Percutaneous dilatation tracheostomy

Percutaneous tracheostomy, a derivation of the Seldinger wire-guided technique for vascular cannulation, was introduced in 1969 as a single-dilatation technique

(IoyeJDd,..Weinstein 1986). Since then it has been modified and refined, and is now used widely throughout the world. The most commonly used method involves the insertion of a needle through the neck into the trachea, followed by passage of a guide-wire through the needle. The needle is removed and its tract gradually enlarged by inserting a series of progressively larger dilators over the wire. After a sufficiently large opening has been created, a tracheostomy tube is inserted. The technique is illustrated in Fig 1... Bronchoscopic guidance is often used to ensure proper tube placement and promote safety (Barbaef a/ 1.995).

Fig. 1 Technique of percutaneous dilatation tracheostomy. The patient is positioned with a roll beneath the shoulders to extend the neck, and the anterior neck is cleansed and painted with antiseptic. The skin overlying the space between the first and second, or second and third, tracheal cartilages is infiltrated with lidocaine. (a) A 16-gauge needle is inserted through the selected space and into the tracheal lumen. (b) A J-tipped guidewire is passed through the 16-gauge needle, and the needle is removed. A 2-cm vertical superficial incision is made through the skin in such a way as to include the tract of the guide-wire. (c) Dilatation begins by insertion of an 8 French tapered plastic dilator, which is then removed and replaced by a plastic guiding catheter of similar size. (d) The opening is gradually enlarged by passing progressively larger dilators over the guiding catheter. Two to six dilatations may be required to create an opening large enough to accommodate the selected tracheostomy tube. (e) A dilator or dilating obturator is inserted into the tracheostomy tube, and this is passed over the guiding catheter and into the stoma. The guidewire, guiding catheter, and dilator are removed, leaving the tracheostomy tube in place. The cuff is inflated and the tube is secured with cloth ties.

The percutaneous technique is attractive because of its simplicity and speed. It can be completed in less than 5 min, whereas conventional operative tracheostomy usually requires more than 30 min (Hazard ei a/ 1.991). Furthermore, percutaneous tracheostomy can be safely performed under local anesthesia at the bedside in the intensive care unit, obviating the sometimes precarious exercise of transporting the critically ill patient to and from the operating room. In part because of this fact, the percutaneous approach is far more economical, with an average cost less than one-third that of the conventional procedure ( Barba eia/ 1995). Most importantly, percutaneous tracheostomy is associated with significantly less morbidity than the operative approach, particularly in terms of infection and tracheal stenosis ( Haza— etai 1991). For these reasons, it is increasingly considered the technique of choice in critically ill patients.

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