eMedicine - Percutaneous Tracheostomy : Article by Joshua S Schindler, MD

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Percutaneous Tracheostomy

Last Updated: October 6, 2006

Synonyms and related keywords: percutaneous tracheostomy, tracheostomy, PCT, percutaneous dilational tracheostomy, PDT, guidewire dilating forceps, GWDF, Rapitrach method, mechanical ventilation, airway obstruction, inflammatory disease, benign laryngeal pathology, webs, cysts, papilloma, malignant laryngeal tumors, laryngeal trauma, laryngeal stenosis, tracheal stenosis, pulmonary toilet, obstructive sleep apnea

AUTHOR INFORMATION Section 1 of 11

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Author: Joshua S Schindler, MD, Assistant Professor, Department of Otolaryngology, Oregon Health and Science University
Coauthor(s): Darius Bliznikas, MD, Staff Physician, Department of Otolaryngology, Division of Head and Neck Surgery, Wayne State School of Medicine; Soly Baredes, MD, Associate Professor of Clinical Surgery, Chief, Section of Otolaryngology-Head and Neck Surgery, Director, Division of Head and Neck Surgery, UMDNJ New Jersey Medical School

Joshua S Schindler, MD, is a member of the following medical societies: Alpha Omega Alpha, and American Academy of Otolaryngology-Head and Neck Surgery

Editor(s): Lanny Garth Close, MD, Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, Columbia University College of Physicians and Surgeons; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Gregory C Allen, MD, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; and Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine

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INTRODUCTION

Section 2 of 11

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Percutaneous tracheostomy (PCT) techniques are gaining greater popularity in surgical ICU wards and trauma centers of certain institutions. However, proof of PCT's superiority to standard tracheostomy is contestable, and further extended prospective studies are required. Investigators who endorse PCT as the preferred technique of airway access maintain that PCT is cost-effective, safe, fast, and easy to perform. However, certain PCT steps, such as endotracheal (ET) tube replacement and blind formation of tracheal stoma, can cause serious perioperative complications.

Complications include accidental extubation, false passage, protracted stomal bleeding, and tracheal wall injury or perforation that requires surgical wound exploration and alteration of the procedure to a standard tracheostomy. These problems cause extended hospitalization, which increases costs of the procedure.

In addition, numerous investigators have proposed a learning curve for PCT, and increased complications result for patients who are treated by a surgeon who is inexperienced with the procedure or at an institution where the procedure is preformed infrequently. Therefore, early experience with PCT should be obtained under controlled circumstances and ideally in the operating room. All surgeons using this technique must be prepared to perform immediate standard open tracheostomy to minimize the potentially lethal complications of this elective procedure.

In the authors' opinion, standard tracheostomy remains the criterion standard for elective airway access. Because many otolaryngologists have been reluctant to adopt bedside techniques, intensivists have started to perform tracheostomies. The authors have written this article to familiarize otolaryngologists with PCT techniques. This article is not an endorsement of these techniques.

History of the Procedure: In 1955, Shelden and colleagues reported the first attempt to perform PCT. They gained airway access with a slotted needle that then was used to guide a cutting trocar into the trachea. Unfortunately, the method caused multiple complications, and fatalities were reported secondary to the trocar's laceration of vital structures adjacent to the airway.

Over the ensuing decades, percutaneous airway access methods have improved, and various techniques have been reported. In 1969, Toye et al reported a tracheostomy technique based on a single tapered dilator with a recessed cutting blade. This dilator was advanced into the airway over a guiding catheter, and the recessed blade was designed to cut tissues under tension as the dilator was forced into the trachea.

In 1985, Ciaglia and colleagues described the percutaneous dilational tracheostomy (PDT), a method based on needle guidewire airway access followed by serial dilations with sequentially larger dilators.

Schachner et al reported the Rapitrach method in 1989. This method consists of using a dilating forceps device with a beveled metal conus that is designed to advance forcibly over a wire into the airway.

In 1990, Griggs and colleagues reported the guidewire dilating forceps (GWDF) method. This method is based on a forceps similar to that of the Rapitrach method, except without a cutting edge on the tip of the instrument.

Problem: Tracheostomy is a widely accepted method for treating patients that are on long-term mechanical ventilation. The Council on Critical Care of the American College of Chest Physicians recommends tracheostomy in patients who are expected to require mechanical ventilation for longer than 7 days.

