The pearls and pitfalls of percutaneous dilational tracheostomy

Ching-Fei Chang, MD
Ching-Fei Chang, MD

More than 100,000 tracheostomies are performed each year to expedite weaning from mechanical ventilation and reduce complications from prolonged intubation. Since 1985, when Ciaglia et al introduced a minimally-invasive technique for achieving airway access, percutaneous dilational tracheostomy (PT) has gained popularity over surgical tracheostomy (ST) due to decreased cost, speed and ease of bedside insertion, and a similar rate of complications. However, despite these benefits, several observational studies still demonstrate a significant proportion of all tracheostomies being performed by the traditional route, with 33%-50% of all critically ill patients across the United States being referred for ST rather than PT.

Why is it, that after more than three decades, ICU providers have not unanimously converted to the newer technique? According to Ching-Fei Chang, MD, a pulmonary and critical care specialist from the University of Southern California Keck School of Medicine, the answer is multifactorial. One of the biggest obstacles, she feels, is the availability of adequate training, which entails not only the procedure itself, but the management of complications.

“Many intensivists were not taught percutaneous tracheostomy during fellowship and feel uncomfortable inserting a device semi-blindly into an area of the neck that is highly vascular,” she said. “If a life-threatening bleed were to occur, they would not know what to do. Thus, for patient safety reasons, they often defer to their ENT colleagues for the placement of a surgical trach.”

However, a new simulation session at CHEST 2018 hopes to change this perspective.

Percutaneous Dilational Tracheostomy: Placement, Management, and Troubleshooting is a one-hour interactive case-based discussion and hands-on training workshop designed to teach participants about not only how to perform PT, but what common complications to look out for and how to manage them.

“Because it is faster and more cost-effective, we need to shift this pendulum towards making percutaneous tracheostomy the default option in ICU’s across the nation.” Dr. Chang says. “We should reserve surgical tracheostomies for patients who have high-risk anatomies or other contraindications. Multiple meta-analyses have already shown that compared to ST, PT tends to have less major hemorrhage, wound infections, and skin trauma. The only complications in which PT has a greater risk is accidental decannulation, obstruction of the airway, and potential creation of a false lumen. But these are very preventable or fixable complications if you know what to do.”

According to Dr. Chang, some of the warning signs to consider ST over PT include:

  • Obese patients with a short thick neck
  • Uncorrectable bleeding diatheses
  • Active soft tissue infection in the neck
  • Neck mass or distorted anatomy
  • Inability to retroflex neck (e.g. rheumatoid arthritis or trauma patient)
  • Pediatric patient

Although complications are rare overall, Dr. Chang feels that the most serious ones to avoid if possible are:

  • Laceration of surrounding vascular structures
  • Accidental decannulation and loss of airway
  • Tracheoinnominate fistula and catastrophic bleed
  • Subglottic stenosis or airway obstruction from granulation tissue
  • Wound infection and fistula formation (e.g. tracheoesophageal)

In this new simulation session, Dr. Chang will review tips on how to avoid causing these complications, and how to manage them if they occur. The use of bronchoscopic guidance versus ultrasound guidance will also be discussed. In addition, there will be a hands-on opportunity to practice placing PT with most commonly used kit called the Ciaglia Blue Rhino®, which utilizes a unique hydrophilic single tapering dilator that bypasses the need for multiple serial dilations.