartile range {IQR} 5–12] vs. 9 [IQR 4–11] days after intubation, p = 0.025). Patients with ST were mechanically ventilated longer (median 19 [IQR 17–24] vs.14 [IQR 11–19] days, p = 0.008) and stayed in the intensive care unit longer (median 23 [IQR 16–27] vs. 17 [IQR 13–24] days, p = 0.047), compared with patients with DT. The intrahospital infection rate was significantly higher in the ST group compared to the DT group (14.6% vs. 1.2%, p = 0.002). At 6 months, decannulation rates (56% vs. 61%), functional outcomes, and mortality were not different. However, decannulation was performed later in the ST group compared to the DT group (median 81 [IQR 66–149] vs. 58 [IQR 32–77] days, p = 0.004). Higher baseline Stroke Early Tracheostomy score negatively predicted decannulation.ConclusionsIn ventilated patients with severe stroke in need of tracheostomy, surgical and dilational methods are associated with comparable decannulation rate and functional outcome at 6 months. However, ST was associated with longer time to decannulation and higher rates of early infections, supporting the dilational approach to tracheostomy in ventilated patients with stroke.

Efficacy and Safety of Percutaneous Dilatational Tracheotomy in the Head and Neck Cancer Surgery

Background and Objectives Percutaneous dilatational tracheostomy (PDT) is an easy and fast technique that can replace surgical tracheostomy (ST). Less bleeding, easy technique and short procedure time are the main advantages of this tecunique. This study is to evaluate the feasibility of PDT during the head and neck cancer surgery.Subjects and Method The medical records of 12 patients who underwent PDT during a head and neck cancer surgery in the period of September 2019 to September 2021 were reviewed retrospectively. Another medical records of 12 patients who underwent ST during the head and neck cancer surgery were acquired for comparison. PDT was performed using Ciglia Percutaneous Tracheostomy Set&lt;sup&gt;®&lt;/sup&gt; (Cook Critical Care). Parameters of blood loss, procedure time, wound communication between the cervical and tracheostomy incision and complications were compared between the PDT group and the ST group.Results The PDT group showed less blood loss, shorter procedure time and showed fewer incidences of wound communication. As for complications, there was one case of conversion to ST due to procedure failure in the PDT group. The complication rate was not different between the two groups.Conclusion PDT can be used as a safe and effective procedure during the head and neck cancer surgery for selected patients.

No: 3897 Is it possible to decrease droplet generation during percutaneous dilatational tracheotomy? A preliminary report of four cases

No: 3897 Is it possible to decrease droplet generation during percutaneous dilatational tracheotomy? A preliminary report of four cases

Percutaneous dilatation tracheotomy in patients on extracorporeal membrane oxygenation after cardiac surgery.

Current practices regarding percutaneous dilatational tracheostomy in adult patients treated with extracorporeal membrane oxygenation (ECMO) after cardiac surgery is not completely defined. This study aimed to evaluate the safety of the percutaneous dilatational tracheostomy in patients with ECMO after cardiac surgery. Between July 2017 and May 2021, 371 ECMO procedures were performed in more than 35,000 adult patients who underwent cardiac surgery in our hospital. Sixty-two patients underwent percutaneous dilatational tracheostomy (PDT) during or after ECMO. A retrospective analysis was performed comparing the incidence of complications and clinical outcomes of the two groups. Of the 371 patients treated with ECMO after adult cardiac surgery during the enrollment period, 22 (7.1%) and 40 (12.8%) underwent PDT during or after ECMO, respectively. The platelet count (PLT) of the day was significantly lower in the PDT during ECMO group (54 (34, 68) vs. 108 (69, 162) (thousands), p < 0.001)). The prothrombin time (PT) and activated partial thromboplastin time (APTT) of the day were longer in the PDT during ECMO group (15.8 (14.6, 19.9) vs. 13.8 (13.2, 15.2) seconds, p = 0.001, 43.8 (38.0, 49.4) vs. 35.2 (28.2, 40.9) seconds, p < 0.001, respectively). There was no significant difference in tracheotomy-related complications between the two groups. Significantly decreased ventilator time was observed in the PDT during ECMO group. Despite poor coagulation of the day, PDT during ECMO is safe and can appropriately reduce the duration of mechanical ventilation compared with PDT after ECMO weaning in adult patients who have undergone cardiac surgery.