Prolonged mechanical ventilation using a translaryngeal tube is problematic and causes numerous complications. Commonly, only patients under considerable sedation tolerate the orotracheal tube, making weaning patients from the respirator more difficult. Another disadvantage is an increase in airway resistance and dead space. Oral ingestion is hindered or even impossible. The permanent nasotracheal tube engenders a higher incidence of sinus infection and the risk of systemic dissemination. Translaryngeal permanent intubation promotes formation of laryngeal and subglottic stenoses. These complications can largely be avoided if tracheostomy is performed.

The main advantages of tracheostomy over prolonged translaryngeal intubation are as follows:

Eases airway care and suctioning
Eliminates the ongoing risks of oral, nasal, pharyngeal, and most laryngeal complications of translaryngeal intubation
Reduces risk of tracheal extubation
Eases tube reinsertion
Facilitates oral communication and speech
Improves oral, nasal, and facial hygiene
Raises patient comfort level
Improves patient appearance
Facilitates nursing care of the overall airway
Improves patient mobility
Eases disposition to long-term care facility

Currently, several approaches to tracheostomy are available, as follows:

Standard tracheostomy in the operation room
Bedside standard tracheostomy
PCT
Translaryngeal tracheostomy

INDICATIONS Section 3 of 11

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In the ICU, the most common indication for tracheostomy is a requirement for prolonged mechanical ventilation. This need may arise from pneumonia refractory to treatment, severe chronic obstructive pulmonary disease, acute respiratory distress syndrome, severe brain injury, or multiple organ system dysfunction.

Most experts agree that patients requiring ET intubation for more than 7 days should have a tracheostomy. Some evidence indicates that a tracheostomy performed early (ie, within 3 days of intubation) may decrease the risk for pneumonia, the length of mechanical ventilation, and the length of stay in the ICU. Therefore, no strict time parameter for PCT performance exists, and applicability of PCT should be based on clinical situation.

Indications for PCT are the same as those for standard tracheostomy.

Airway obstruction due to the following:
- Inflammatory disease
- Benign laryngeal pathology (eg, webs, cysts, papilloma)
- Malignant laryngeal tumors
- Laryngeal trauma or stenosis
- Tracheal stenosis
Pulmonary toilet
Obstructive sleep apnea

RELEVANT ANATOMY AND CONTRAINDICATIONS Section 4 of 11

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Relevant Anatomy: See Intraoperative details.

Contraindications:

Necessity of emergency airway access because of acute airway compromise
Evidence of infection in the soft tissues of the neck at the prospective surgical site
Medically uncorrectable bleeding diatheses
- Prothrombin time or activated partial thromboplastin time more than 1.5 times reference ranges
- Platelet count less than 50,000/mL
- Bleeding time longer than 10 minutes
Gross distortion of the neck anatomy due to the following:
- Hematoma
- Tumor
- Thyromegaly (second or third degree)
- High innominate artery
- Scarring from previous neck surgery
Documented or clinically suspected tracheomalacia
Need for positive end-expiratory pressure (PEEP) of more than 15 cm of water
Patient obesity with short neck that obscures neck landmarks
Patient age younger than 15 years

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WORKUP

Section 5 of 11

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Lab Studies:

Complete blood count: Platelet count must be more than 50,000/mL.

Coagulation profile: Prothrombin time or activated partial thromboplastin time must be less than 1.5 times reference ranges.

Bleeding time: Bleeding time should be checked if blood urea nitrogen is more than 40 mg/dL or if the creatinine level is above 4 mg/dL. Bleeding time must be less than 10 minutes.

Imaging Studies:

Recent chest radiography: A standard chest radiograph can provide information regarding the tracheal air column. Anteroposterior filtered tracheal views and lateral soft tissue views of the neck provide information regarding the glottic and subglottic air columns.

TREATMENT

Section 6 of 11

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Surgical therapy: Numerous investigative reports show that all techniques for PCT (eg, GWDF, Rapitrach, PDT, others) have similar success rates. All techniques are based on the use of a needle guidewire to gain airway access. However, each method requires unique equipment and follows a different intraoperative procedural sequence. For example, all techniques that are conducted by serial dilatations of the stoma with commercial dilatators could be classified under PDT.

