LARYNGOLOGY SEMINAR
Percutaneous Tracheostomy
R3 黃同村 2002-11-13
Introduction
 Seldinger CH, 1953: catheter replacement of the needle in percutaneous
arteriography
 Shelden et al, 1955: trocar, laceration of vital structure
 Toye & Weinstein,1969: single tapered dilator
 Ciaglia et al, 1985: percutaneous dilational tracheostomy (PDT)
 Schachner et al, 1989: dilating forcep, Rapitrac

Griggs et al, 1990: guide wire dilating forceps (GWDF)
Indication for Percutaneous Tracheostomy
 The same as surgical tracheostomy (table 1)
Contraindication
 Absolute
1. Emergent airway setup
2. Children
 Relative
1.
2.
3.
4.
5.
6.
7.
Degree of ventilator support: PEEP > 8cm H2O, inspired O2 > 50%
Unstable cervical spine
Uncorrectable coagulopathy
Presence of neck mass or goiter
Previous neck surgery or surgical tracheostomy
Previous mediastinal irradiation
Marked obesity, poor identification of landmark
Technique of Percutaneous Dilational Tracheostomy
 ICU setting
 PCT team with 3 individuals (operator, bronchoscope, monitoring/medication)
 Neck extension, 100% oxygen, sedation, short-acting muscle relaxation, LA
 Bronchoscopic guidance: prevent paratracheal insertion
 Withdraw endotracheal tube

Needle (1st~ 3rd tracheal ring)Wire Dilator  Tracheostomy tube (fig)
Multiple serial dilation, ex Ciaglia Cook kit: (8 or 11 F38 F)
Single-step dilation, ex Blue Rhino percutaneous tracheostomy kit
Complication (table 2)
 Early: paratracheal insertion, pneumothorax, subcutaneous emphysema,
aspiration, bleeding, loss of airway, transient hypoxia, death
 Late: TE or tracheoinnominate fistula, tracheal or subglottic stenosis following
decannulation
Percutaneous Tracheostomy (PCT) versus Surgical Tracheostomy
 Previous report about advantage of PCT:
Smaller skin incision, less dissection and tissue trauma, less hemorrhage, fewer
infection, decreasing risk and cost to OR, require less personnel and equipment,



lower cost, fewer operative and longterm complication, performed by physicians
without surgical training, less time (11.7 vs 26.9min)
Dulguerov et al, 1999: meta-analysis of previous report
PCT: higher perioperative complication (10% vs 3%)
Perioperative death (0.44% vs 0.03%)
Serious cardiorespiratory events (0.33% vs 0.06%)
ST: higher postoperative complication (10% vs 7%)
Lim et al, 2000: PDT no advantage over standard tracheostomy (table3, 4)
Massick et al, 2001:
Bedside ST: post-op complication 2%, cost $ 436 (OR: $2670)
Bedside PDT:
16%,
$ 910
Reference
1. Massick DD et al: Bedside tracheostomy in the ICU. Laryngoscope 2001; 111:
494-500
2. Lim JW et al: Experience with percutaneous dilational tracheostomy. Ann Otol
Rhinol Laryngol 2000; 109: 791-796
3. Rogers S & Puyana JC: Bedside percutaneous tracheostomy in the critically ill
patient. International Anesthesiology Clinics 2000; 38: 95-110
4.
Dulguerov P et al: Percutaneous or surgical tracheostomy: a meta-analysis. Crit
Care Med 1999; 27: 1617-1625
5. Powell DM et al: Review of percutaneous tracheostomy. Laryngoscope 1998; 108:
170-177