Feasibility of Percutaneous Dilatational Tracheotomy in Head and Neck Cancer Surgery: A Preliminary Study

ObjectivePercutaneous dilational tracheostomy (PDT) is a technique that can place a tracheostomy tube safely without visually identifying the trachea. We evaluated its feasibility during head and neck cancer surgery.Summary of background dataPDT has many advantages, such as less bleeding, easier technique, and shorter procedural time.MethodsTwelve patients who underwent PDT during head and neck cancer surgery from September 2016 to March 2018 were enrolled, and their medical records were reviewed retrospectively. Medical records of another 12 patients who underwent conventional tracheostomy during head and neck cancer surgery were analyzed. PDT was performed using a Ciaglia Percutaneous Tracheostomy Set. The tracheostomy point was determined by palpation without the guidance of bronchoscopy or ultrasonography. Blood loss, procedural time, communication between the cervical wound and tracheostomy wound, and complications were compared between the PDT group and the conventional group.ResultsThe PDT group had less blood loss, a shorter procedural time, and a lower incidence of communication between the cervical and tracheostomy wound. There was 1 case of conversion to conventional tracheostomy due to wrong tracheal penetration in the PDT group.ConclusionsPDT is safe and effective as an adjunctive procedure during head and neck cancer surgery.

Repeat percutaneous tracheostomy in a COVID-19 patient

A 73-year-old man with history of hypertension and chronic obstructive pulmonary disease was admitted to the emergency department with acute respiratory failure from COVID-19. After 10 days of mechanical ventilation (MV) the patient underwent a successful trial of extubation. However, 3 days later his neurological status deteriorated and required re-intubation. A brain computed tomography (CT) scan showed right cerebellar hemorrhage. Considering extent and location of the hemorrhage we decided to perform a percutaneous tracheostomy on the 18th day. The patient was then successfully weaned from MV (day 47th), and finally decannulated (day 50th). On day 62nd, the patient experienced an episode of septic shock, requiring oro-tracheal re-intubation, for we decided to perform a repeat percutaneous tracheostomy. All the procedure steps were uneventful. The patient was subsequently transferred to another ICU, and then successfully discharged to the Respiratory Ward. Keywords: coronavirus; airways; dilational tracheostomy

Navigation system for percutaneous tracheotomy

Background Percutaneous dilatational tracheotomy (PDT) is a well-established method. The prerequisite is to identify anatomical landmarks of the neck. We introduce a three-dimensional navigation system – SafeTrach. Aims/objectives We present an alternative technique using internal landmarks that can be used in patients with difficult anatomy. Material and methods The device is a forceps-like instrument with an outer and an inner shank. The later serves as a ventilation lumen and stabilizes the orotracheal tube in the midline of trachea. The outer shank acts as a three-dimensional guide for the puncturing needle. Results Out of 48 patients we have determined the level of puncture in 20 patients by using intraoperative measurements. The distance from the vocal cords to the puncture site was about 50 mm for men and 40 mm for women. In 13 of the patients who had had CT scans, we studied the distance between the vocal cords and the optimal puncture site and found the median distance for men 45 mm and for women 42 mm. Conclusions and significance With the studied navigation system one may use external or internal landmarks to indicate the puncture level in PDT. The device may minimize the risk of injuring the posterior tracheal wall.

Ultrasound-guided Percutaneous Dilatational Tracheotomy: A fast and safe technique for airway management

Purpose: To describe a modified technique for percutaneous dilational tracheotomy (PDT) offering possible significant advantages over currently used procedures.&#x0D; Methods: An observational animal study using ultrasound for PDT was performed. After pre-incisional ultrasonic examination, and with continuing ultrasound guidance, the trachea was punctured with an 18-gauge introducer needle and a tracheal tube was inserted using the Seldinger technique and a Ciaglia single dilator. Setting: University Hospital animal laboratory center. Subjects: 11 pietrain pigs (weight 26–36 kg).&#x0D; Results: Successful tracheotomy was accomplished in all 11 pigs. The mean duration of the procedure was 20 seconds from skin penetration to guide wire placement. In one pig, the dorsal wall of the trachea was punctured.&#x0D; Conclusion: This novel procedure is a simple and effective technique for PDT tube placement.