Preoperative details:
Equipment

PDT kit (Cook, Inc., Bloomington, Ind): 22-gauge needle and syringe; 11-French (F) short punch dilator; 1.32-mm guidewire; 8F guiding catheter; 18F, 21F, 24F, 28F, 32F, 36F, and 38F dilators; Shiley size 8 double-cannula tracheostomy tube; fiberoptic bronchoscope

GWDF kit: 14-gauge needle and syringe, guidewire (J-tipped Seldinger wire type), scalpel, Howard-Kelly forceps modified to produce a pair of GWDF (see Image 1), Shiley size 8 double-cannula tracheostomy tube with curved obturator, fiberoptic bronchoscope
Rapitrach kit (Fresenius, Runcorn, Cheshire, UK): 12-gauge needle and syringe, short guidewire, scalpel, Rapitrach PCT dilator (see Image 2), standard Portex 8-mm tracheostomy tube with curved obturator, fiberoptic bronchoscope

Anesthesia

Premedication consists of 5 mg of morphine, 5 mg of midazolam, and 10 mg of cisatracurium. Place the patient on 100% oxygen at least 15 minutes before surgery.
Hyperextend the patient's neck if permitted. Before preparation of the surgical area begins, withdrawal of the endotracheal tube under direct vision of bronchoscope is recommended to place the balloon just under the vocal cords. The respiratory therapist then protects the tube against any further movement during the procedure.
Intravenous sedation with 50-100 mcg of fentanyl and 1-2 mg/kg of either methohexital or ketamine is provided.

Intraoperative details:
PDT technique

The neck is cleansed with antiseptic solution and properly draped. The cricoid cartilage is identified, and the skin is anesthetized with 1% lidocaine with 1:100,000 epinephrine below the cricoid cartilage. A 1.5- to 2-cm transverse skin incision is made on the level of the first and second tracheal rings. Then, the blunt dissection of the midline is performed. A 22-gauge needle is inserted between the first and second or the second and third tracheal rings (see Image 3).

When air is aspirated into the syringe, the guidewire is introduced (see Image 4). After the guidewire is protected, the dilators are introduced (see Image 5). All dilators are inserted in a sequential manner from small to large diameter. The tracheostomy tube then is introduced along the dilator and guidewire (see Image 6). The guidewire and dilator are removed, the cuff of the tracheostomy tube is inflated, and the breathing circuit is connected. The ET tube is removed.

GWDF technique

The neck is cleansed with antiseptic solution and properly draped. The neck is palpated, and the cricoid cartilage is identified. The skin below this level is anesthetized with 1% lidocaine with 1:100,000 epinephrine solution. A 1.5- to 2-cm midline transverse cutaneous incision is made at this level. A 14-gauge IV needle with syringe is inserted in the midline of the incision. The needle is directed to pass between the first and second or the second and third tracheal rings. As soon as air begins to bubble into the syringe, the outer plastic cannula is advanced into the lumen of the trachea and the inner needle is removed. A J-tipped Seldinger wire is introduced into the trachea, and the plastic cannula is removed. The tip of the Seldinger wire is passed through the closed GWDF (see Image 1).

The forceps are advanced through the soft tissues of the neck until resistance is felt. The GWDF are opened to dilate the soft tissues anterior to the trachea. The forceps then are closed and reinserted over the wire into the trachea. A slight loss of resistance occurs as the tracheal membrane is pierced (see Image 7). To prepare the stoma of the tracheostomy, the GWDF are opened to the same diameter as the skin incision (see Image 8). A tracheostomy tube with obturator is inserted over the guidewire and advanced into the trachea. The obturator and guidewire are removed, the cuff of the tracheostomy tube is inflated, and the appropriate breathing circuit is connected. The ET tube is removed.

Rapitrach technique

The neck is cleansed with antiseptic solution and properly draped. The skin is anesthetized with 1% lidocaine with 1:100,000 epinephrine below the cricoid cartilage. A 1.5- to 2-cm skin incision is performed at the level of the first and second tracheal rings. Subcutaneous layers are then bluntly dissected with a pair of forceps. Blunt dissection is continued until the tracheal rings can be palpated with a finger. A 12-gauge needle is inserted into the trachea between the first and second or the second and third rings. A short, flexible guidewire is inserted into the trachea, and the needle is removed. The Rapitrach dilator (see Image 2) is introduced into the trachea over the guidewire. The dilator is opened when its tip lies in the trachea. A tracheotomy tube with obturator is inserted through the dilator jaws to the trachea. The dilator and guidewire are removed, the cuff of the tracheostomy tube is inflated, and the breathing circuit is connected. The ET tube is removed.

Bronchoscopic guidance of the gauge needle and the guidewire insertion is optional but strongly recommended, especially for less experienced operators. A large number of paratracheal cannula insertions and pneumothoraces can be avoided if endoscopic monitoring is employed. Bronchoscopic monitoring also allows patients with short, fat necks to undergo PCT. However, bronchoscopic guidance during PCT appears to be the most important factor responsible for the hypercarbia that develops during the procedure. Therefore, bronchoscopic guidance should be limited to initial dilatation steps only.

Postoperative details:

Air entry into the lungs is checked by chest auscultation and respiratory plethysmography.
Excess secretions or blood should be suctioned to prevent a drop in oxygen saturation and to provide good bronchopulmonary hygiene.
Everyday antiseptic wound care must be provided. A tracheostomy tube with an inner cannula facilitates care and hygiene and ensures added safety (due to easy removal) if obstruction from secretions occurs.
In the event of accidental decannulation within 5 days of the procedure, the patient must be reintubated orally and the tracheostomy tube reinserted because the tracheostomy tract is still relatively immature.

Follow-up care:

Monitor the patient to prevent dislodgment of the tracheostomy tube.
Use a nebulizer to deliver 40% oxygen.
Deflate the balloon once each 15 minutes every hour for the first 24 hours; then, leave the balloon inflated.
Clean the inner cannula at least once every 8 hours.
Suction the trachea as needed.

COMPLICATIONS Section 7 of 11

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Complications of the various PCT techniques are largely similar. See the table below for the most common perioperative, intraoperative, and late complications reported by different investigators.

Studies on Percutaneous Tracheostomy Complications by Various Investigators

Author Year Patients Complications

Total Decan- nulated* Death Hemorrhage False passage Stomal infection Granu- lations Tracheal stenosis Other† Total

Hazard et al 1998 55 21 - 2 - 1 - - 3 6

Schachner et al 1989 150 Nd 1 3 - - 4 1 8 17

Marelli et al 1990 61 13 1 1 - 2 - - 4 8

Ciaglia et al 1992 165 52 - 3 1 2 - - 8 14

Friedman et al 1993 100 15 1 5 1 3 - - 10 20

Rosenbower et al 1994 75 56 - 1 1 - 1 1 1 5

Gaukroger et al 1994 50 Nd - 1 3 - - - 1 5

Manara et al 1994 77 Nd - - - 2 - - 2 4

McFarlane et al 1994 121 Nd - - - - - 4 - 4

Winkler et al 1994 71 12 - 2 - 1 - - 1 4

Marx et al 1995 254 Nd 1 3 3 1 - 2 7 17

Kahveci et al 1996 72 30 - 3 - 2 - - - 5

Fernandez et al 1996 162 Nd - 1 - 3 - - 5 9

van Heurn et al 1996 147 100 1 5 2 - - 1 9 18

Hill et al 1996 356 214 1 16 6 2 - 8 36 69

Velmahos et al 1997 100 35 - 4 1 - - - 4 9

Petros et al 1997 137 Nd - 4 - - - - 11 15

van Heerbeek et al 1998 50 36 - 2 1 2 - 1 1 7

Walz et al 1998 326 141 2 2 2 4 - 1 23 34

Kearney et al 1998 829 405 5 25 6 4 2 5 10 57

Escarment et al 1999 162 81 2 3 1 4 7 4 9 30

Total 3520 1288 15 86 29 32 14 28 153 357

100% 36% 0.4% 2.44% 0.8% 0.9% 0.39% 1.9%‡ 4.3% 10%

*Nd indicates no data.
†Complications listed under other include pneumothorax, subcutaneus emphysema, tracheoesophageal fistula, tracheoarterial fistula, tracheocutaneous fistula, posterior wall perforation or laceration, and disfiguring scar.
‡The tracheal stenosis percentage is based on 1288 decannulated patients.