Ultrasound Guided Percutaneous Tracheostomy versus Conventional Tracheostomy: Technique and Outcome

Abstract Background: In the 21st century, the majority of trache-ostomies are now inserted by the intensivists in the intensive care unit (ICU). It is one of the most frequent procedures performed in critically ill patients. It has been advocated for those requiring prolonged mechanical ventilation because it facilitates weaning by decreasing the work of breathing, decreases the requirement for sedation and may allow for earlier patient mobilization, feeding and physical and occu-pational therapy. Aim of Study: To evaluate ultrasound guided percutaneous tracheostomy and conventional tracheostomy in critically ill patients regarding effect on outcome (weaning from mechanical ventilation and ICU stay), duration of the technique, success rate and to evaluate incidence of perioperative, early and late complications. Patients and Methods: Our study is a randomized con-trolled clinical trial conducted on 40 critically ill patients admitted to the Intensive Care Unit at Ain Shams University Hospitals, from the period from September 2020 until March 2021 they were intubated and mechanically ventilated and required elective percutaneous dilatational tracheotomy. Results: US-guided group showed fewer procedural com-plications compared to conventional group. We had faced procedural complications in conventional group in form of 2 (10%) of patients suffer from hypoxemia, Pneumothorax, decannulation and post. Tracheal wall injury. 3 (15%) of patients had transient hypotension and false passage. And 5 (25%) cases of perforation of ETT cuff during insertion, one case (5%) of subcutaneous emphysema and 7 (35%) cases of minor bleeding compered to three cases of minor bleeding in US-guided group, one case of decannulation and three case of transient hypotension. No early complications were detected in both study groups; except one case of tube obstruction or displacement in conventional group. According to late com-plications our analysis illustrates decrease in late complication in US-guided group 2 (10%) versus 4 (20%) in conventional group. In US-guided group only two cases of Stoma site infection resolved by antibiotic and local care. In conventional group there were two case of Tracheoesophageal fistula, one case of Stoma site infection and one case of Tracheoinnominate fistula. Conclusion: Percutaneous dilatational tracheostomy could be a safer procedure when performed by using peri- and preoperative US assistance. The use of US guidance for percutaneous dilatational tracheostomy could reduce the complication rates of the procedure. The ultrasound-guided percutaneous dilatational tracheostomy seems to reduce the late and early complications when compared to the anatomical landmark guided Percutaneous dilatational tracheostomy. Pre-procedural US-guided percutaneous dilatational tracheostomy can be considered as a reliable tool to increase safety and improve outcomes of elective tracheostomy.

Five cases of the failure and complications of percutaneous dilatation tracheotomy

Five cases of the failure and complications of percutaneous dilatation tracheotomy

Percutaneous dilatational tracheotomy in high-risk ICU patients

BackgroundPercutaneous dilatational tracheotomy (PDT) has become an established procedure in intensive care units (ICU). However, the safety of this method has been under debate given the growing number of critically ill patients with high bleeding risk receiving anticoagulation, dual antiplatelet therapy (DAPT) or even a combination of both, i.e. triple therapy. Therefore, the purpose of this study, including such a high proportion of patients on antithrombotic therapy, was to investigate whether PDT in high-risk ICU patients is associated with elevated procedural complications and to analyse the risk factors for bleeding occurring during and after PDT.MethodsPDT interventions conducted in ICUs at 12 European sites between January 2016 and October 2019 were retrospectively analysed for procedural complications. For subgroup analyses, patient stratification into clinically relevant risk groups based on anticoagulation and antiplatelet treatment regimens was performed and the predictors of bleeding occurrence were analysed.ResultsIn total, 671 patients receiving PDT were included and stratified into four clinically relevant antithrombotic treatment groups: (1) intravenous unfractionated heparin (iUFH, prophylactic dosage) (n = 101); (2) iUFH (therapeutic dosage) (n = 131); (3) antiplatelet therapy (aspirin and/or P2Y12 receptor inhibitor) with iUFH (prophylactic or therapeutic dosage) except for triple therapy (n = 290) and (4) triple therapy (DAPT with iUFH in therapeutic dosage) (n = 149). Within the whole cohort, 74 (11%) bleedings were reported to be procedure-related. Bleeding occurrence during and after PDT was independently associated with low platelet count (OR 0.73, 95% CI [0.56, 0.92], p = 0.009), chronic kidney disease (OR 1.75, 95% CI [1.01, 3.03], p = 0.047) and previous stroke (OR 2.13, 95% CI [1.1, 3.97], p = 0.02).ConclusionIn this international, multicenter study bronchoscopy-guided PDT was a safe and low-complication airway management option, even in a cohort of high risk for bleeding on cardiovascular ICUs. Low platelet count, chronic kidney disease and previous stroke were identified as independent risk factors of bleeding during and after PDT but not triple therapy.