Perioperative complications (<24 h postoperative) include the following:

Death: The mortality rate due to PCT procedures is 0.4%.
Hemorrhage: In most cases, bleeding is controlled by local pressure or ends spontaneously. Bleeding arising from within the trachea, especially in the presence of pneumothorax or surgical emphysema, merits urgent fiberoptic endoscopic investigation. These findings suggest a mucosal tear or a serious posterior tracheal wall injury.
Hypoxia (Oxygen saturation [SaO₂] <80%): Hypoventilation caused by an air leak following the opening of the trachea is the main cause of hypoxia. Delayed insertion of the tracheostomy tube by an inexperienced operator could cause hypoxia. One hundred percent oxygen and the increased tidal volume compensate partly for the air leak. Occult hypercarbia due to use of endoscopic guidance is possible. Because of this, investigators limit use of the endoscope only for the initial steps of tracheal stoma formation.
False passage: The most common cause of paratracheal insertion is performing the procedure on a patient with a short, thick neck or choosing a tracheostomy site that is too low (ie, more tissue is present anteriorly and, thus, the tube is too short). Failure to make the incision large enough leads to difficulty in tube insertion and creates a false passage. Not ensuring intraluminal insertion of the dilator by oscillation of the guidewire also causes paratracheal tube placement. Most investigators urge use of endoscopic guidance to precisely control guiding catheter passage into the trachea.
Posterior tracheal wall perforation: The cause of tracheal wall mucosal laceration or perforation is due to guiding catheter and guidewire instability. The authors speculate that these injuries could cause subcutaneous emphysema, mediastinal emphysema, and pneumothorax. The guiding catheter and guidewire should be stabilized firmly throughout the procedure to avoid or minimize such tracheal injury.
Subcutaneous emphysema: The causes of subcutaneous emphysema are false tracheal tube placement or tracheal wall trauma during the dilation procedure. The condition usually resolves spontaneously. In rare cases, subcutaneous emphysema indicates an underlying pneumothorax.
Tension pneumothorax: This condition requires transthoracic tube placement.
Accidental extubation: This complication is rare, although respiratory therapists should keep it in mind and protect the ET tube from dislodgment during the procedure.

Postoperative complications (>24 h postoperative) include the following:

Hemorrhage: The major causes of bleeding are multisystem disease, sepsis, and renal failure. These findings are common in ICU patients and can contribute to problematic coagulopathies. Correction of coagulopathies and local wound care usually solve this problem. Stomal granulation accounts for most episodes of late bleeding after tracheostomy. The serious possibility of tracheoarterial fistula must not be overlooked.
Excessive granulation tissue: The most important cause of stomal tissue granulation is perichondritis of cricoid and tracheal cartilages. Treatment may involve inserting a smaller diameter tube, resisting the tracheostomy lower, removing granulation tissue with forceps or carbon dioxide laser, treating infective perichondritis with systemic antibiotic therapy, and regularly applying a disinfectant around the tracheostomy wound.
Tracheoarterial fistula: Tracheoarterial fistula is a very rare but fatal complication. A tracheoarterial fistula may arise if the stoma is located below the fourth tracheal ring or if the tip of a misplaced tracheostomy tube erodes through both the anterior wall of the trachea and the posterior wall of an adjacent brachiocephalic artery. A pulsatile tracheostomy tube raises strong clinical suspicion of tracheoarterial fistula. Such complications can be minimized if the trachea is initially cannulated no lower than the fourth tracheal ring and preferably between the second and third rings.
Stomal infection: Avoidance of broad dissection, tissue disruption, and appropriate antiseptic stoma care should result in lower rates of wound infection.
Tracheoesophageal fistula: This rare complication is caused by perioperative trauma of the posterior tracheal wall.

Late complications (>6 mo postoperative) include the following:

Tracheal stenosis: Tracheal narrowing is localized in the area of previous tracheal lesion. Most cases of stenosis are asymptomatic with 10-40% tracheal narrowing. Tracheoplasty to restore an adequate airway in symptomatic tracheal stenosis is seldom necessary. Symptoms of tracheal stenosis include dyspnea on exertion or at rest, persistent cough, inability to clear secretions, and stridor. These symptoms are typically reported when 75% of the tracheal lumen is obstructed. To minimize risk factors, the use of properly sized tracheostomy tubes with high-volume low-pressure cuffs is recommended. Flexible connecting tubing between the tracheostomy tube and the mechanical ventilator minimizes traction on the tracheostomy tube and decreases pressure on the trachea. Placement of the tracheostomy tube between the first and second or the second and third tracheal rings lowers the risk of cricoid cartilage injuries.
Tracheocutaneous fistula: This rare complication is caused by excessive granulation and chronic infection of the stoma and requires surgical treatment. Stomas usually close within 2-5 days after decannulation.
Voice change: Change in voice is the most commonly reported symptom, with prevalence of up to 50%. However, it seems more likely that hoarseness and voice changes are caused by previous ET intubation.
Disfiguring scar: Cosmetic results after decannulation are good in 77.3% of patients, moderate in 18.9% of patients, and unsatisfying (keloids that require cosmetic correction) in 3.8% of patients.

OUTCOME AND PROGNOSIS Section 8 of 11

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Because PCT is performed in critically ill patients, late outcome of the procedure is difficult to describe. See the table for the PCT mortality rate and complication frequency found by different investigators. The mortality rate is high, but this high rate related to medical problems other than PCT. Mortality because of PCT or related complications is relatively rare.

Conditions after PCT that significantly affect patients' lives and everyday activities are few. Symptomatic tracheal stenosis, the most difficult long-term complication to manage that requires operative correction, is relatively rare (1.9%). Hoarseness and temporary voice changes were reported by a significant number of patients (with a prevalence of up to 50%). In most cases, however, these changes are related to previous translaryngeal intubation. Direct injuries to the vocal cords or recurrent laryngeal nerve are extremely rare. Small skin incisions and few adjacent anatomical structure injuries due to blunt tissue dissection lead to favorable cosmetic results in stomal wound healing.

FUTURE AND CONTROVERSIES Section 9 of 11

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PCT has undergone and continues to undergo rigorous evaluation regarding its safety and the simplicity of its techniques. Recently, early results of the modified Ciaglia technique (ie, Ciaglia Blue Rhino) have been reported by Byhahn et al. The technique represents a major modification of PDT and is different because the dilation of the stoma is formed in a single step by means of a hydrophilically coated, curved dilator—the Blue Rhino. Therefore, the risk of posterior tracheal wall injury and intraoperative bleeding is reduced, and the adverse effect on oxygenation during repeated airway obstruction by the dilators is reduced. However, prospective clinical trials must be conducted before a definitive evaluation of this technique can be made.

In 1993, Fantoni et al presented a new translaryngeal airway access method. The basic principle of this technique passes the dilator between the vocal cords and pushes out through the neck tissues to obtain stoma. Since then, the author and other investigators introduced several modifications regarding safety and convenience of this technique. This procedure is now considered an alternative to PCT at some institutions.