Percutaneous dilatational tracheotomy in high-risk ICU patients

Abstract Funding Acknowledgements Type of funding sources: None. Background Percutaneous dilatational tracheotomy (PDT) has become an established procedure in cardiac intensive care units (ICU). However, the safety of this method has been under debate given the growing number of critically ill patients with high bleeding risk receiving anticoagulation, dual antiplatelet therapy (DAPT) or even a combination of both, i.e. triple therapy. There is a need for critical evaluation of these safety concerns. This is the first and largest international, multicenter study on PDT to date including such a high proportion of patients on antithrombotic therapy investigating whether PDT in high-risk ICU patients is associated with elevated procedural complications and analysing risk factors for bleeding occurring during and after PDT. Methods PDT interventions conducted in ICUs at 12 European sites between January 2016 and October 2019 were retrospectively analysed for procedural complications. For subgroup analyses, patient stratification into clinically relevant risk groups based on anticoagulation and antiplatelet treatment regimens was performed. Procedure-related complications for each risk group were analysed until hospital discharge. Additionally, predictors of bleeding occurrence were analysed by uni- and multivariable regression models. Results In total, 671 patients receiving PDT according to Ciaglia’s technique with accompanying bronchoscopy were included. Patients were stratified into seven clinically relevant antithrombotic treatment groups. Within the whole cohort, 74 (11%) bleedings were reported to be procedure-related, none of which required surgical intervention. In almost all cases bleedings were associated with skin bleedings from the entry site and could easily be treated with minimally invasive stitching. Subgroup analysis showed no increase in the rate of procedure-related complications in patients with elevated body mass index. In a multivariable regression model bleeding occurrence during and after PDT was independently associated with platelet count (Odds ratio [OR] 0.73, 95% confidence interval [95% CI] [0.56, 0.92], p = 0.009), chronic kidney disease (OR 1.75, 95% CI [1.01, 3.03], p = 0.047) and previous stroke (OR 2.13, 95% CI [1.1, 3.97], p = 0.02). Neither PTT (OR 1.01, 95% CI [0.99, 1.02], p = 0.32), nor DAPT (OR 1.11, 95% CI [0.56, 2.04], p = 0.75) nor triple therapy (OR 0.93, 95% CI [0.49, 1.66], p = 0.82) were associated with bleeding risk. Conclusion In this international, multicenter study bronchoscopy-guided PDT was a safe and low-complication airway management option, even in a cohort of high risk for bleeding on cardiovascular ICUs. Platelet count, chronic kidney disease and previous stroke were identified as independent risk factors of bleeding during and after PDT whereas DAPT and triple therapy had no influence on bleeding events.

Safety of percutaneous dilatational tracheotomy (PDT) with the rigid tracheotomy endoscope (TED): a 6-month follow-up multicenter investigation

BackgroundThe rigid tracheotomy endoscope (TED) was recently introduced to improve the fiberoptic technique during percutaneous dilatational tracheotomy (PDT) in critically ill patients. The aim was to evaluate the long-term complications of PDT using TED equipment in a prospective multicenter investigation.MethodsOne hundred eighty adult patients underwent PDT using TED in four German hospitals. Patients who were alive or their guardians were contacted via telephone and interviewed using a structured questionnaire 6 months following the tracheostomy procedure. Patients with airway complaints were invited for outpatient clinical ENT examination. The incidence of adverse events related to PDT was registered.ResultsOf 180 patients who received tracheostomy, 137 (76.1%) were alive at the time of follow-up. None of the 43 lethal events was related to the PDT. Fifty-three (38.7%) patients were available for follow-up examination, whereas 14 (10.2%) were able to visit ENT physicians. Two (3.8%) out of 53 patients developed tracheocutaneous fistula with required surgical closure of tracheostoma. Dyspnea (7.5%), hoarseness (5.7%), stridor and swallowing difficulties (both with 3.8%) were the most common complaints. Tracheal stenosis was confirmed in 1 patient (1.88% [95% CI: 0.33; 9.93]).ConclusionThe use of TED for PDT in the clinical setting is safe regarding adverse events at 6-month follow-up. The incidence of tracheal stenosis after PDT with TED is comparable with that of flexible bronchoscopy; however, its role for PDT at the intensive care unit should be clarified in further investigations.

Comparison of percutaneous dilatational tracheotomy versus open surgical technique in severe COVID-19: Complication rates, relative risks and benefits

ObjectivePatients with acute respiratory failure due to COVID-19 have a high likelihood of needing prolonged intubation and may subsequently require tracheotomy. Usually, the choice of technique (percutaneous dilatational tracheotomy [PDT] versus open surgical tracheotomy [OST]) depends on the preference of surgeons and patient-related factors. In case of COVID-19, airborne spread of viral particles and limited time of apnea must be considered in the choice of the safest technique. The aim of this study is to compare the complication rates and offer an assessment of relative risks and benefits of PDT versus OST in patients with severe COVID-19. MethodsWe performed a retrospective study considering 47 consecutive patients affected by severe acute respiratory distress syndrome due to SARS-CoV-2 infection, needing invasive mechanical ventilation and subsequent tracheostomy. This study was performed at the Intensive Care Unit of our tertiary referral center. Complication rates were analyzed. ResultsSeventeen patients underwent PDT and 30 patients were submitted to OST. Twenty-six patients (55.3%) had post-operative complications (local infection, hemorrhage, subcutaneous emphysema) with no significant difference between PDT and OST. ConclusionPDT and OST are characterized by similar postoperative complication rates in severe COVID-19 patients. These findings suggest that OST might be preferred if expert ENT surgeons are available, as PDT could result in longer apnea and exposure to generated aerosol. However, authors recommend considering either OST or PDT at the discretion of the medical staff involved, according to the personal experience of the operators performing the procedure.

Critical care surgical tracheotomy

Evaluating and performing open surgical tracheotomy for critical care patients requires special considerations and techniques. Although percutaneous dilational tracheotomy is largely performed in critical care patients, it has not completely eliminated the need for the open surgical approach. A preoperative evaluation with a safety checklist derived from expert recommendation is presented to aid the consulting otolaryngologist. Tracheotomy in an endotracheally intubated patient should be performed in a controlled, safe fashion with clear communication between the anesthesia provider and the surgeon. Rupture of the endotracheal tube cuff can turn a deliberate controlled operation into an emergency situation if the patient can no longer be properly ventilated. A widely known but infrequently discussed strategy for prevention of this complication is reviewed in this manuscript.

Tracheotomy in Ventilated Patients With COVID-19.

Tracheotomy in Ventilated Patients With COVID-19.

Application of percutaneous dilatation tracheotomy in patients with difficult airway

Objective:To explore the application of percutaneous dilatation tracheotomy for patients with difficult airway. Method:Retrospectively analyzed the clinical data of percutaneous dilatation tracheotomy in difficult airway patients, summarized the difficulties, technical points and advantages. Result:Collecting the clinical data of 28 patients with difficult airway, 20 cases were head and neck tumor recurrence after surgery, radiation and chemotherapy, 3 cases were cervical hematoma, 2 cases were laryngeal neoplasm with heart failure, 2 cases were mandatory spondylitis, and 1 case was airway stenosis. The difficult points for tracheotomy were unable to lie down, neck stiffness, displacement of the trachea, coagulation disorder, unclear neck structure, etc. All patients accepted percutaneous dilatation tracheotomy, including cone and forceps dilatation tracheotomy, with none complication. Conclusion:Percutaneous dilatation tracheotomy was a safe, rapid and minimally invasive surgical method for patients with difficult airway requiring tracheotomy, and could be used as the preferred solution.