PICTURES Section 10 of 11

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Barba CA: The intensive care unit as an operating room. Surg Clin North Am 2000 Jun; 80(3): 957-73, xi [Medline].
Benjamin B, Kertesz T: Obstructive suprastomal granulation tissue following percutaneous tracheostomy. Anaesth Intensive Care 1999 Dec; 27(6): 596-600[Medline].
Berrouschot J, Oeken J, Steiniger L, Schneider D: Perioperative complications of percutaneous dilational tracheostomy. Laryngoscope 1997 Nov; 107(11 Pt 1): 1538-44[Medline].
Bodenham A, Cohen A, Webster N: A clinical evaluation of the 'Rapitrach'. A bedside percutaneous tracheostomy technique. Anaesthesia 1992 Apr; 47(4): 332-4[Medline].
Byhahn C, Wilke HJ, Halbig S, et al: Percutaneous tracheostomy: ciaglia blue rhino versus the basic ciaglia technique of percutaneous dilational tracheostomy. Anesth Analg 2000 Oct; 91(4): 882-6[Medline].
Byhahn C, Wilke HJ, Lischke V, Westphal K: Translaryngeal tracheostomy: two modified techniques versus the basic technique--early experience in 75 critically ill adults. Intensive Care Med 2000 Apr; 26(4): 457-61[Medline].
Caldicott LD, Oldroyd GJ, Bodenham AR: An evaluation of a new percutaneous tracheostomy kit. Anaesthesia 1995 Jan; 50(1): 49-51[Medline].
Ciaglia P, Firsching R, Syniec C: Elective percutaneous dilatational tracheostomy. A new simple bedside procedure; preliminary report. Chest 1985 Jun; 87(6): 715-9[Medline].
Ciaglia P, Graniero KD: Percutaneous dilatational tracheostomy. Results and long-term follow-up. Chest 1992 Feb; 101(2): 464-7[Medline].
Cobean R, Beals M, Moss C, Bredenberg CE: Percutaneous dilatational tracheostomy. A safe, cost-effective bedside procedure. Arch Surg 1996 Mar; 131(3): 265-71[Medline].
Cole IE: Elective percutaneous (Rapitrac) tracheotomy: results of a prospective trial. Laryngoscope 1994 Oct; 104(10): 1271-5[Medline].
Escarment J, Suppini A, Sallaberry M, et al: Percutaneous tracheostomy by forceps dilation: report of 162 cases. Anaesthesia 2000 Feb; 55(2): 125-30[Medline].
Fantoni A, Ripamonti D: A non-derivative, non-surgical tracheostomy: the translaryngeal method. Intensive Care Med 1997 Apr; 23(4): 386-92[Medline].
Fernandez L, Norwood S, Roettger R, et al: Bedside percutaneous tracheostomy with bronchoscopic guidance in critically ill patients. Arch Surg 1996 Feb; 131(2): 129-32[Medline].
Friedman Y, Franklin C: The technique of percutaneous tracheostomy. Using serial dilation to secure an airway with minimal risk. J Crit Illn 1993 Feb; 8(2): 289-97[Medline].
Friedman Y, Mayer AD: Bedside percutaneous tracheostomy in critically ill patients. Chest 1993 Aug; 104(2): 532-5[Medline].
Futran ND, Dutcher PO, Roberts JK: The safety and efficacy of bedside tracheotomy. Otolaryngol Head Neck Surg 1993 Oct; 109(4): 707-11[Medline].
Gaukroger MC, Allt-Graham J: Percutaneous dilatational tracheostomy. Br J Oral Maxillofac Surg 1994 Dec; 32(6): 375-9[Medline].
Griggs WM, Worthley LI, Gilligan JE, et al: A simple percutaneous tracheostomy technique. Surg Gynecol Obstet 1990 Jun; 170(6): 543-5[Medline].
Hazard PB, Garrett HE, Adams JW, et al: Bedside percutaneous tracheostomy: experience with 55 elective procedures. Ann Thorac Surg 1988 Jul; 46(1): 63-7[Medline].
Hill BB, Zweng TN, Maley RH, et al: Percutaneous dilational tracheostomy: report of 356 cases. J Trauma 1996 Aug; 41(2): 238-43; discussion 243-4[Medline].
Kahveci SF, Goren S, Kutlay O, et al: Bedside percutaneous tracheostomy experience with 72 critically ill patients. Eur J Anaesthesiol 2000 Nov; 17(11): 688-91[Medline].
Kearney PA, Griffen MM, Ochoa JB, et al: A single-center 8-year experience with percutaneous dilational tracheostomy. Ann Surg 2000 May; 231(5): 701-9[Medline].
Kollig E, Heydenreich U, Roetman B, et al: Ultrasound and bronchoscopic controlled percutaneous tracheostomy on trauma ICU. Injury 2000 Nov; 31(9): 663-8[Medline].
Leonard RC, Lewis RH, Singh B, van Heerden PV: Late outcome from percutaneous tracheostomy using the Portex kit. Chest 1999 Apr; 115(4): 1070-5[Medline].
Lin JC, Maley RH Jr, Landreneau RJ: Extensive posterior-lateral tracheal laceration complicating percutaneous dilational tracheostomy. Ann Thorac Surg 2000 Oct; 70(4): 1194-6[Medline].
MacCallum PL, Parnes LS, Sharpe MD, Harris C: Comparison of open, percutaneous, and translaryngeal tracheostomies. Otolaryngol Head Neck Surg 2000 May; 122(5): 686-90[Medline].
Manara AR: Experience with percutaneous tracheostomy in intensive care: the technique of choice? Br J Oral Maxillofac Surg 1994 Jun; 32(3): 155-60[Medline].
Marelli D, Paul A, Manolidis S, et al: Endoscopic guided percutaneous tracheostomy: early results of a consecutive trial. J Trauma 1990 Apr; 30(4): 433-5[Medline].
Marx WH, Ciaglia P, Graniero KD: Some important details in the technique of percutaneous dilatational tracheostomy via the modified Seldinger technique. Chest 1996 Sep; 110(3): 762-6[Medline].
Massick DD, Powell DM, Price PD, et al: Quantification of the learning curve for percutaneous dilatational tracheotomy. Laryngoscope 2000 Feb; 110(2 Pt 1): 222-8[Medline].
McFarlane C, Denholm SW, Sudlow CL, et al: Laryngotracheal stenosis: a serious complication of percutaneous tracheostomy. Anaesthesia 1994 Jan; 49(1): 38-40[Medline].
McHenry CR, Raeburn CD, Lange RL, Priebe PP: Percutaneous tracheostomy: a cost-effective alternative to standard open tracheostomy. Am Surg 1997 Jul; 63(7): 646-51; discussion 651-2[Medline].
Muhammad JK, Major E, Wood A, Patton DW: Percutaneous dilatational tracheostomy: haemorrhagic complications and the vascular anatomy of the anterior neck. A review based on 497 cases. Int J Oral Maxillofac Surg 2000 Jun; 29(3): 217-22[Medline].
Petros S, Engelmann L: Percutaneous dilatational tracheostomy in a medical ICU. Intensive Care Med 1997 Jun; 23(6): 630-4[Medline].
Reilly PM, Sing RF, Giberson FA, et al: Hypercarbia during tracheostomy: a comparison of percutaneous endoscopic, percutaneous Doppler, and standard surgical tracheostomy. Intensive Care Med 1997 Aug; 23(8): 859-64[Medline].
Rodriguez JL, Steinberg SM, Luchetti FA, et al: Early tracheostomy for primary airway management in the surgical critical care setting. Surgery 1990 Oct; 108(4): 655-9[Medline].
Rosenbower TJ, Morris JA, Eddy VA, Ries WR: The long-term complications of percutaneous dilatational tracheostomy. Am Surg 1998 Jan; 64(1): 82-6; discussion 86-7[Medline].
Schachner A, Ovil Y, Sidi J, et al: Percutaneous tracheostomy--a new method. Crit Care Med 1989 Oct; 17(10): 1052-6[Medline].
Shelden CH, Pudenz RH, Freshwater DB: A new method for tracheostomy. J Neurosurg 1955; 12: 428-31.
Smith I, Fleming S, Cernaianu A: Mishaps during transport from the intensive care unit. Crit Care Med 1990 Mar; 18(3): 278-81[Medline].
Toye FJ, Weinsten JD: A percutaneous tracheostomy device. Surgery 1969; 65: 384-9.
van Heerbeek N, Fikkers BG, van den Hoogen FJ, et al: The guide wire dilating forceps technique of percutaneous tracheostomy. Am J Surg 1999 Apr; 177(4): 311-5[Medline].
van Heurn LW, van Geffen GJ, Brink PR: Clinical experience with percutaneous dilatational tracheostomy: report of 150 cases. Eur J Surg 1996 Jul; 162(7): 531-5[Medline].
Van Natta TL, Morris JA, Eddy VA, et al: Elective bedside surgery in critically injured patients is safe and cost-effective. Ann Surg 1998 May; 227(5): 618-24; discussion 624-6[Medline].
Velmahos GC, Gomez H, Boicey CM, Demetriades D: Bedside percutaneous tracheostomy: prospective evaluation of a modification of the current technique in 100 patients. World J Surg 2000 Sep; 24(9): 1109-15[Medline].
Walz MK, Peitgen K, Thurauf N, et al: Percutaneous dilatational tracheostomy--early results and long-term outcome of 326 critically ill patients. Intensive Care Med 1998 Jul; 24(7): 685-90[Medline].
Wang MB, Berke GS, Ward PH, et al: Early experience with percutaneous tracheotomy. Laryngoscope 1992 Feb; 102(2): 157-62[Medline].
Winkler WB, Karnik R, Seelmann O, et al: Bedside percutaneous dilational tracheostomy with endoscopic guidance: experience with 71 ICU patients. Intensive Care Med 1994 Aug; 20(7): 476-9[Medline].

Percutaneous Tracheostomy excerpt